Pursuing a peaceful death.

On the face of it, one might be forgiven for thinking that death at the hands of modern technological medicine should be a far more benign, sensitive event than it was in earlier times. Do we not have a much greater biological knowledge, thus enabling more precise prognoses of death? Do we not have more powerful analgesics, thereby enhancing the capacity to control pain? Do we not possess more sophisticated machines, capable of better managing organs gone awry? Do we not have greater psychological knowledge, suitable to relieve the anxieties and suffering of an anticipated death? Do we not, adding all that up, have at hand exactly what we need to enhance the possibility of a peaceful death? The answer in each case is yes and no. Yes, we do have much more knowledge than we did prior to modern medicine. But no, that knowledge has not made death a more peaceful event, either in reality or in anticipation. The enhanced biological knowledge and technological skill have served to make our dying all the more problematic: harder to predict, more difficult to manage, the source of more moral dilemmas and nasty choices, and spiritually more productive of anguish, ambivalence, and uncertainty. In part this is because, with the advent of modern medicine, the earlier superstructure of meaning and ritual was dismantled, thus setting death adrift in a world of uncertain value and import. But also in part it is because modern medicine brought with it a stance toward death that is ambivalent about its necessity and inevitability. In response to that ambivalence, without knowing it, without using quite that language, we have come to feel only now the loss of what the late French historian Philippe Aries called a "tame" death. [1] By that he meant a death that was tolerable and familiar, affirmative of the bonds of community and social solidarity, expected with certainty and accepted without crippling fear. That kind of human ending, common to most people throughout history until recently, Aries contrasted with the "wild" death of technological medicine. The latter death--which began to occur in the nineteenth century--is marked by undue fear and uncertainty, by the presence of medical powers not quite within our mastery, by a course of decline that may leave us isolated and degraded. It is wild because it is alien from and outside of the cycle of life, because modern technologies make its course highly uncertain, and because it seems removed from a full, fitting presence in the life of the community. The technologies of that death, ever more clever in their ability to sustain failing organs, provide a set of tools that endlessly sustain our ambivalence and allow it to be played out in tortuous detail. Precisely because they have opened up new possibilities in the ancient struggle with our mortality, those technologies have made our understanding of that mortality all the more difficult. To confound us more, they have misled us into thinking we have a greater dominance over our mortality than was earlier the case. What can be done to gain a better way of thinking about medical technology and our human mortality? How can that technology be made to serve a peaceful death, not to be its enemy? What can be done to bring about a change? I want to try to make plausible a different way of thinking about the use of technology and then suggest some ways of implementing it. The change I propose can be put very simply, however strange and odd it may sound. We should begin backward. Death should be seen as the necessary and inevitable end point of medical care. Death as the End Point of Medical Care In considering its appropriate goals, medicine should, so to speak, simultaneously work backward as well as forward. Medicine now characteristically works forward only, looking to promote the good of life, both to lengthen life and improve its quality. Death is reluctantly admitted into the realm of medicine as the limit to achieving those ends, but that limit is itself uncertain at its boundary, not readily located. …