Richard Smith: Death becomes fashionable

Richard SmithDeath is becoming fashionable. London’s Southbank is planning a two day festival of death, the BMJ has a Christmas editorial urging us to think of death as a friend rather than an enemy, and last week the Centre for Humanities and Health at King’s College London held a death workshop where philosophers and doctors worked hard to understand each other.

I’ve attended one of these workshops before, and for me it wasn’t a success. The doctors talked to the doctors and the philosophers to the philosophers in a haze of mutual incomprehension. This time it worked much better—perhaps because we are learning or perhaps because everybody has something to say about death.

But the main reason for improvement was, I think, the introduction of two simple rules. Firstly, everybody had a red card that they could hold up when they didn’t understand what somebody was saying. Nobody held up a card while I was there, but several of the speakers referred to the card and clearly were being careful to be understood for fear of the card. The second rule was that you put up a hand if you wanted to say something new but a finger if you wanted to contribute to a discussion underway—and a finger trumped a hand. This is a marvellous way of focusing the discussion and keeping comments short, and I can’t think how I’ve got through 45 years of discussion without using these rules. (Somebody said that they are called the “Canberra Rules,” but I couldn’t find them on the web).

Philosophical discussions on death tend to begin with Epicurus, the Greek philosopher who lived around 300 BC and famously said: “Death is nothing to us” because where we are death is not and where death is we are not. (Andrew Morley, an anaesthetist who spoke to the title “Death is nothing to us” conceded that it wasn’t the best of slogans for a department of anaesthetics.)

James Warren, senior lecturer in ancient philosophy from Cambridge, did a magnificent job of explaining the thinking of Epicurus and objections to it. For the Epicureans there is only pleasure and pain, which can be experienced physically and mentally. To fear death is debilitating and irrational for death cannot harm us for two reasons. The “weaker” reason is that we no longer experience anything after death and the “stronger” reason is that the person no longer exists and so cannot be harmed by death. (The whole seminar was conducted on the assumption that there is no afterlife, although probably most of the people who have ever lived have believed in afterlife as do probably 80% of those live today).

Those who want to disagree with Epicurus must answer two questions: how can death be harmful and when can it be harmful? They also have to deal with a supplementary argument that we have already experienced non-existence—before we were born—and we weren’t harmed by that. This is the symmetry argument.

Thomas Nagel, the contemporary American philosopher, has tried to take on Epicurus by arguing, firstly, that you can be harmed without perceiving it—for example, by being betrayed behind your back. Similarly a person with a severe brain injury is clearly harmed but does not perceive it. (I thought of my mother, who has no short term memory but insists that she is happy and very fortunate. I feel that if the younger her could see her now she’d be appalled, but does that matter?) Nagel argues as well that death cuts short the life that might have been, full of good things that an Epicurean would appreciate. Against that, of course, you may miss suffering that you would have experienced had you lived longer, so death can be good.

In relation to the symmetry argument, Warren asked whether he, a football fan, had been harmed by being born after England won the World Cup in 1966? Epicurus says no, and Nagel agrees even though he is arguing that you can be harmed without perceiving it—because if you had been born earlier you would have been a different person.

One of the philosophers took exception to the seemingly Epicurean view that life is overall a good thing and that more is better than less. Buddhists and Nietzsche argue that all life is suffering with the implication that it is best not to be born at all and if born to die as quickly as possible. As almost always, the Greeks got their first, and Sophocles argued this line in his play Oedipus. Epicurus was familiar with the argument and wrote: “If he believes what he says, why does he not take his departure from life? He has every opportunity to do so, supposing that his resolve were serious. If he is joking, his words are idle and will be greeted with incredulity.”

Warren illustrated the Epicurean line on the length of life by arguing that life is like going to the opera: you don’t want it to go on forever but nor do you want it to be cut short.

With the general sense that death is not a bad thing, we moved onto immortality and soon reached the conclusion that it would be unbearable. One of the great philosophical tracts on immortality was a lecture given in California in 1972 by Bernard Williams, the British philosopher of whom Gilbert Ryle said: “he understands what you’re going to say better than you understand it yourself, and sees all the possible objections to it, all the possible answers to all the possible objections, before you’ve got to the end of your sentence.”

Williams’s lecture is titled “The Makropulos case: reflections on the tedium of immortality,” and Elina Makropulos, a character in a play by Karel Čapek, reached the age of 342 after being given the elixir of life by her father, a 16th century physician. Although 342 she is better thought of as having been 42 for 300 years, explained David Galloway, lecturer in philosophy at King’s. Although vulnerable like any human being, she has not suffered from disease or injury, but, writes Williams, “her unending life has come to a state of boredom, indifference and coldness. Everything is joyless.” For her “singing and silence” are the same. She refuses to take more of the elixir, ages horribly and dies. The formula for the elixir is destroyed.

Think, said Galloway, of something you enjoy and then imagine doing it again and again forever. You would surely become fed up. Or try to “fill in the detail” of what you might be doing forever. It’s impossible. Everything would surely come to be seen as pointless, but Richard Taylor, the American philosopher, reflected on the fate of Sisyphus, who for all eternity was condemned to push a boulder up a hill only for it to roll down again, and thought that if the result of Sisyphus’s labour was a beautiful temple then perhaps an eternity of boulder pushing would make sense. But the temple would eventually fall to dust, again making immortality unbearable.

Not everybody was convinced that immortality would be unbearable. “There are always new films, new books, new ideas, new fashions to keep us stimulated.” I couldn’t help thinking that by the mathematics of infinity you would eventually have read every book and seen every film an infinite number of times. Immortality is not for me.

Death and dying are not, of course, the same thing, and a friend of mine who is a palliative care physician has no fear of death but he does fear dying because he has seen so many people dying badly, often because of doctors going on too long—torturing people. Rob George, professor of palliative care at King’s, described how doctors may treat people as a collection of bundles and how his job was “rebundling them into people.”

The doctors at the workshop generally felt that people were being kept alive too long. “Everybody is obliged to stay alive,” said Iona Health, a GP. It’s hard for people to chose to let nature take its course, For Heath death is a gift, and she described people who died so well that they left everybody who was left uplifted. This unnerved some who felt that we would now be under tremendous pressure to die well and leave everybody uplifted—rather as women may feel pressure to hav a “natural birth.”

The idea of death as a gift was too much for Geoffrey Scarre, professor of philosophy in Durham, and author of a book on death. He couldn’t see total extinction as a gift, although he could see it as an escape from unbearable suffering. Nor did he believe in a “good death” because he thought it impossible to combine tranquillity with staring into the abyss of nothingness.

The seminar took an odd turn at this point and the temperature rose with doctors who cared for the dying insisting that they had seen people have a good (or healthy) death and Scarre refusing to believe them and quoting the many philosophers who have described death as terrible. This was experience against quotes, but it was not a place where experience inevitably took precedence—because how can we be sure of our own experience?

So what? I imagine a pragmatic doctor asking—not that it is conceivable that a pragmatic doctor would start reading a blog like this let alone get to the end of what has become rather long. For me the day was a delight, which is enough. But beyond that there is feeling that our society has gone badly wrong in its relationship to death, and surely philosophy, ancient and modern, can help is find a better way to relate to death both as individuals and as society.

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