Note: This was apart of a series of posts I wrote in COVID in my first year of University. Very early writing days, and unformed thoughts. Read at your own peril!
New Zealand is holding a euthanasia referendum on the 17th October 2020, deciding whether or not the End of Life Choice Act 2019 comes into effect (this occurs on the same day as the general election, as well as another referendum on cannabis - lotta big things happening in 2020). To many, this may come as a shock. How often are we asked to confront the prospect of our death? Voting ‘yes’ means we give the option for people with a terminal illness for requesting assisted dying - the ability to request for medically assisted death. But this post does not concern itself with the politics involved; rather, it concerns the idea of death itself.
Personally, I feel inadequate to comment on the philosophy of death as a nineteen-year-old who does not give a second thought to his body’s frailties. Instead, I will use the ideas from Being Mortal, Atul Gawande’s book which explores his experiences as an American surgeon. The medical profession is the antagonist to death - the role of the doctor in a sense is to prolong life as long as possible - who better to describe Death than the surgeon? I will attempt to distil some of his thoughts (as well as my own) into two digestible (kinda, not really) chunks.
What lies at the end of our lives?
The last years of our life are painful. But what is most disturbing and excruciating is not necessarily the feeling of our bodies losing function, but what that means to our psyche. Losing autonomy - the ability to control our environment and our situation - is perhaps the most crippling loss. My maternal grandparents exemplify this dichotomy.
When I was young, my grandfather could still hear what I said. His hearing was already beginning to fade, but if we ‘talked’ loud enough, something got through. He would nod in acknowledgement, and respond to us. But as I grew, his body weakened. His wooden cane changed into a metallic stroller. His deafness extended from one ear to the next; he was given hearing aids, but dislikes (and sometimes refuses) to use them. And most recently, his eyes began to lose vision. When I look into them, they are cloudy. He’s losing all of his senses, his ability to interact with our world. And us.
My grandmother on the other hand, was his caretaker. She helped him with everything; from making him meals, to helping him bathe, he was completely dependent on her. From what I can tell, she was healthy. She went on walks everyday, often checked her blood pressure, and made sure to drink an adequate amount of warm water. Her mind is still quick; when I talk to her she can go on at length about her past, never missing a beat. Yet when I look at both my grandparents, I do not consider them in distinct situations. Yes, physically they are very different, but how happy are they? My grandfather has completely ceded his autonomy, whilst my grandmother less so. But she still has little control over what she has now. She cannot choose to go back to China, she cannot arrange for certain appointments because her handle of English is weak. So instead, she holds on to the parts of life she can control. She is adamant about buying her own groceries, of walking to everywhere, of maintaining that she is capable. But what happens on that day when she isn’t?
My grandparents live independently from my parents. Many families opt for another option; the rest home. It sounds like the ideal; families are removed from the burden of caring for them (in the case where families live together) or worrying about them (if they live like my grandparents). But from the perspective of my grandmother, this would be the ultimate hell. She moved here around 20 years ago, but can speak very little English. Why would she want to be in an environment which she has no control over, which she could barely communicate in, and most importantly, have lost her autonomy? In this sense, it’s nonsensical.
Which leaves us with a sad conclusion of what old age looks like. We are forced to “[...] choose between neglect and institutionalization.” Certainly, with enough financial freedom and support we could escape this - but for many (and I suspect most) families, this is not possible.
“Our elderly are left with a controlled and supervised institutional existence, a medically designed answer to unfixable problems, a life designed to be safe but empty of anything they care about.” [Journal of the American Medical Association 281 (1999): 163-68]
How should we die?
With this glum prospect of old age, the next question to consider is: When do our lives end? (incredibly blatant, I recognise, but Atul notes the importance of having these conversations. It prepares us for when it does happen.).
Biologically, this is a straightforward question. Our bodies are fragile - as a result, we’re engineered to have many fail-safes and backups. We have extra organs (such as the kidney and lung) and DNA replacement systems which expect there to be damage. But as time goes on, the issues pile on, and the fail-safes and backups run out. Our hair goes gray because we run out of pigment cells; our eyes go because our lens change chemically so that our retinas are exposed to less light. Humans do not die of a single disease - death is an accumulation of the gradual damage our bodies suffer. “We just fall apart.”
Philosophically, this is less straightforward. What this question asks us to consider is essentially what is important for us when we are older. A study from the book suggests that:
“Surveys find that their top concerns include: avoiding suffering, strengthening relationships, being mentally aware, being a burden”
What does this tell us? Avoiding suffering means dying prior to diseases which cause pain; strengthening relationships means we want to be in an environment which allows us to interact and chat with those we care about. Being mentally aware means we want to maintain our ability to think and work; not burdening our family with our difficulties, and finally, achieving our goals in life leads us to a sense of completion. These features are what we want; but is this what we get? Atul describes some deaths in his book as being between cold white walls, with family distantly away - a lonely death which makes no sound. Have we forgoed the quality of life over a manic need to focus on its preservation? A question that modern medicine needs to address.
There is one final part to this story. We’ve discussed how elderly people live out their lives; but what about when the prospect of death is in our immediate periphery? This is not limited to the elderly; unexpected cancers, injuries, diseases could result in our lives being determined by a risk percentage. When we are young, we fight for life; our bodies are fit, there is so much life left to experience in which we have not. But when we are old; should we fight? The human instinct is to say yes. Some argue that you’re simply delaying the inevitable, but is that not the purpose of medicine? When Death looms close, the practitioner pushes him back for a few more weeks.
Yet this contradicts the points raised earlier of what is important to us. Fighting against these terminal illnesses means we suffer, we lose awareness, we burden our family. Do we want to spend the last moments of our life undergoing treatments which have questionable efficacy and tangible harm to our quality of life? Or should we instead accept death, and maximise our time doing the things we love with the people we love?
I hope that after reading this, you will have come to your own unique conclusion to the question when should we die?
“A landmark 2010 study from the Massachusetts General Hospital had even more startling findings [...] Those who saw a palliative care specialist stopped chemotherapy sooner, entered hospice far earlier, experienced less suffering at the end of their lives - and they lived 25 percent longer.”
“I had believed that hospice care hastens death, because patients forgo hospital treatment and are allowed high-dose narcotics to combat pain. But multiple studies find otherwise. In one, researchers followed 4,493 Medicare patients with either terminal cancer or end-stage congestive heart failure. For the patients with breast cancer, prostate cancer, or colon cancer, the researchers found no difference in survival time between those who went into hospice and those who didn’t. And curiously, for some conditions, hospice care seemed to extend survival. Those with pancreatic cancer gained an average of three weeks, those with lung cancer gained six weeks, and those with congestive heart failure gained three months.”