Wednesday, September 23, 2009

The Art of Dying

In the July/August issue of the Hastings Center Report, John Hardwig, professor of philosophy at the University of Tennessee, offers guidance on "the art of dying." Hardwig encourages us to think deeply about what we want for the end game of our lives and to create the groundwork for life to end the way we want it to.

Here's how Hardwig sets the context:
When the sensible fear is that death will come too soon, the reasonable course is to flee it - try to postpone it or put it off...

However, many of us now worry that death will come too late - long after life has lost its usefulness and its savor, long after we have ceased to have a 'life,' perhaps long after we even are ourselves. When the more sensible fear is that death will come too late, the reasonable course is to make death come sooner - to seek it out. Learning how to go to meet death is, I believe, one of the basic tasks of our time.
In Hardwig's view, and I agree, "our institutions - our law, our medicine, our customs and traditions, our ethics, our religions - are all designed to respond to the older kinds of death [deaths that came too soon]." He tells us that he is 69, and he envisions a generation that will have to grapple with the question of life's end game without much help from others. Insofar as he's right, what a sad situation!

I'm part of Hardwig's generation, but I wouldn't have had the guts to speak as directly as he does prior to reading his essay. Consider this:
At my age I should be ready to die...I should realize that I have already had a full life...If I am not yet ready to die, something is deeply amiss in my outlook on life. My basic beliefs and values need revision.
Hardwig warns about the danger of waiting for an exact point at which one wants death to come. We can't count on having that kind of control. Probably most of us mid-life or older know people who found themselves imprisoned in a prolonged end of life that they dearly wanted to avoid. He discusses refusing life-sustaining treatment, cessation of eating, and active suicide. It's my impression that many, perhaps most, people in their 60s and beyond mull over these questions, but that relatively few discuss the issues in depth with those they are close to.

Before I decided to go into medicine and psychiatry my alternative career plan was to become a philosopher. Had I done that (I decided I wasn't scholarly enough to take to a full time academic career) I would have hoped to do Hardwig's kind of writing - disciplined, well argued, and fully engaged with questions of personal meaning.

The Hastings Center Report article isn't addressed to physicians. I was pained by Hardwig's view that my profession is not ready to partner with patients in the kind of thinking he presents. I'd like to think that he's underestimating the capacity of the profession - that if doctors felt they had permission to help their patients think about - and talk about - "the art of dying," most would be ready to do so. When I was a medical intern at UCLA in 1964 my first outpatient undertook to teach me about Hardwig's topic. I was 25. He was 50, with a lymphoma that wasn't curable. At our first appointment he asked me to renew his sleeping pills. He told me that when the time came he would use them to end his life. Even though he didn't know I was going into psychiatry he gave an important lesson in succinct form - "I'm not depressed - I enjoy my life - but I'm realistic, and I know what I want." I renewed the pills. He was still alive when I ended the year of medicine and returned to Boston to do my residency in psychiatry. If his spirit has access to the Hastings Center Report I expect that he's saying "right on John Hardwig!"

(The July/August Hastings Center Article is not yet available online, but many of Hardwig's earlier articles, including his important essay "Is There a Duty to Die?" are available at his website.)

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