Introduction	Part 2	Part 3	Appendices
Part 1	Introduction to Part 2	Introduction to Part 3	Appendix A
Introduction to Part 1	Chapter 6	Chapter 9	Appendix B
Chapter 1	Chapter 7	Chapter 10	Appendix C
Chapter 2	Chapter 8	Chapter 11	Appendix D
Chapter 3	Conclusions to Part 2	Thesis Conclusions	Appendix E
Chapter 4			Appendix F
Chapter 5			Bibliography
Conclusions to Part 1			Books and Articles
			Legal Cases

Chapter 9: A Good Death

The aims of this chapter are:

(i) to establish that it is meaningful to speak of a death as being ‘a good death’

(ii) to clarify the concept of ‘a good death’ and to consider whether it can have any relevance to the making of ‘end-of-life’ decisions for PVS patients, and

(iii) to establish that ‘a good death’ is a moral - as distinct from an aesthetic - ‘good’.[i]

Once these points are established, the conclusion readily follows that:

“Carers have a moral obligation to a patient, who has entered onto the threshold of their own death, to help that patient achieve ‘a good death’.”

Because to assert that ‘a good death’ is a (moral) good necessarily implies the existence of such a moral obligation.[ii]

In attempting to accomplish these aims, it is certainly possible to address them directly - that is to attempt to define ‘a good death’ and to show that it is a ‘good’.[iii] Paradoxically, however, an indirect approach - to challenge the truth of the proposition ‘Death is an evil’ [iv] where this is asserted without qualification - is both more powerful and more instructive.

The proposition ‘Death is an evil’ is itself of pivotal significance in any discussion of assisted suicide and euthanasia and, I suggest, ‘end-of-life’ decisions for PVS patients, because once this proposition is accepted, it determines the response to many of the ethical questions relating to ‘end-of-life’ decisions in that the answers follow by necessary logical implication; a statement by James Rachels exemplifies this point:

“We do, of course, commonly assume that death is a bad thing. That is why we regard murder as a heinous crime, and why we anticipate our own deaths with dismay and weep over the deaths of those we love.” [v]

Rachael’s statement is not true: the basis for condemning murder lies not in the fact that death is a bad thing - as is clear when we consider that the victim would have died in any case[vi] - but rather in that untimely death is a bad thing.[vii]

TThus, before embarking on any wider ethical discussion concerning death and dying, it is important that the proposition ‘Death is an evil’ be not accepted as part of the conventional wisdom but be critically analysed as a proposition in its own right. The untruth or ‘inappropriateness ’ [viii] of the proposition ‘Death is an evil’ - considered as a universally true proposition - will be shown by arguing that, although it is meaningful to speak of some deaths as being evil, it is not meaningful to speak of all deaths as being evil. Once this is demonstrated, the existence of ‘good deaths’ follows as a corollary - because if not all deaths are evil then either some deaths are morally neutral or some deaths are good, or both. It is relatively easy to see that not all those deaths, which are not morally evil, are morally neutral - in the sense that a moral agent would be indifferent as to whether they occurred or not - hence, it will follow that some deaths are morally good. This would establish the logical existence - but not the content - of morally good deaths. A death which is morally good - that is, ought to be striven for - I term ‘a good death’.

____________

This chapter is structured into four Sections:

Section 1:	seeks to establish that the proposition ‘Death is an evil’ is, if unqualified, untrue.[ix]
Section 2:	considers some of the consequences that flow from an unqualified acceptance of the proposition ‘Death is an evil’, both in regard to the role played by death in the practice of clinical medicine and the denial of death,[x] these being intimately connected.[xi]
Section 3	clarifies the meaning of the concept of ‘a good death’[xii] and examines whether the usage of the term ‘a good death’ as here proposed - i.e. as a death which is a moral good - is in accord with the vernacular usage of the term and, if not, the nature of the distinction between these usages.[xiii]
Section 4	draws some conclusions from the discussion.

Section 1: The proposition ‘Death is an evil’ (simpliciter) is untrue.

