The new way of death: one possible future

How will death and dying change?

Perhaps we are living through the beginning in a revolution concerning how we die.  It’s a potential development that might seem dark for some readers, fraught for others, and dangerously complex for all, so please bear with me.  Remember, the future always presents to us not one future, but a range of possibilities.

Here’s the potential change: we will generally accept different forms of suicide and euthanasia, culturally, politically, and practically.*

Currently many human societies have strong norms and laws against taking one’s life or ending another’s.  These often draw on religious and cultural traditions, remain supported by their representatives and adherents, and persist as well in part through inertia and a general sense of the value of human life.

Developed nations also have highly advanced medical care, which offers ways of maintaining human life beyond the points where it would have ended scant decades ago, even while access to such care is wildly uneven in America.  This has led to several generations of increasing life spans.  Now there is a strong drive to extend human lifespans beyond 100.  Some medical researchers argue that we haven’t hit a limit to that lifespan, and we should expect it to rise to 125 before the century is out.  The medical profession enjoys enormous cultural respect, along with massive economic clout, which gives it a lot of say in how we die.

In the face of such strong forces, how might our attitudes towards death change?  What could drive such a powerful cultural transformation?

To begin with, humans are living longer than ever in developed nations, which suggests the opposite of, say, suicidal ideation.  Yet as a result we are falling prey in growing numbers to disorders and diseases that used to be rare, and that terrify many people: memory loss, cognition decline, and myriad ways for the body to malfunction, turn on itself, and become a prison-house of humiliation and agony.

Being Mortal coverMoreover, there is growing awareness that while medical professionals perform heroic care to preserve life in extremity, they generally refuse such care for themselves.  (The contradiction between these two attitudes is really extraordinary.)

At the same time more people choose to die outside of hospitals, either at home (as we used to do) or through hospice care, which emphasizes not life extension but comfort through the process of dying.  Atul Gawande’s Being Mortal (2014) offers a moving yet sad plea for us to choose – and support – that kind of death (my review).

There are already signs of a quietly rising interest in allowing and enabling people to choose the manner of their death.  In public policy several American states, most recently Hawaii, have recently passed laws allowing medical staff to prescribe treatment that ends life.  Several institutions and organizations help drive such laws, with one referring to a “death with dignity movement”. Several other nations, notably Belgium, Canada, Colombia, Luxembourg, the Netherlands, and Switzerland, have passed related laws, also supported by their local organizations (for example).  Indeed, Dutch law explicitly allows that “under certain conditions is euthanasia not considered an offence.”

There may also be a rising incidence of suicide.  The Centers for Disease Control (CDC) reports that

[f]rom 1999 through 2014, the age-adjusted suicide rate in the United States increased 24%, from 10.5 to 13.0 per 100,000 population, with the pace of increase greater after 2006.

Suicide rates increased from 1999 through 2014 for both males and females and for all ages 10–74.

This suggests a growing practical interest in controlling one’s death, even in the face of legal and cultural opposition.  And those numbers might be low.  One article questions if a number of opiate overdose deaths weren’t, in fact, suicides:

“[Based on the literature that’s available], it looks like it’s anywhere between 25 and 45 percent of deaths by overdose that may be actual suicides,” said Dr. Maria Oquendo, immediate past president of the American Psychiatric Association.

Some proportion of deaths may be suicides, yet described in other ways for reasons of insurance, religion, family desires, or reputation.  How many deaths by car accident were intentional?  How often does someone die of exposure deliberately?  How many people have helped a loved one die, then successfully made it look like something else?

Speaking of religion, we may see shifts in belief which could drive new attitudes towards death.  As I mentioned last year, recent research has found rising numbers of religiously unaffiliated Americans, especially young people:

religiously unaffiliated 1976-20167

That cultural shift could augur a decline in the power of religious objections to assisted death and/or euthanasia.

Some distinct features of the American experience can add other reasons for people to want to control the manner of their demise.  Earlier I mentioned our unusual method of financing health care, and that it shaped very uneven access to treatment.  Rising income inequality surely exacerbates this.  We now know that large numbers of Americans refuse medical treatment of all sorts due to financial anxiety.

Americans avoiding health care_ West Health

How many of us will turn, or have already turned, to some form of killing ourselves in order to spare families massive economic burdens?  More directly put, how many Americans will choose death because continuing to live is too expensive?

(I am speaking here of contemporary and recent developments.  There are, of course, antecedents, like this British organization founded in 1935, or the famous/notorious American Jack Kevorkian, active in the 1980s.  Obviously various forms of suicide and euthanasia have been practiced and debated for millennia.  I don’t have time to dive into the history fully in this post, but do wish to note that if the change I’m forecasting does occur, those antecedents will be re-viewed in that light.)

My analysis of present day factors could well be wrong, and I leave open the comment box below for your thoughts, as ever.  But if this is close to accurate, and if we admit my forecast for at least the sake of argument, let’s think about that future.  What could this change in death and dying look like?  Let’s set aside some wild cards and black swans for the moment, like the onset of a new plague, or the invention of a medical treatment that radically extends lifespans.

For starters, the medical system will need to change, and this will take a lot of work.  Not only would the ethics and practice of many, many health care providers have to alter, but so would hospital administration and medical schooling.  That’s a big sea change for a huge industry.  It would require a great deal of soul-searching, conversations, reflection, arguments, and professional development.  Perhaps a new subfield will emerge. Again, see Gawande for more.

