Editorials Christmas 2011: Editorial

Death can be our friend

BMJ 2011; 343 doi: http://dx.doi.org/10.1136/bmj.d8008 (Published 21 December 2011) Cite this as: BMJ 2011;343:d8008
  1. Murray Enkin, professor emeritus1,
  2. Alejandro R Jadad, professor and chair 2,
  3. Richard Smith, chair3
  1. 1McMaster University, Canada
  2. 2University Health Network and University of Toronto, Toronto, Canada
  3. 3Patients Know Best, London SW4 0LD, UK
  1. richardswsmith{at}yahoo.co.uk

Embracing the inevitable would reduce both unnecessary suffering and costs

“As birth and death actually occur, and our brief career is surrounded by vacancy, it is far better to live in the light of the tragic fact, rather than to forget or deny it, and build everything on a fundamental lie.” (George Santayana)

“Oh build your ship of death. Oh build it!

for you will need it.

For the voyage of oblivion awaits you.” (D H Lawrence)

Would you like to die the way your patients do, doctor? We suspect that many of you will answer no. Too many people are dying undignified graceless deaths in hospital wards or intensive care units, with doctors battling against death way past the point that is humane. Because too many doctors have forgotten that death is a friend, people are kept alive when all that makes life valuable has gone. Denying the inevitable comes with a heavy price. We believe that doctors and their patients need to adopt a much more positive attitude to death to reduce suffering and costs.

Death is one of the two great events of our lives. Beyond early childhood we must live with the certain knowledge of death; until medicine began its unwinnable war against death, coming to terms with your death was one of life’s most important tasks. Ars Moriendi (The Art of Dying) from the early 15th century was a best seller for 200 years, and William Caxton printed 100 copies in 1491. Michel de Montaigne wrote in the 16th century: “Tis the condition of your creation; death is a part of you, and whilst you endeavour to evade it, you evade yourselves.” He urges his readers to “Give place to others, as others have given place to you.” Sir Thomas Browne, the 17th century physician, said “We are happier with death than we should be without it.” Iona Heath, a general practitioner, also writes positively about death: “Without death, there is no time, no growth, no change . . . If we avert our eyes from death, we also erode the delight of living. The less we sense death, the less we live.”1

But this way of thinking seems to have been largely forgotten or is ignored. Denial, a remarkably powerful force with undoubted benefits, is now the main social and personal response to death. “Death now seems to be optional,” says Ian Morrison, the futurologist. Consequences include huge sums of money being spent in the last months of life, intense pressure to license extremely expensive drugs that extend life for just weeks, and uproar when a dying person is shown on television. Denial of death is a major cause of health costs rising everywhere, but the damage may be much wider than simply to our finances. “The reluctance [to look death in the face] I take to be the root cause of most of our 21st century American sorrows (socioeconomic and aesthetic as well as cultural and political),” writes Lewis Lapham, the American essayist.2 Without death every birth would be a tragedy, and sadly we may already be at that point in our overpopulated polluted planet.

Francis Bacon in the early 17th century was the first to argue that one of the tasks of medicine was to prolong life. He divided medicine into three parts: preservation of health; cure of disease; and prolongation of life—“this,” he wrote, “is a new part, and deficient, though the most noble of all.”3 In fact medicine, in contrast to public health, had little success with prolonging life until comparatively recently. But now that most of us die of complications of chronic incurable diseases, death is very much the territory of doctors. Nobody is dying until a doctor says so, and an increasing number of people die in intensive care units. “I’m running a warehouse for the dying” says an intensive care doctor quoted in an essay on death by the surgeon Atul Gawande.4 Only about a fifth of patients emerge alive from American intensive care units.4

Are doctors the main villains in the futile fight against death? “Who benefits,” asks Lapham, “from the inventory of suffering gathered in the Florida storage facilities?” Ivan Illich argued that doctors became rich and influential in part because of their supposed ability to hold back death, and by their right to preside over death.5 Modern medicine encouraged the decay of traditional means of making sense of death and dying in exchange for an implied but false promise of immortality. Gawande doesn’t mention Illich in his brilliant and chilling essay, but he reaches the same conclusion: “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.”4 Siddhartha Mukherjee, the oncologist, in his Pulitzer prize winning book on cancer quotes a ward nurse who says: “The resistance to providing palliative care to patients was so deep that doctors would not look us in the eye when we recommended that they stop their efforts to save lives and start saving dignity instead . . . doctors were allergic to the smell of death. Death meant failure, defeat—their death, the death of medicine, the death of oncology.”6 All the evidence shows that the diagnosis of dying is made too late.7

The authors’ different points of view

  • Enkin, who is in his late 80s and as he puts it bluntly “statistically closest to death,” has confidence in conversation and education. He thinks that pieces like this, together with others that we have quoted, and—for example, from BMJ columnist Des Spence,8 will encourage debate and a change in attitude to death

  • Jadad, a supportive and palliative care physician who is horrified by much of what he sees, thinks something more drastic and urgent is needed to eliminate the iatrogenic suffering fuelled by our denial of death

  • Smith adds that perhaps those who pay for medicine and regulate it need to act. Ironically, it may be the financial rather than the social and cultural cost of death that will encourage change

Is it possible for us to return to recognising all that is positive about death? If doctors have been the villains of the story might they now become the heroes? Perhaps the BMJ would like to promote a roadshow to discuss death; it is likely that many people and many doctors will be ready to make a change.

Notes

Cite this as: BMJ 2011;343:d8008

Footnotes

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; all of us expect to die, and ARJ is paid part of his salary to support dying people; all of us have at some time been practising clinicians and benefited in status and salary from people’s fear of death.

  • Provenance and peer review: Commissioned; not externally peer reviewed.

  • The authors thought that some readers might be interested in the process that they went through to reach the final version. You can see everything in the document on bmj.com. We suggest that if you want to respond to the material you send a rapid response to the editorial.

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