There appears to be a wide consensus amongst philosophers - with some few, but notable, exceptions - that the proposition that ‘Death is an evil’ is not only true, but so obviously true as to be unworthy of serious consideration. Some have given reasons for considering death as an evil - William James, for example, suggests that the acceptance of life as a good implies that death must be an evil:

“In short, life and its negation are beaten up inextricably together. But if the life be good, the negation of it must be bad. Yet the two are equally essential facts of existence; and all natural happiness thus seems infected with a contradiction. The breath of the sepulchre surrounds it.” [xiv]

However, most philosophical discussion has centred on the fear of death and as to whether such a fear is ‘rational’, the implicit corollary being that if such a fear is rational then death is in fact an evil.

To enable a more structured discussion, Section 1 is divided into five subsections:

Subsection 1 sets out to establish that, because death is an intrinsic part of the human condition[xv] - that is, because it is one of the parameters within which a life is lived - it cannot, without further qualification, be considered to be evil.

Subsection 2 seeks to explain the prevalence in Western culture of the proposition ‘Death is an evil’ by showing its origin in Christian belief. A brief sketch of Eastern religious attitudes to death - which appear not to support the belief that ‘Death is an evil’ - will also be included in this subsection.

Subsection 3 considers the arguments of some philosophers who dispute the proposition ‘Death is evil’ (simpliciter).

Subsection 4 considers the arguments of some philosophers who assert that death is an evil.

Subsection 5 considers those philosophical arguments which are based on the fear of death and which - from the very existence of such fears or by considering their rationality - seek to draw conclusions on the question of whether death is an evil.

Subsection 1: Death being an intrinsic part of the human condition cannot be considered to be an evil.

It is said of Diogenes of Sinope that he masturbated in the marketplace saying

“If only heaven let us rub our bellies too, and that be enough to stave off hunger!” [xvi]

The ability to dispel one’s hunger by rubbing one’s belly would seem to be of unconditional benefit to any individual; it might be suggested that an individual with such a facility would be deprived of the pleasures of the table but we may assume that the imagined ability to be in addition to and not in place of existing pleasures. Would it be meaningful to talk of this newly imagined ability as a ‘good’ and its absence as an ‘evil’? What sense could be ascribed to such propositions?

In an attempt to answer this question consider a less extreme example. Imagine that a biologist has managed to isolate a new food substance of hitherto unimagined potency such that a single tablet is sufficient to sustain an individual for many months. Furthermore, the substance is inexpensive and simple to produce. This new substance holds out the promise of ending world hunger. Would such a substance be universally regarded as a good? Would not the multinational company, who purchased the patent to this new substance in order to ensure that it was not developed so that its own market dominance might be protected, be universally regarded as evil? Similar judgements would also apply to an imagined cure for cancer. Why is it that the terms ‘good and ‘evil’ appear to have a ready applicability to the development of a universal cure for cancer but seem inappropriate when applied to Diogenes’ belly rubbing cure for hunger?

The reason I suggest is that one aspect of the terms ‘good’ and ‘evil’ is that they distinguish between possible choices. In an actual situation some of the choices open to us are good, some are evil, and we are urged to choose the good. A universal cure for cancer appears to us as a distinct possibility, Diogenes’ belly rubbing cure as a flight of fancy, an impossibility. The term ‘good’ is applicable to the first but not to the second. Morality and ethics belong to the sphere of the contingent, not to that which is considered as necessary.[xvii] Furthermore, if the terms ‘good’ and 'evil' could be used in relation to situations which must exist, then they could be used in relation to situations which could not exist, for these are but the negative of the first. This would result in nonsense. Consider how one who accepts that the killing of animals is evil, could answer the question:

“Is it evil to kill unicorns?”

Is it not possible to assert both that “Is it evil to kill unicorns?” and “Is it good to kill unicorns?” simultaneously and without contradiction, since unicorns do not exist? This leads us to the conclusion that the contingency of X - i.e. the possibility of X occurring - is a precondition for the asserting either that ‘X is good’ or that ‘X is evil’.

