To Go Gently Into That Good Night?

Cigarette smoke by Thomas Herbrich

I’ve been thinking a lot about death lately. It all started after reading a handful of unrelated, but interconnected, essays on the topic over the past week.

I’ll confess, death has always been a problem for me. Not in the traditional sense, though. I don’t fear it. I fear pain and discomfort, but not death. Death is an end to all of that. My problem with death is that it creates practical problems for the living.

Roughly 680 Americans will die today of an unexpected heart attack. Another 680 will die tomorrow and another 680 the day after that. How many do you think would have lived their lives differently if they anticipated their sudden end?

I’d wager most would.

But what’s to be done? The clichéd advice to “live each day as your last” offers no useful insight. Every day is very likely not your last. There are real and negative consequences for behaving otherwise.

Far from living our final day, some of us will need to provision for lives that extend well into our nineties and perhaps beyond. The vast majority of us, however, won’t live nearly that long. But because there is no way to know in advance whether we’ve won the longevity lottery until after our number is called, we all have to organize our lives around the possibility that we’ll continue on into some distant horizon. And in so doing it’s easy to fall into a kind of anti-cliché. We live as if we have days to spend without end. That has consequences of its own.

One possible antidote is reading the stories of people like D.G. Myers who is “in the end stage of metastatic prostate cancer.” He makes clear in his essay “The Mercy of Sickness before Death” that “there is nothing good about dying of cancer.” And yet he has nonetheless noticed “some improvements in the old habits of thought and feeling” that serve as inspiration.  

You may, for instance, become more conscious of time. What once might have seemed like wastes of time—a solitaire game, a television show you would never have admitted to watching, the idle poking around for useless information—may become unexpected sources of joy, the low-key celebrations of being alive. The difference is that when you are conscious of choosing how to spend your time, and when you discover that you enjoy your choices, they take on a meaning they could never have had before.

You no longer waste or mark time. You fill it, because now you can see the brim from where you are lying.”

There’s plenty worth considering in that single passage. The first obvious takeaway is the value of making conscious choices about how to spend our time. That’s not something most of us do enough of. We tend to outsource a lot of our daily decisions to routine and inertia. Today is pretty much the same as yesterday because it’s just easier that way.  

The bigger point, though, is about how we perceive things. Whether minutes are wasted or filled is entirely subjective. We can’t control how many minutes we have to spend and, quite frankly, we can’t always control how we spend them. But the one thing we can control completely is how we feel about what we’re doing.

Choosing our moments thoughtfully, living life deliberately, and appreciating the simple joys of being alive as they’re happening is an aspiration we can have for each and every one of the minutes left for us, however many they may be.

Approaching life that way may even impact how we approach death. Up until now the overwhelming presumption was that more minutes are always better than fewer minutes. But that might be changing. A growing number of people are starting to focus more on the quality of those minutes than on their absolute number.

A recent New York Times Sunday opinion column asks the intriguing question, “When should we set aside a life lived for the future and, instead, embrace the pleasures of the present?” To make the point it highlights singer songwriter Leonard Cohen’s decision to start smoking again on his 80^th birthday. “It’s the right age to recommence,” he says.

A more extreme and thought provoking take on the tradeoffs between living long and living well comes from a recent essay in The Atlantic by Dr. Ezekiel Emanuel titled “Why I Hope to Die at 75.”

He begins with an interesting observation.

In the early part of the 20th century, life expectancy increased as vaccines, antibiotics, and better medical care saved more children from premature death and effectively treated infections. Once cured, people who had been sick largely returned to their normal, healthy lives without residual disabilities. Since 1960, however, increases in longevity have been achieved mainly by extending the lives of people over 60. . . . Over the past 50 years, health care hasn’t slowed the aging process so much as it has slowed the dying process. ”

It’s indisputably a good thing that we’re now surviving things like heart attacks and strokes that would have killed us a generation or two ago. But oftentimes in such cases the price for survival comes in the form of chronic debilitation. “The bad news,” says Dr. Emanuel, “is that many of the roughly 6.8 million Americans who have survived a stroke suffer from paralysis or an inability to speak.” 

As we get older the likelihood of us being afflicted by one of these conditions grows. The crippling impact of each occurrence is cumulative. Instead of “growing stronger” from whatever doesn’t kill us, we grow weaker. That is in part why “half of people 80 and older live with functional limitations. A third of people 85 and older with Alzheimer’s,” he says.

After citing these statistics and plenty of others detailing the long decline of old age Dr. Emanuel doesn’t go where you think he might. He remains staunchly opposed to euthanasia and doctor assisted suicide. Instead, the treatment he’s proscribed for himself is to accept no treatment at all.

Once I have lived to 75, my approach to my health care will completely change. I won’t actively end my life. But I won’t try to prolong it, either. . . .

This means colonoscopies and other cancer-screening tests are out—and before 75. If I were diagnosed with cancer now, at 57, I would probably be treated, unless the prognosis was very poor. But 65 will be my last colonoscopy. No screening for prostate cancer at any age. After 75, if I develop cancer, I will refuse treatment. Similarly, no cardiac stress test. No pacemaker and certainly no implantable defibrillator. No heart-valve replacement or bypass surgery. If I develop emphysema or some similar disease that involves frequent exacerbations that would, normally, land me in the hospital, I will accept treatment to ameliorate the discomfort caused by the feeling of suffocation, but will refuse to be hauled off.

What about simple stuff? Flu shots are out. Certainly if there were to be a flu pandemic, a younger person who has yet to live a complete life ought to get the vaccine or any antiviral drugs. A big challenge is antibiotics for pneumonia or skin and urinary infections. Antibiotics are cheap and largely effective in curing infections. It is really hard for us to say no. Indeed, even people who are sure they don’t want life-extending treatments find it hard to refuse antibiotics. But, as Osler reminds us, unlike the decays associated with chronic conditions, death from these infections is quick and relatively painless. So, no to antibiotics.”

These thoughts are as novel as they are extreme. They cut against everything we’ve come to accept as true about our lives, our aging and our approach to healthcare. Instead of “raging against the dying of the light,” as Dylan Thomas once implored, Dr. Emanuel suggests it may be better to “go gently into that good night.”

I wouldn’t say I agree entirely with Dr. Emanuel’s conception of what constitutes a life worth living. And I’m not quite sure I understand the logic of allowing yourself to needlessly succumb to a simple infection so as to foreclose the mere possibility of contracting Alzheimer’s instead of planning to swallow a bunch of pills if and when that diagnosis is actually rendered.

I also imagine that foregoing medical treatment sounds more reasonable from the perspective of a relatively youthful 57 years of age than it will to someone who is, say, 75. But even if he has a change of heart, as I suspect he might, the firm commitment of fixing an expiration date on your life may have an overlooked side benefit. Dr. Emanuel knows something most of us do not. Like D.G. Myles, he can see the brim.

That is, after all, exactly what a different New York Times writer discovered after using an internet site called the “Death Clock” to calculate the date and time of his demise.

“Call me crazy” concludes Steve Petrow in a blog post chronicling his decision, at the age of 50, to pursue his long-standing dream of writing full time, “but I have to say I love the ticktock of the Death Clock. Without it, I might not be living.”