death has become a stranger
We react instinctively, and often poorly, when death approaches largely because we don’t know death anymore. We don’t see it and we rarely talk about it. Sure, we see more than our share of dead bodies, which are shown graphically on the front pages of newspapers and on television—bodies shot by gunmen, crushed by debris, or blown to pieces by bombs—and we see actors playing dying patients, but we rarely witness the process of dying as it routinely occurs. Most of us reach our thirties or forties without ever having seen a death or helped someone through a terminal illness. We may not have even heard about anyone’s death in any great detail—the gradual decline, the fear, the treatments, the pain, or the intimacy that can occur in the final stage of life.
And so, while we know that death happens, we don’t quite believe that it will happen to us, or to those we love—not in the foreseeable future anyway. We also don’t have any vision of what we would do if it were to happen. We say that we wouldn’t want to be “kept alive,” but do we know exactly what life support is, and when it is used, how it might be stopped, or whether it can be refused? Do we have any idea what we might do for a loved one who is gasping for air but does not want to be “hooked to machines”?
The irony is that death has become unfamiliar territory just when there is so much more that we need to know about it. Advances in medicine have complicated death. We need to be savvy, and instead we have become less experienced and less knowledgeable about death than previous generations were.
Once upon a time people knew death. It was never welcome, of course, but throughout most of history it was at least familiar. People grew up seeing parents, children, spouses, friends, and neighbors die. They knew how death occurred, what to expect, and how to behave in the face of it. They knew this because people died at a relatively young age, they died quickly, and they died quite publicly.
The late French historian Philippe Ariès described death in the early part of the 20th century like this: a person, young or old, would become acutely ill with some infectious disease, such as influenza, pneumonia, or tuberculosis, and would die within two or three weeks. During those weeks of illness, the person would be at home under the care of family, friends, neighbors, and often some spiritual guide, such as a priest. As death approached, the bedroom shutters were pulled closed, candles were lit, and perhaps holy water was sprinkled. After the death, an announcement was posted on the front of the house, and the doors were left open to admit visitors, who came in droves. Everyone attended the funeral, and then for weeks afterward people continued to visit the cemetery and the family. “It was not only an individual who was disappearing, but society itself that had been wounded and that had to be healed,” Ariès wrote in his book The Hour of Our Death.
Over the past hundred years, and particularly in the last few decades, death has become an increasingly private and individual act. Most notably in America, the care of dying people has passed from the community to the family and then, in recent decades, to hospitals, nursing homes, and other institutions. This shift occurred for many reasons, foremost among them the rapid changes in medicine.
At one time hospitals discharged people as soon as they became incurable because there was little doctors could do for them beyond offering a little comfort and compassion. Early in the 20th century, narcotic painkillers were available without a prescription, so doctors were not needed even for that. People who died in a hospital were there either because they were poor or because they had no family. Then medicine began to make enormous strides, developing ways to fight deadly infections, recharge failing hearts, transplant sickly organs, and refuel the body with blood and oxygen. Suddenly doctors had an arsenal of treatments to offer critically ill patients. Their care was no longer something simple and spiritual, but something prolonged and complex, something that had to be done in a hospital. In 1950, half of all deaths in America occurred in institutions, mostly hospitals. Today that figure is up to nearly 80 percent.
Not only did death disappear into the hospital, it has disappeared within the hospital. In all the time I have spent in hospitals, as a child following behind my physician father, as a medical reporter trailing a story, as an author researching books, as a patient, and as a visitor, I don’t believe I have ever seen a dead patient. Come to think of it, I can’t recall having seen a gathering of grief-stricken survivors either. Certainly people die along these hallways. They die here all the time. So where are they?
It turns out that when a patient dies in a modern American hospital, the door is closed immediately or the curtains are drawn, and the staff goes quickly and quietly into action. The body is wrapped in plastic and laid in a special stretcher sent from the morgue. It is placed in a sling or box that hangs beneath the metal frame of a gurney, and then a cloth is laid over the top so that, to the untrained eye, the vehicle appears to be an empty gurney or a laundry cart. The cart is wheeled down to a service elevator or, in smaller hospitals, to the regular elevators after staff members have made sure that the coast is clear and that no members of the public are loitering in the hallway. Once in the morgue, bodies are picked up at a rear entrance of the hospital by undertakers driving unmarked vans or station wagons. Meanwhile, grieving family members, if they happen to be around, are whisked into a private family room where they can grieve without being noticed, or they are taken to the morgue if they wish to see the body. No one in the hospital is reminded that death occurs here, or that it occurs at all for that matter.