However, an assertion that ‘X is good’ or that ‘X is evil’ not only requires that X must be neither inevitable nor impossible, but also that its occurrence must be dependent on some human agency. To suggest otherwise is surely to adopt the standpoint of the child who having tripped over a stone attempts to blame and punish the stone. But is the adult who, looking on the damage wrought by a hurricane, says ‘hurricanes are evil’ different from that child who says ‘the stone is evil’? And what of the person who says ‘Death is evil’? Thus, not only is a belief that death is not intrinsic to the human condition required before the proposition ‘Death is an evil’ can be meaningfully asserted, but also the belief that such death that does occur is attributable to human agency.[xviii]

Conclusion _{9 - 1} : The belief in the contingency of X and that the occurrence of X is, to some extent, dependent on human agency are preconditions for asserting either ‘X is good’ or ‘X is evil’.

The belief that death is not intrinsic to the human condition is precisely what is meant by the phrase ‘the denial of death’. Thus, the proposition ‘Death is an evil’ implies a denial of death. Conversely, an acceptance of death as an intrinsic part of the human condition implies that the predicates ‘good’ or ‘evil’ cannot be applied to death without further qualification.

A different argument to the same conclusion can be based on the observation that the term ‘good’ can be applied in a life but not of a life and that to attempt to do so results in logical difficulties. Some of the logical paradoxes studied by Russell and others occurred because predicates, which although unproblematic when applied to the elements of a set or collection, become so when applied to the collection itself. The example of the concept of ‘a journey’ clearly shows the difficulties. One might well ask of a particular event in a journey whether it helped or hindered the journey but one may not ask the same of the journey itself; thus - if one considers that to be a ‘good’ which helps one to live one’s life - one may ask weather an event in life was ‘a good’ but one cannot ask the same of life itself. Furthermore, one may not ask whether it is ‘a good’ that a journey has an end in that the concept ‘journey’ entails that it has an end; thus, to assert that ‘Ends of journeys are evil’ is to indulge in nonsense, though, of course, this does not preclude us asking whether a particular destination was a fitting end to a specific journey; similarly, though we may ask whether a specific death was a good or an evil, we may not ask that of death itself. Wittgenstein observed[xix] that our death is not an event in our lives but is, to our lives, rather like the frame or horizon is to a picture. Thus, if ‘good’ is a term which can be applied to events, or possible choices, in our lives, it is by no means clear that it has meaning when applied to the limits of such a life. Although this may appear to argue against the use of the term ‘a good death’, it doesn’t. It argues against regarding death (simpliciter) as either good or evil; the term ‘a good death’ is - as shall be seen - defined to a considerable extent by the process or series of events which precedes it - a good dying; such events are doubtlessly in the life in question.

Conclusion _{9 - 2} : The predicates ‘good’ or ‘evil’ cannot meaningfully be applied to ‘death’ without further qualification. The assertion that ‘Death is an evil’ (simpliciter) implies a denial of death in that it implies a refusal to accept human mortality.

If, as has just been argued, the proposition ‘Death is an evil’ (simpliciter) is meaningless then why is it so commonly asserted, particularly in Western societies? I suggest that there are principally two reasons: our Western Christian heritage and a denial of death which is prevalent in Western society. The denial of death is not necessarily connected with religious belief; it can be found even in a ‘scientific’ guise in cryonics[xx] and in the belief that medicine will soon conquer death;[xxi] the denial of death is examined in Section 2. We now examine the interrelationships in Christianity between the cluster of ideas: ‘death is an evil’, ‘death is not intrinsic to the human condition’, ‘the existence of death is dependent on human agency’.

Subsection 2: Religion and the evil of death.

