We’ve forgotten how to die

Modern faith in technology critically depends on the assumption that, as new problems result from our use of technology, solutions to those problems will also eventually present themselves. We assume that it is the nature of problems that they should be solvable.

But what if this isn’t true at all? Why couldn’t it be that pursuing some new direction in technology could take us into social territory where there are no solutions to the problems that it creates, where the old solutions no longer work and all attempts at new solutions at best do nothing and often make things worse than the problem they address?

According to Atul Gawande, we used to know how to deal with death, because death used to be a simple thing.

For all but our most recent history, dying was typically a brief process. Whether the cause was childhood infection, difficult childbirth, heart attack, or pneumonia, the interval between recognizing that you had a life-threatening ailment and death was often just a matter of days or weeks. Consider how our Presidents died before the modern era. George Washington developed a throat infection at home on December 13, 1799, that killed him by the next evening. John Quincy Adams, Millard Fillmore, and Andrew Johnson all succumbed to strokes, and died within two days. Rutherford Hayes had a heart attack and died three days later.

Some deadly illnesses took a longer course: James Monroe and Andrew Jackson died from the months-long consumptive process of what appears to have been tuberculosis; Ulysses Grant’s oral cancer took a year to kill him; and James Madison was bedridden for two years before dying of “old age.” But, as the end-of-life researcher Joanne Lynn has observed, people usually experienced life-threatening illness the way they experienced bad weather—as something that struck with little warning—and you either got through it or you didn’t. […]

But the wonders of modern medicine have turned the journey towards death into something that is prolonged, excruciating, of dubious worth to the sufferer, and uncertain in nature.

These days, swift catastrophic illness is the exception; for most people, death comes only after long medical struggle with an incurable condition—advanced cancer, progressive organ failure (usually the heart, kidney, or liver), or the multiple debilities of very old age. In all such cases, death is certain, but the timing isn’t. So everyone struggles with this uncertainty—with how, and when, to accept that the battle is lost.  […]

Medicine has made it almost impossible to be sure who the dying even are. Is someone with terminal cancer, dementia, incurable congestive heart failure dying, exactly?

Gawande offers an excellent of how difficult it is to answer this question.

I once cared for a woman in her sixties who had severe chest and abdominal pain from a bowel obstruction that had ruptured her colon, caused her to have a heart attack, and put her into septic shock and renal failure. I performed an emergency operation to remove the damaged length of colon and give her a colostomy. A cardiologist stented her coronary arteries. We put her on dialysis, a ventilator, and intravenous feeding, and stabilized her.

After a couple of weeks, though, it was clear that she was not going to get much better. The septic shock had left her with heart and respiratory failure as well as dry gangrene of her foot, which would have to be amputated. She had a large, open abdominal wound with leaking bowel contents, which would require twice-a-day cleaning and dressing for weeks in order to heal. She would not be able to eat. She would need a tracheotomy. Her kidneys were gone, and she would have to spend three days a week on a dialysis machine for the rest of her life.

She was unmarried and without children. So I sat with her sisters in the I.C.U. family room to talk about whether we should proceed with the amputation and the tracheotomy. “Is she dying?” one of the sisters asked me. I didn’t know how to answer the question. I wasn’t even sure what the word “dying” meant anymore. In the past few decades, medical science has rendered obsolete centuries of experience, tradition, and language about our mortality, and created a new difficulty for mankind: how to die.

The last sentence above is not quite right. Mankind has always been faced with the difficulty of how to die. But until recently mankind has also been blessed by the fact that dying was almost always a short and uncomplicated process, and as a result socially manageable. The difficulty isn’t a new one, but our technological wizardry has turned it into something that people can no longer handle.

This is a discussion that we all will be engaging in soon, simply because we can only sustain our current state of denial by throwing money at the problem, and the money is fast running out. Unfortunately, the heart of the problem is still well obscured, and I doubt that the discussion will come anywhere close to penetrating it.


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