The clandestine nature of death in American hospitals first became apparent to me about 20 years ago when I was traveling in China, a kid with a backpack trying to learn about the world. Somewhere around Shanghai my finger became swollen and green with infection, so I found my way to a local hospital and was led to a doctor who ordered a series of shots. As I walked back down the hallway, trying to remember how to get to the front door and wondering what had just been injected into my rear end, I heard a scream. Then I heard several screams, and then a chorus of shrieking and wailing. As I came around the corner I saw about a dozen people, jammed in the doorway of a room, sobbing and holding each other and carrying on. In the room were six beds, each one occupied by a patient. One of the patients was dead. The other five patients lay calmly, watching the commotion in silence. A nurse stood by, allowing this scene to continue.
I walked away, stunned. I was surprised because in the months that I had been in China I had found people to be reserved, and I was surprised because I had never seen such a thing—not anything even remotely like it—in a Western hospital. Maybe that is just as well. But maybe it’s not.
a funeral of flowers
As death was moved into institutions and hidden behind doors, it was further concealed from the public eye by the rise of the funeral industry, which profited from our growing discomfort with death. Once upon a time, Aunt Mary’s dead body would have been cleaned, clipped, combed, and dressed by family members, viewed by most of the community, and laid out in a homemade pine box to be buried. The cost in today’s dollars: a couple of hundred bucks, if that, because the family or a local carpenter built the casket and neighbors brought the food. Then, after several days of viewings and visitors and services, the family would begin a period of public grieving that lasted weeks or months.
Today, Aunt Mary is zipped up in a bag and whisked out the door. A team of morticians, makeup artists, caterers, and florists, who don’t know the patient or family, go to work hiding any sign of illness or death. Bodies are often embalmed (a process in which blood and other bodily fluids are replaced with preservatives), even though this is rarely necessary, and then they are beautified—plumped and waxed and airbrushed, given new hair, new lips, new teeth, new skin color—to make them look “lifelike” and give them a “natural” glow. They are bedded in cushioned caskets made of pine, oak, rolled steel, or copper bronze (one of hand-polished African mahogany costs $10,000), lined with velvet, velour, or twill, and covered with an abundance of flowers. To further the illusion of eternal existence and make the burial more palatable (and more expensive) for the survivors, the casket can be sealed and placed in a vault of galvanized steel. This is done under the pretense of protecting the body—from decay, worms, gophers, air, moisture—although nothing prevents the body from decomposing. For those who still can’t deal with death, there are other options outside the realm of the funeral home, such as cryonic freezing or mummification (“Keeps you looking healthy and robust for millennia” boasts one ad).
The funeral is then packaged into a single day, or at most a few days, of services and social gathering. Black mourning clothes are either not worn or are worn only briefly, and the fact that someone has died is barely mentioned. Overt grief is seen as morbid or hysterical; survivors are urged to get on with life as quickly as possible. The cost of the funeral: $4,000 and up.
This is all part of the $7 billion funeral industry. We used to be able to sidestep some of the carnival by opting for cremation (or maybe we were simply furthering the illusion that nothing had happened), but even cremation isn’t necessarily simple anymore. Funeral directors, realizing they are losing money on caskets, now offer products aimed at what are called “cremains.” You can buy solid bronze urns or custom-designed urns that come shaped like cowboy boots, golf club bags, hunting trophies—you name it. You can buy clusters of urns so each loved one can have their own handful of ashes, or cremation jewelry in case you want to carry a sprinkle in a locket. You can put your loved one in a pricey mausoleum vault built specially for urns or pay to scatter your loved one’s ashes around in a special cemetery garden.
All of this stands in sharp contrast to the funeral of Duane Whelan, a lawyer from my hometown. Duane was a big man and very handsome, with a ruddy complexion and a mop of unruly white hair. He went to church every Sunday and sailed whenever he got the chance, but more than anything else, Duane was a family man who raised 12 children of his own and kept in very close contact with his siblings and their children.
When Duane died, at the age of 76, several of his children drove to a nearby funeral parlor to pick out a casket. They walked up and down the aisles, looking at the simple and the ornate. They pondered the soft cushions and spring mattresses. They ran their fingers along the velvet and crepe liners. They examined the different woods and metals, the cherry, the poplar, the copper, and the silver. But in the end, they simply could not pick anything out. None of the caskets seemed right. Not for Duane. Not for their dad. “It felt so distant, looking at these things that had no connection at all to my father,” his son Peter recalls.
So Peter and his brothers left the funeral home and drove over to the local lumberyard. There, they walked through the tall storehouses, taking in the scent of fresh-cut wood and feeling the smooth grain of the planks. After some time, they selected several long, broad pieces of pine and some crown molding, loaded it in the back of Peter’s truck, and headed home.
