- Rewriting the End
An article in this issue of the Hastings Center Report feeds into a long-run and heated debate in bioethics, and about bioethics. "Going to Meet Death: The Art of Dying in the Early Part of the Twenty-First Century" argues that if one thinks that many years of incapacity and illness are generally to be avoided, then it is possible for death to come later than is ideal, and indeed that one of the draw-backs of the advance of medicine is that death does often come later than is ideal. It is therefore necessary, says the author, John Hardwig, to think of death not just as a thing that happens to one, but as something one may have to go out and meet. Often that will just mean that we must be ready to refuse or withdraw medical treatment for an illness that might be treatable, and whose treatment might give us some additional years. Sometimes, that can even mean suicide—says Hardwig.
Hardwig's position is occasionally thought to be the general view within bioethics and the position specifically of The Hastings Center. Not so. Hardwig is not alone, but he is also very far from setting out a consensus position within bioethics. In his own acknowledgments, he thanks a former student who "has refined my thinking" but who "would disagree with almost everything in this paper." One of my colleagues at The Hastings Center and a companion on the Report's editorial committee commented, "I prefer the Emily Dickinson approach—'Because I could not stop for death, he kindly stopped for me'—to going and meeting it." Dan Callahan, the Center's founder, has long opposed the legalization of physician-assisted suicide.
Hardwig is right that new medical capacities have paradoxically increased the disease and dysfunction at the end of life, but as he notes in passing, these are not purely individual dilemmas. Among the issues that Hardwig's topic broaches but that he sets to one side (on the reasonable ground that one can write only one article in an article) are questions about the social and institutional management of the sometimes long dwindling and disability at the end of life. And this could go in different directions. Social policy might be arranged so as to facilitate Hardwig's vision of the art of dying—by changing the presumption of treatment for certain classes of people, so that instead of gravitating toward treatment we might set up checkpoints where treatment becomes less likely. But it could also go the other way: if we designed the system so as to provide better long-term care, better palliative care, and better support for family caregivers, then we might be less likely to worry that death will come too late, and have less need to run out and meet death while death is actually looking up somebody else. A valuable discussion of these institutional issues is available in "Improving End of Life Care: Why Has It Been So Difficult?" a special report in the November-December 2005 issue of the Hastings Center Report. As the contributions to that report make clear, another thing Hardwig is right about is that we need to rethink the dying process. But exactly where that thinking ends up is unsettled. [End Page 2]