The Christian attitude to death

In Christianity death was a punishment inflicted by God on man for his disobedience. Three consequences follow. Firstly, that because death was a punishment, it must be evil; secondly, its very coming into being is due to man; thirdly, because there was a time in the Garden of Paradise before the Fall when man was not mortal, death is contingent. Its contingency is also emphasised in the doctrines of the resurrection of the body and the immortality of souls.[xxii]

In Christian doctrine one of the chief consequences of the Fall was the introduction of death. Milton, in his Paradise Lost, describes it thus:

“Of Mans First Disobedience, and the Fruit

of that Forbidden Tree, whose mortal taste

Brought Death into the World, and all our woe,

With Loss of EDEN, ... ” [xxiii]

However, in Christianity death was not regarded as permanent because man would have eternal life either in heaven or on earth after the resurrection of the body:

“He will swallow up death in victory ... Thy dead men shall live, together with my dead body shall they arise. Awake and sing, ye that dwell in dust; for thy dew is as the dew of herbs, and the earth shall cast out the dead.” [xxiv]

Neither was death regarded as intrinsic to man’s condition:

"And God shall wipe away all tears from their eyes; and there shall be
no more death, neither sorrow, nor crying, neither shall there be any more
pain: for the former things are passed away." [xxv]

Eastern religious attitudes to death

The understanding of death amongst Eastern religions is quite different to that found in Christianity. For example, in Chinese Taoist philosophy, dualities such as ‘good and evil’, ‘high and low’, ‘life and death’ necessarily exist as dualities. ‘Good’ can no more exist without ‘evil’, nor ‘death’ without ‘life’ than 'left' without ‘right’.[xxvi] This viewpoint can be interpreted in two ways; firstly, as a statement of logic - the concept ‘good’ cannot exist without its opposite ‘evil’; secondly, as a maxim for a philosophy of life: one should not attempt to cleave to any one half of a duality otherwise suffering will inevitably ensue. The Hindu attitude to death is not dissimilar:

"For to the one that is born death is certain,

and certain is birth for the one that has died.

Therefore, for what is unavoidable thou shouldst not grieve.” [xxvii]

The Indian poet Rabindranath Tagore[xxviii] in his essay The Four Stages of Life beautifully elaborates on this theme:

"We have come to look upon life as a conflict with death - the intruding enemy, not the natural ending - in impotent quarrel with which we spend every stage of it. When the time comes for youth to depart, we would hold it back by main force. When the fervour of desire slackens, we would revive it with fresh fuel of our own devising. When our sense organs weaken, we urge them to keep up their efforts. Even when our grip has relaxed we are reluctant to give up possession. We are not trained to recognise the inevitable as natural, and so cannot give up gracefully that which has to go, but needs must wait till it is snatched from us. The truth comes as conqueror only because we have lost the art of receiving it as guest ... The flower must shed its petals for the sake of fruition, the fruit must drop off for the rebirth of the tree. The child leaves the refuge of the womb in order to achieve the further growth of the body ..." [xxix]

Contrast between Eastern and Christian myths on the origin of death

It is clear that the Eastern attitude to death differs markedly from current Western attitudes. I have suggested that modern Western attitudes derived from earlier Christian beliefs on the origin of death as punishment; not surprisingly Eastern religious beliefs on the origin of death are quite different from the Christian. Elisabeth Kübler-Ross in her Death The Final Stage Of Growth, includes an essay which discusses the Hindu and Buddhist views of the origin of death:

“Brahma created so many beings that the earth began to fill up to the point that ‘there was no room to breath’. Since Death had not yet entered the world, multitudinous creatures were being born but none were dying. As a result of the absence of Death, Mother Earth began to feel so overburdened by the weight of this excessive number of creatures that she pled with Brahma to lighten her load by ‘removing’ a reasonable number of his progeny. He repressed a portion of his creative energy in order to provide for creation and destruction.” [xxx]

Out of the intensification of this repressed energy a goddess was born whom Brahma named ‘Death’. However, out of love for the creatures of the Earth, she refused to remove any of these creatures and she retired from the world. Brahma, out of desperation and after much unsuccessful pleading with Death to fulfil her role, finally decreed that Death’s tears of grief be changed into diseases and that these diseases be used to remove creatures from the earth.