A key part of the American medical system is our unusual financial model, based on private health insurance.  Insurance companies would have to support people choosing death.  During a heartbreaking talk Elaine Fong mentioned an insurance company paying far more for a potentially painful death pill than for a painless one.  Actually, you should all watch her story:

Changing insurance also means altering state and federal policies – by no means an easy thing to accomplish, as we’ve seen in the struggle over the Affordable Care Act.

Perhaps a new death culture would trigger another round in various culture wars.  In the United States blue (liberal or reliably Democratic) states have led the way in passing such laws:California, Colorado, Hawaii, Oregon, Vermont, Washington (state) and Washington (the District of Columbia).  We could see red (conservative or reliably Republican) states oppose this change for a variety of reasons: religious affiliation, partisan politics, etc.  Imagine the United States divided in two by its attitudes towards and practice of death; indeed, one could say we already are, given the sharp divide in attitudes and practice of capital punishment.  Alternatively, red states might follow suit, but through different ways: a religious transformation, or de facto acceptance while de jure prohibitions persist, with authorities looking the other way.

I’ve emphasized how complex such a change would be, and need to add another level of complexity.  So far I’ve spoken of people in physical agony choosing to die, but how do we determine a threshold for the right to make that choice?  What level of pain, which prognoses justify self-controlled death, and which do not?  What forms of mental illness will we admit to this decision, and which will we bar?  Is there an age before which we ban assisted suicide, and, if so, what would it be?  Should we allow people deemed healthy in most ways to end their lives, as Jacob Appel argues? Those are fantastically difficult questions for complex societies to answer, especially ones riven by political strife.

Let’s go further into the future with this idea.  Imagine America and other nations complete such a transformation, and some form(s) of death with dignity is (are) the norm, supported by policy, professions, and mores.  What happens net?

We could process the change like the United States did Prohibition’s end in the 1930s, looking back at the past with regret and mockery, with a touch of pushing the embarrassment under the rug.  Maybe “prohibition” or a similar term will characterize the part.  Yet what if many people feel outrage against those who fought to deny the right to death?  Religious leaders, insurance administrators, hospital directors, politicians, and more could become subjected to popular dismay or wrath.  Family members could sue these people for causing unnecessary distress to loved ones.  Perhaps we could set up something like truth and reconciliation commissions to air out grievances, seek redress, and move forward.

Our sense of medical progress has been very strong for a century, and the belief in overall progress is still a global article, if unevenly held.  How will we culturally process an end to that rising curve, if enough “earlier” deaths occur?  What will it mean to live through the advent of peak lifespan?  How will that change us?

Perhaps a new culture war will ignite, as people like Aubrey de Grey and Ray Kurzweil keep fighting for longer lifespans and even immortality while others call for and practice death with dignity.  This could break down along lines of different ways of responding to science, or in attitudes towards what it means to be human. Is a Hegelian synthesis of these views possible?  Or will such high-tech projects move to red states to continue their work, leading to a new cultural-political alliance combining science and religion: pro-life, pro-life-extension?  That would make the red versus blue dichotomy more interesting.

Several times in this post I’ve referenced unevenness and inequality, and want to return to that theme.  How will assisted suicide and euthanasia play out in practice?  That is, who will successfully choose such deaths, and who will not?  How will the choice divide by economic class, by gender, by race, by region, or religion?   Will we acculturate death in new ways, so that choosing one’s death is marked by (say) irreligion or profession?

If we accomplish this change, we would revisit the past accordingly.  Writers and activists like Arthur Koestler would be thought of as cultural heroes ahead of their times.  We might consider this line from Robert Chambers’ The King in Yellow (1895) to be prescient in the way speculative fiction sometimes is, if wrong on the date:

In the following winter began that agitation for the repeal of the laws prohibiting suicide which bore its final fruit in the month of April, 1920, when the first Government Lethal Chamber was opened on Washington Square.

Oregon, the first American state to legalize a form of suicide, would be lauded as a trailblazer.  Which date will become celebrated as a recognition of the new death?  How will we think of the many, many people who chose death in the face of illegality and censure: as heroes, even martyrs?  What kind of culture will grow up specific to an achieved right to die?  What words will we use or invent to name actions and practices?  Will we create new rituals around death?

Look further ahead still.  Could all of the world’s nations embrace the right to die?  That would be an epochal transformation, a major “before and after” for human civilization.  Or might that change become a sign of national progress, something for developing nations and regions to aim for in their developmental arc… or a dangerous cultural practice to avoid?  Perhaps the globe will divide by this new way of death.

I began writing this post in response to a news story about a new law.  This is a lot to build upon such a narrow base.  What do you think?  How likely is this future?  What am I missing?  What alternatives are likely?

PS: I have written this post as impersonally as possible, trying to leave myself out of it as best I can to aim for objectivity.  The post is already too long for me to intrude.  Perhaps with another post, down the road.

*Terms here are tricky, and each are loaded.  For now I’m using suicide, assisted suicide, choosing death, voluntary euthanasia, death with dignity more or less interchangeably, in part because there seems to be no clear consensus over which is best.  I’m open to suggestions and pointers to resources on this score.

(many thanks to my very patient and knowledgeable wife as well as thoughtful and brave commentators on Facebook for helping me prepare this post, like Anna Chatelain Bruce, Valerie Bock, Garthster Lucerne, and Tom Elliot)

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