- Death:"The Distinguished Thing"
Faced with his imminent death, Henry James is reported to have said, "So it has come at last, the distinguished thing." Distinguished? That seems an odd term to use, but James was a master at choosing the right word, and he may have seen better than most of us what death is all about. My dictionary defines "distinguished" as "having an air of distinction, dignity, or eminence." Yet there is dissent from that judgment. The late theologian Paul Ramsey contended that there could be no death with dignity. Death is too profound a blow to our selfhood, to everything good about our existence. James or Ramsey?
For at least forty years now—Ramsey notwithstanding—a massive effort has been under way to bring about death with dignity. The leading techniques have been the use of advance directives, hospice and palliative care, and improved end of life education for physicians, nurses, and other health care workers. As the Hastings Center Report 1995 special supplement on the SUPPORT study indicated, that effort achieved only a mixed success; a decade later, this report describes progress since then, but points to the long road for creating real and lasting improvement.
There has always been some ambiguity in that effort. James and Ramsey, for instance, seem to be talking about the meaning and place of death in human life, not about what kind of care is desirable at the end of life. Ramsey was no opponent of those efforts to improve end of life care. He objected to the sentimentalizing of death: even the best end of life care could not sugarcoat death's fundamental offense. Was he right? Unless it is possible to work out some reasonably satisfactory answer to that question, my guess is that the care of the dying will remain seriously hamstrung. I sometimes get the impression that recent efforts to improve that care are managing, perhaps inadvertently, to evade dealing with death itself, focusing instead on palliative techniques and strategies.
I want to get at the core question here—that of the appropriate relationship between the care of the dying and our stance toward death itself—by proposing some historical ways these two issues have either been blended or separated.
My point of departure is the premodern era, most plausibly described in the French historian Philippe Ariès's fine 1977 book The Hour of Death. He detailed "the persistence of an attitude toward death that remained unchanged for thousands of years, an attitude that expressed a naïve acceptance of destiny and nature." He called that "the tame death" and showed how it was accompanied by practices at the end of life that stressed death's public impact—the loss to the community of an individual's life, underscored by rituals of mourning that made the same point. How people died and the meaning of death were inextricably blended.
Though Ariès specified no particular time at which that long era ended, I believe it wound down in the 1950s and 1960s. By then postwar medical progress, rapidly enriched with lifesaving drugs and technologies, was in full flower and eagerly embraced. Medicine could finally do something about death, and doctors were quick to take up the new arms in a new cause, that of aggressively fighting to save lives, now a plausible effort. [End Page SR5]
No quarter was to be given. I recall in the 1960s arguing with physicians, educated in the postwar years, who told me that they had a moral duty to save life at all costs. The quality of life, the actual prognosis, or the pain induced by zealous treatment were all but irrelevant. The technological imperative to use every possible means to save life was combined with the sanctity of life principle in what seemed the perfect marriage of medicine and morality.
Then came the backlash, beginning in the late 1960s. Often bitter complaints about useless but painful treatments, about abandonment at the end of life, and about death in a cocoon of tubes and monitors, began to turn the tide.
These complaints led to reform efforts that focused on means to improve end of life care. What...