The contrast between the religious myths of the East and the West on the origin of death, is fully reflected in the attitudes found in their modern-day cultures and philosophies and goes a considerable distance to explain their contrasting attitudes to death.

Conclusion _{9 - 3} : Christianity considers ‘death’ to be a punishment inflicted on man and as not intrinsic to the human condition; it - unlike many Eastern religions - subscribes to the proposition ‘Death is an evil’.

It is convenient at this stage of the discussion on Christian attitudes to death to examine the Christian attitude to killing.

Christian attitude to killing

Rachels, in discussing the Christian attitude to killing, contrasts it with the ancient Greek which considered it ‘perfectly acceptable to kill newborn babies if they were deformed’ [xxxi] The Greeks however, regarded suicide as cowardly; not so the Romans, who considered it an acceptable option whenever a person considered their life to be a burden. In contrast to these attitudes, to the Christian all killing[xxxii] was an evil because it presumed on the power of God; no one having the right to shorten a divinely ordained life span. However, as Hume pointed out, this reasoning has as a further consequence that any lengthening of one’s life span also offends the divine will; Rachels suggests[xxxiii] that Christianity does not recognise this latter implication in that it accepts the morality of medical assistance in attempts to stave off death. A contrary view is that the implication is partly embodied in the distinction between ‘ordinary and extraordinary means’ and the injunction that one need not[xxxiv] use extraordinary means to keep someone alive. The Christian beliefs concerning death and killing could be synthesised in the proposition that ‘the gift of death’ - to use Derrida’s phrase [xxxv] - is solely within the power of God and that whilst one may ‘work with the will of God’ any attempt to direct the situation - either by killing or overzealously trying to keep alive - presumes on the power of God.

Rachel’s point - that modern, supposedly secular, attitudes unconsciously reflect much of Christian teaching and are a ‘reminder of the extent to which our attitudes are a product of historical Christianity’ [xxxvi] - is useful to bear in mind in our subsequent discussion of ‘end-of-life’ decisions for PVS patients.

Subsection 3: Philosophical arguments disputing the proposition ‘Death is an evil’

The unqualified proposition ‘Death is an evil’ is disputed by many philosophers: for example, in classical philosophy: Plato and Spinoza; in modern Continental philosophy: Jaspers, Heidegger and Derrida; in modern British philosophy: Foot and Scruton. The reasons offered by each of these philosophers for disputing the evil of death are separately considered and some conclusions are drawn at the end of this Subsection.

Plato

in Phaedo Plato describes how Socrates spent his last hours in the company of his friends and disciples in discussing death, philosophy and the immortality of the soul. Philosophy was portrayed in these discussions as that discipline which enabled man to gain a stability and balance in his life so that he might not be as easily swayed, as are others, by the fears and pleasures of life; most importantly, it permitted him to overcome the fear of death.[xxxvii] Some who are not philosophers - in particular, the ‘prudent’ and the ‘courageous’ - can also overcome the fear of death but these do so because of a greater fear; only the philosopher overcomes his fear of death through wisdom, through the recognition that death is not an evil:

" ... all others think death is a great evil?" [xxxviii]

That death cannot be universally regarded as an evil is again recognised when the morality of suicide is discussed. Socrates argues -

“... that although sometimes and for some people death is better than life.” [xxxix]

and that, although normally it would be right for someone to act to their advantage, they should not do so if it required taking their own life. Plato’s attitude to the dualities of ‘pain and pleasure’ [xl] and ‘life and death’[xli] is similar to the Taoist attitude:[xlii] life and death are so intimately connected, each being a precondition for the other then to attempt to hold fast to just one - to argue for example that ‘life is a good’ and ‘death is evil’ - is doomed to failure.