That afternoon, assorted members of the family—children, grandchildren, in-laws, nieces, and nephews—gathered to build Duane’s final resting place. It was early October, but the autumn air was still warm, so they worked outside, sawing, hammering, shaping, and measuring, throughout the day and into the night. One A.M. Two A.M. Three A.M. The hours passed without notice. This was a mission of love. Sleep was not an issue. They built the interior frame like the inside of a sailboat, a place where Duane had always been happy. They designed a recessed panel for the top of the casket. They screwed on hand-forged hinges of shiny brass that one son had bought in India many years ago, attached six handles of heavy rope to be used for carrying, and then lined the interior with a soft black blanket that had been given to Duane and his wife as a gift some years earlier. With the smell of sawdust and varnish in the cool night air, the family talked as they worked, reminiscing about Duane and the years they had had with him. Sometimes, while they talked, they laughed. Sometimes, they wept. Either way, it felt good.
“It was a wonderful experience,” Peter says. “I can’t really explain it. It gave us a focus and a whole different feeling to the funeral. It gave the family a connection to the process because everyone had a part in it.”
Unfortunately, this is far from the norm. In fact, people are often stunned, and even put off, by the idea of such personal involvement in a funeral and such open acknowledgment of grief. This is not our way anymore. Death has been removed from our sight and replaced with a final display of lilies.
Oddly enough, rather than making death more manageable, this quarantining of death has made it that much more difficult. It has distanced us from the process and, in doing so, has turned death into an unknown, unseen and, therefore, more frightening prospect. It has stripped us of experience and wisdom, and stolen from us the rituals and the intimacy that, while deeply painful, used to make death and the ensuing grief more bearable.
illusion of immortality
As we have been increasingly insulated from death, we have also been bombarded by suggestions that we are, to some extent, immune from it. Almost daily we hear about medical breakthroughs, miraculous recoveries, foods and hormones and chemicals that can fend off disease, potions and regimes that will keep us young. The newspapers, self-help books, and infomercials insist that we can win the battle against life-threatening diseases, that we can slow the aging process, and that we can extend our lives significantly, if not indefinitely. This feeling of immunity, this sneaking suspicion that we can control our lives as well as our demise, has further distanced us from death, made us that much more naïve about the dying process, and fooled us in such a way that we are often completely shocked when death comes.
Larry and Candy Wood of California, who were featured in a New York Times Magazine article, are shining examples of this preoccupation with extending life. The Woods spend most of their time trying to have more time. Lean and muscular, they exercise obsessively, don’t touch alcohol or tobacco, and gulp down or inject everything from the relatively mundane (melatonin, vitamins, beta-carotene) to the unpronounceable (glutathione, manganese picolinate, L-Ornithine). Soon, they contend, scientists will know how to extend life and they don’t want to kick off before that ship comes in.
The Woods are part of a rapidly growing subculture of “immortalists,” people who believe that life can be preserved almost indefinitely, in one form or another. Life Extensionists, like the Woods, think life can be preserved as we now know it, both a mind and a body, while other immortalists are focused on saving just one piece of the pie. Some want to preserve the body, mummified or frozen, until it can be revived when science has found the key of life. Some are socking away a complete set of their own DNA in the hope of becoming whole again at a later date. Still others contend that the intellect, the ego, the soul can be made eternal. Through “uploading” or “cybernetic immortality,” they believe that people will be able to transfer all their thoughts, memories, desires, impulses, biases—everything, pretty much, that makes them who they are—onto a computer. Then, according to the Principia Cybernetica Web site, “if at a certain stage the biological individual of this symbiotic couple would die, the computational part might carry on as if nothing had happened.” In other words, your body would be kaput, but the cyber-you could go on, teaching your children, finishing your book, e-mailing your friends.
All of this may be a bit on the fringe, but it’s not as far out as you might think. A number of reputable scientists now insist that senescence is not as immutable as we once thought, and that one day, probably one day not all that far off, the human life span will be extended significantly, perhaps even doubled. They hold up as their proof several recent discoveries: with a few genetic alterations, scientists have doubled the life span of worms, fruit flies, and mice, and allowed them to live those extra years in exuberant health; scientists have pinpointed a genetic flaw that causes yeast to grow old quickly and humans to age prematurely; researchers have known for some time that a low-calorie diet extends the lives of mice significantly; and they have discovered and isolated “immortal” human cells, known as embryonic stem cells, which grow and divide indefinitely.
