Intended for healthcare professionals

Editor's Choice

Answering deaths's questions

BMJ 2001; 322 doi: (Published 10 February 2001) Cite this as: BMJ 2001;322:0

Five minutes after reading this you might be dead or in a vegetative state. Are you ready? Have you made your wishes clear? Are you happy to donate your organs? All of them? How do you feel about a necropsy? Can some organs be kept for research? What should the doctors do if your vegetative state persists? Should they stop feeding you? Would you rather be killed? Once dead do you insist on being kept in the mortuary, or are you happy to be left in the chapel?

Montaigne advised us to come to terms with death by thinking about it all the time. In his day the options around death were limited. There was no brain death, no persistent vegetative state, no transplantation. You weren't offered the options of dissection or cremation. You died and were buried. Now you need to think about death all the time not just to prepare yourself but also to think through the options.

Most modern people seem to ignore Montaigne's advice. They'd rather not think about death and its complex questions. “Very few men,” writes Allan Bloom, in The Closing of the American Mind, “are capable of coming to terms with their own extinction. … It is the hardest task of all to face the lack of cosmic support for what we care about.” We should thus not be surprised by the failures of our society to confront death's questions and of individuals to prepare themselves. Britain has in the past month been horrified by corpses being left unrefrigerated in a hospital chapel and by the mass retention of childrens' organs by the pathologist at Alder Hey hospital in Liverpool (pp 309, 320 and 371). Nobody can excuse the abuses at Alder Hey, but it's easy to understand why there might be a shortage of candid conversations.

“Death, like eating roast chicken or going to war,” writes pathologist Derek Roskell (p 373), “is an area in which no absolutely kind or wholesome things happen.” Relatives don't want to be asked whether they want the road scrubbed to pick up the last bits of brain. The public doesn't seem to want to know too much, and doctors and the other agents of death have gone along with them—probably mistakenly.

But if death is hard the persistent vegetative state is harder. Frederick Nenner describes the distress felt by nurses watching a man with the persistent vegetative state starve to death (p 372). “They saw him suck the moisture they placed on his lip and they watched him wither.” Derick Wade asks whether such patients shouldn't be actively killed and contemplates without enthusiasm a world where increasing resources flow to those with little or no awareness—denying many who are aware (p 352). How uncomfortable.