Richard Smith: Should the first priority of the NHS be to stop us dying or to help us die well?

Richard Smith Good Friday is an excellent day for thinking about death, but I think about death every day. I find it energising. As I write this blog on Easter Sunday, I read that Bruce Keogh, the medical director of NHS England, thinks that the first priority if the NHS is to stop us dying.  Minutes after reading that I read in The Atlantic a piece entitled “The coming death shortage: why the longevity boom will make us sorry to be alive.”  Who. I wonder, is on the side of the angels?

Another feature of this weekend when Jesus was nailed to a cross is to wonder if Nelson Mandela, by any measure one of the greatest figures of the 20th century, is dying. He’s 94 and has a chest infection, “the old man’s friend,” as every doctor knows. We are asked by the South African government to pray for his recovery. But I’d rather pray for a dignified death. Perhaps he’s one of those rare 94-year-olds who is sound in body and mind and full of the joy of life, but it sounds like he isn’t. It won’t be a tragedy when such a magnificent man dies. It will be a cause for celebration of a life well lived and for the continuation of the search to see what we can learn from him.

 Charles C Mann (I imagine the C to stand for Cancer) describes in the Atlantic the horrible consequences that are likely to follow, are already following, our misplaced enthusiasm for keeping people alive. “From religion to real estate, from pensions to parent-child dynamics, almost every aspect of society is based on the orderly succession of generations.” You walk to the centre of the stage, make your speech, and get off; and getting off is just as important as getting on. We don’t want the stage cluttered with yesterday’s people, most of them with diminished powers. Mann sees a world of “intergenerational warfare…pregnant 70 years olds, offshore organ farms, protracted adolescence, and lifestyles policed by insurance companies [to keep their costs down].”

“It is,” wrote the “crusty” economist Kenneth Boulding in 1965, “the propensity of the old, rich, and powerful to die that gives the young, poor, and powerless hope.” Economists like death because it transfers resources from the largely unproductive old to the entrepreneurial young. Leon Kass, the chair of the President’s Council on Bioethics, takes a similar view: “Human beings, once they have attained the burdensome knowledge of good and bad, should not have access to the tree of life.” The old should “resist the siren song of the conquest of aging and death.” So, I suggest Mr Keogh, should the medical profession and the NHS.

Mann spells out in detail in his essay the awful consequences of “the longevity boom:” huge and ultimately unsustainable costs; increased inequalities, a tripartite society with “the very old and very rich on top, beta-testing each new treatment on themselves, a mass of the ordinary old, forced by insurance into supremely healthy habits, kept alive by medical entitlement, and the diminishingly influential young;” stasis in the young unable to take over; increased divorce as “a functional substitute for death;” dictators keeping themselves alive; and universities burdened with senile professors.

The essay doesn’t mention climate disturbance, but this is another reason for avoiding a world full of people kept alive and exceeding their ration of carbon beyond their Biblical time. We don’t want health systems that consume resources allowing the rich old to “refashion their flesh to every higher levels of performance…adjust their metabolism on computers, install artificial organs that synthesise smart drugs, and swallow genetically tailored bacteria and viruses that clean out arteries, fine tune neurons, and repair broken genes.”

I don’t suppose that this is the kind of NHS that the beleaguered Keogh has in mind as he struggles to keep the service functioning and solvent, but it’s the logic of where we are headed. So let’s put helping people die well ahead of keeping them alive.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.


  • Sam H Ahmedzai

    Dear Dr Smith,
    Thanks for a very nice article on the balance between life and death, which as you respectfully point out, may this week have resonances for those who believe in the alleged putting to death and resurrection of an historical figure, but is also highly relevant to those who don’t share that belief.

    To quote exactly what Sir Bruce Keogh is reported to have said to the Guardian: “There are five things the NHS should do,” he explains. “First, it should stop you dying. Second, it should treat you well if you’ve got a long-term condition such as diabetes or asthma. Third, if you need an acute episode of care, like a cataract operation, it should look after you well. Your operation should not be delayed. Fourth, it should treat you decently. And finally, it should treat you safely.”

    Yes, it’s a pity that he didn’t say, for the first priority, “First, it should stop you dying – but if you are, it should help you die well.” Maybe he thought the second, fourth and fifth priorities somehow covered the latter clause.

    I don’t have a problem with seeing ‘prolonging life’ and ‘easing death’ as complementary parts of one aim in medicine. In my daily work in hospital supportive care I am proud to embrace both. On my ward rounds I see many patients through stem cell transplantation for leukaemia or myeloma. My team has expertise in managing the acute toxicities of the transplant procedure such as mucositis, nausea and vomiting and psychological stresses. Our involvement ensures that patients can haematologists can deliver the maximum life-prolonging therapies. The procedure may not be curative but most patients can live for many years with very reasonable quality of life if it succeeds. But if it doesn’t – and the acute mortality rate is up to 10% for some procedures – then my team and I can slip from life-extending mode to end of life care mode within hours. Even if the patient survives the transplant and relapses 3 years later and then succumbs, chances are my team will provide excellent care for them and their families if they choose to die in hospital.

    So, to answer your question, Dr Smith – I would say the question is invalid. Do both!

    Sam H Ahmedzai
    Professor of Palliative Medicine
    Academic Unit of Supportive Care
    Department of Oncology
    The University of Sheffield.