Coupled with this work on senescence are a host of medical discoveries—new cancer treatments, gene therapies, clot-clearing drugs, and the like—each aimed at defeating a particular life-threatening illness. We hear about them almost every day. And indeed, they are awesome and inspiring. Breakthroughs in medicine, even when they are made only in petri dishes, add to the belief that death can be defeated, or at least that death from the usual causes can be prevented. We just have to hang on until the final trials are finished and the FDA approvals are in place.
Two other trends have also altered our sensibility about death. The first, a hot topic, is prevention. Dozens of new studies insist that we can fend off age and disease by the way we live. We simply need to eat five servings of fruits and vegetables a day; exercise regularly, but not too strenuously; have one glass of wine, but not two, each day; toss out our cigarettes; pray; consume vitamins; buckle our seat belts; avoid fat, salt, cholesterol, charred food, pesticides, bovine hormones and anything we can’t pronounce; take hormones, antioxidants, and a lot of stuff we can’t pronounce; trust alternative medicine; reduce stress; eat garlic; and stay away from people who haven’t tossed out their cigarettes.
Don’t get me wrong. These are good things to do. In fact, they are great things to do. It’s just that we have become so fixated on life-prolonging habits and so strident in our desire for—indeed, our right to—self-determination, that we have gained a false sense of control over death. We feel that if we live right, we’ll live long; if we live wrong, we’ll die early. If only it were that simple. These things may give us a little more life, or a little more energy, but they won’t change the inevitable. We will die, no matter how much broccoli we devour.
The second trend that has altered our thinking about death is a change in our attitudes about old age. Old age used to be revered and respected, but today it is viewed with full-blown disdain. Gathering years is nothing to be proud of; rather, it is something to hide. Forget the glory of age; the fountain of youth is what we are after. We work fervently to get rid of wrinkles, white hairs, extra folds. More creams, surgery, implants, injections, lifts, peels, suctions, skin smoothers, and hair dyes. The American Academy of Anti-Aging Medicine claims, complete with uppercase letters, that “Aging is NOT inevitable,” and the Longevity Institute in Arizona, which offers biomarker analysis, matrix profiles, and hormone therapy, states, with ample exclamation points, “Remember—Aging is a Treatable Condition!!!” According to a recent article in The Washington Post, the sales of products touting “age-defying” or “anti-aging” properties went from $325 million in the mid-1990s to a whopping $3.6 billion by the end of the century. You want to get rid of wrinkles? There are now more than 1,700 anti-wrinkle creams available to choose from.
Even those who accept old age as a fact of life are convincing us that we don’t have to grow old in the traditional way; we can grow old with spark and spunk and zip. We can live “fully.” We can age “successfully.” We can travel and read and learn and love and dance along beaches and jump over tennis nets. We don’t have to sit in wheelchairs, growing weaker and blinder and denser. We have the power to stay young, in appearance and action. This is the ethos of our times.
As seductive as all of this is, most of us accept, intellectually at least, that life is finite, that we probably won’t see 100, and that Jeanne Calment, the French woman who lived to be 122, was a rare bird. Many might even argue that they don’t want to double their life spans; that 75 or 80 years is ample time on this planet. It is overcrowded anyway.
And yet, with all this talk of longevity and medical triumphs and successful aging in the air, one can’t help wondering. The message that we can win the battle, or at least put up a very good fight, is hard to ignore. It is loud and alluring, and it is always there, in the background of our lives, teasing us, tempting us, baiting us. How can we disregard it? We know that people die, but when it happens, a little voice in us asks: What did he do to deserve it? Did he smoke? Did he drink? Did he live near a nuclear power plant? Did he eat too many Twinkies? What did he do that we don’t do or could avoid doing? We know that death happens, but maybe it is not a random occurrence or strike of God; maybe it is, after all, something we can control.
Throughout history, death has loomed over life, shaping religions, philosophies, cultures, and everyday practices. But today, it doesn’t loom. We don’t ruminate over death and the meaning of life. Instead, we talk almost incessantly about how to prolong a youthful and energetic life. We Americans are particularly prone to this notion that we can control death. As someone once said, “Americans don’t die; they underachieve.”
We are not stupid. We are victims of our culture, of the news and hype that surround us each and every day. All the things that once prepared us for death—regular experience with illness and death, public grief and mourning, a culture and philosophy of death, interaction with the elderly, as well as the visibility of our own aging—are virtually gone from our lives. Instead, we are tempted daily by that perfect apple, by promises of youth and immortality.
And so it is in this state, with little knowledge of death, a blind faith in medicine, and a strong sense of personal control over life, that we enter the doctor’s office and the realm of terminal illness, and begin making decisions about how we and our loved ones will die. It is no wonder that we have trouble accepting the reality of death, managing death once it arrives, or making sense of it once it has happened.