DEATH AND DYING
Death, the most awful of evils, is nothing to us, seeing that, when we are, death is not come, and, when death is come, we are not.
Epicurus, The Enchiridion
Another important reason that ACP is not widespread is our general reticence to talk about death. Too often, clinicians are reluctant to use the words “death” or “dying,” even when caring for terminally and critically ill patients. This tacit omission may lead patients and families to assume that all is well or that things are at least stable for the time being. Stambovsky (2011) notes that “loath to hobble any momentum of hope, we intimate the possibility of recovery, which may compel families to insist upon continuing treatments” (p. 197). In this way, providers can unwittingly lead patients along corridors of hope and make their inevitable encounter with a loved one's deterioration and death all the more difficult. By contrast, when the requirements of honesty are fully met, patients and families have the opportunity to face their situation, show courage, and take comfort in being able to trust and rely on their providers. Becoming “master clinicians,” able to facilitate critical conversations with patients and families, is especially challenging in a culture that shuns talking about death (Back, Arnold, & Tulsky, 2009).
Even while we intellectually recognize that death is the natural and inevitable outcome of every life, many of us at the same time assume that a patient's death is an evil, to be avoided at all costs. The idea that death is always something we should resist is in fact enshrined in statutes in a handful of states, which allow persons completing a “directive to physicians” to request that every possible treatment be employed in the event they become incapacitated, irrespective of whether the treatment is beneficial or futile. For example, in Nevada a patient can direct, “I desire that my life be prolonged to the greatest extent possible, without regard to my condition, the chances I have for recovery or long-term survival, or the costs of the procedures” (Nevada Revised Statue, 1993). The practical effect of such laws can be to discourage health professionals seeking to practice responsible medicine. As noted already, although physicians should accept whatever reasonable option the patient chooses and should refer to another provider when appropriate, there will be instances where a patient's preferences can be ethically overridden. Thus, when a treatment is clearly futile based on empirical evidence and widespread professional consensus, it is ethically permissible to withhold or withdraw treatment (Schneiderman & Jecker, 2011). In such cases, there may be no reasonable prospect of finding a willing alternate provider for the disputed treatment.
Is there any philosophical basis for our tendency to regard death as an evil, to be avoided at all costs? As Epicurus noted long ago: death cannot possibly harm the person who dies, because once we die, whatever happens no longer causes us to suffer. In other words, death leaves us immune to future harm. Likewise, philosophers, such as Lucretius, have pointed out that it is irrational to think of death as bad because we do not think that the nonexistence preceding our births was bad. When we compare the time
before we existed to a future time when we are dead and no longer exist, we see that the two are mirror images, alike in all respects.
Although death itself is not an evil to the one who dies, contemplating our future nonexistence and preparing for the dying process is a formidable challenge to the living. Yet this challenge brings rewards, namely: the prospect of dying well and living more fully. Since we know that death, that closing of the circle, is our fate, we have every reason to treat it with the same foresight and planning that we treat the rest of our lives. Just as the unexamined life is not worth living, the unexamined death can feel empty and meaningless to the dying person. Understood as a distinctively human good, death contemplation and planning can be a counterpoise to hubris. Rather than feeling invincible and overconfident about our place in the universe, contemplating mortality reminds us that our human life is temporary and will end. Preparing for this ending can create perspective. It furnishes an opportunity to reflect on our life's value and on the goods and values that will outlast us.