Spinoza

Spinoza argued that that which enables the continued existence of an individual is, for that individual, ‘a good’; indeed he takes it as the very definition of ‘good’:

“Rather than desiring something because we judge it to be good, we call it good because we desire it. ‘Consequently, what we are averse to we call evil.’ ” [xliii]

On the basis of such a definition it would appear that death was, to the individual concerned, an evil. However, Spinoza, regards such a view as a distorted and limited perspective; he considers that to adhere to such a partial view is to be in ‘bondage’ to illusion. He argues that we must strive to see the larger whole of which we form but a part. To him, freedom, such as it is, lies in the recognition and willing acceptance of the wider necessities of the universe. Spinoza believes that if one sees one’s misfortunes as they are in reality, as part of a concatenation of causes stretching from the beginning of time to the end, then one will see that they are only personal misfortunes, not misfortunes to the universe to which they are merely passing discords which heighten the ultimate harmony. He believes that only when such a perspective is achieved can contentedness - which to him is the goal of philosophy - be reached. The fear of death is dissipated not by imagining an immortal existence in some eternal heaven but by freeing ourselves from the desire for immortality by fully accepting the inevitability of our death.[xliv]

In conclusion, Spinoza starts from the standpoint of the unreflective individual for whom death is indeed an evil and shows how this judgement must yield to one which regards death as neither good nor evil but simply part of the structure of the universe and of the human condition and, as such, to be willingly accepted. There is a very modern flavour to Spinoza’s philosophy; his refusal to countenance any denial of death is echoed in the writings of Ernest Becker; the importance that Spinoza attaches to the individual appropriating his own death and using it as the anvil on which to forge his own philosophy of life foreshadows the Existentialists.

Jaspers

Karl Jaspers, in common with Plato and Spinoza, sees the primary task of philosophy - not in some abstract study of substance or perception - but in learning ‘how to live and to know how to die’. [xlv] However, whereas to Plato man discovers his true nature in the general (for example, as a philosopher) his individuality being a defect or a departure from the ideal; to Jaspers - and to the existentialists generally - man and philosophy are irredeemably rooted in the life of the particular individual.[xlvi] To philosophise is to forgo the generalities of life and to come into hard collision with the actual conditions and limitations of one’s own life. Once I remain in the realm of the imagination and possibility, I encounter no limits, it is only when I come face to face with my actual situation in the world that these are encountered. I can refuse to accept these limits, I can imagine my death as contingent, but then I have lost myself in the world and lost myself to myself. I have refused to encounter my own life. These limits in my life are not:

“ ... dead-ends but frontiers where being-in-itself is to be encountered. Death, for example, so long as I am forgetting it or fleeing from it or merely taking note of it as the inevitable end, is just an empirical fact about an empirical object in the world of being-there; it is not constitutive of my life, and in so far as it is not I am not living at the level of being-oneself.” [xlvii]

To enter into my own life, I must not only resign myself to these limits but - as it were - consent to them; for Jaspers, to speak of death as an evil is to refuse to consent to these limits.

Heidegger

Martin Heidegger is primarily concerned with the problem of ‘Being’ - not in the metaphysical sense of attempting to catalogue and categorise the abstract principles of some generalised ‘being’ - but in the sense of the problem of being as it manifests to the individual ‘thrown’ into the world. Such an individual can live in an ‘inauthentic’ sense, by acting as ‘they’ do - by being busy and active and taking his definition of himself from the role ascribed to him by others - or he can set out on a lonely journey to attempt to excavate his ‘being-in-the-world’ for himself.[xlviii]

The existence of death, not as a general concept or an empirical fact but as his very own death,[xlix] is one of those ultimate questions which, if clearly faced, forces an individual out of the easy acceptance of general answers and leads him towards his own ‘authenticity’.[l] Death thus becomes an existential phenomenon for the individual - his own inalienable death, a means whereby he can flesh out his own existence - and is no longer just a sociological or physiological phenomenon. “This full-blooded acceptance of death, lived out, is authentic personal existence.” [li]

George Steiner, in discussing Heidegger’s philosophy, describes the ‘authentic death’ as one that must be striven for, particularly against:

“... the rhetoric of medical optimism and social taboo. To think on death is regarded as a sign of morbid insecurity and pathological inadequacy ... The chattering ‘they’ ‘does not allow us the courage for anxiety in the face of death.’ ... those who would rob us of this anxiety - be they priests, physicians, mystics or rationalist quacks - by transforming it into either fear or genteel indifference alienate us from life itself.” [lii]

Steiner suggests that death may well be the identifying phenomenon of life:

“The point to be stressed is at once existential and logical: the possibility of Dasein depends on and makes sense only in respect of the ‘impossibility of Dasein’ which is death. The one cannot be without the other.” [liii]

The Taoist flavour of this last quotation is inescapable[liv] and it comes as no surprise to discover that Heidegger, through his acquaintance with Japanese philosophers, was knowledgeable of Taoism - to the extent of beginning (though he did not complete) a translation of the Taoist text ‘Tao Te Ching’.[lv]

Derrida

Jacques Derrida in his extended essay The Gift of Death[lvi] seeks to examine the concept of ‘responsibility’; however, it is the conflict between the particularity of the responsibility of the individual to himself or to his God[lvii] on the one hand, and the generality of the norms of ethical responsibility on the other, that is his main concern. Derrida is interested in exploring the preconditions of this conflict - what is it that brings this conscience or interior voice into being and that allows it to assert its preeminence over, what society considers to be, the rules of ethics. The essay is an extended meditation on the biblical story of Abraham who was commanded by God to sacrifice his son but whose life was reprieved at the last moment. Had Abraham sacrificed his son - as he was willing to do - he would have been a murderer in the eyes of his family and of society; his actions would have been unjustifiable to them, beyond explanation, truly Abraham’s ‘secret’ [lviii]. However, had Abraham not been willing to do his duty to God, he would then have been condemned in his own eyes. Thus, he could only do what he perceived as his duty by ‘sacrificing ethics’; [lix] this is because ethics, in so far as it deals with general rules, is oblivious to the individual qua individual, and sees him only in his role.[lx]

From whence this singularity, or uniqueness, of the individual which is the very precondition of individual responsibility? What sets the individual apart from the general rules governing all others? Why does he feel himself exempt from these, or rather why does he feel constrained to rebel, so that he can become ‘the irreplaceable uniqueness of the responsible self’ ?[lxi] To Derrida, it originates in the acceptance of one’s own mortality: ‘the identity of oneself is given by death’:[lxii]

“ ... to have the experience of one’s absolute singularity and apprehend one’s own death, amounts to the same thing. Death is very much that which nobody else can undergo or confront in my place. My irreplaceability is therefore conferred, delivered, 'given', one can say, by death. ... In this sense only a mortal can be responsible.” [lxiii]

and again:

“... responsibility demands irreplaceable singularity. Yet only death or rather the apprehension of death can give this irreplaceability, and it is only on the basis of it that one can speak of a responsible subject, of the soul as conscience of self, of myself etc.” [lxiv]

Thus, to Derrida, the acknowledgement and acceptance of the inevitability of my dying is the gateway not only to my individuality but to my innermost being.

Foot

Phillipa Foot’s essay on euthanasia[lxv] - particularly her distinction between the differing obligations that flow from Justice and from Charity - has been of considerable assistance in formulating the conceptual scheme proposed in this thesis; because of this and because her article embodies a particularly subtle logical argument it is summarised in Appendix D. The distinction between the obligations due to Justice and to Charity is developed in Chapter 10 and is of considerable assistance in formulating the conceptual scheme to be proposed in Chapter 11. Her argument on the proposition ‘Death is an evil’ is set out below and is followed by a critique which focuses on the role she assigns to the concept of ‘death’ (tantamount to a ‘denial of death’) in the formulation of her argument.

‘Death is an evil’

Foot begins her essay by first noting that the usual dictionary definitions of euthanasia concentrate on the manner of the death, i.e. its being ‘gentle and easy’, and thus unintentionally but nonetheless logically encompassing, for example, the murderer who kills his victim in their sleep; it was this sense of the term that allowed the Nazis to speak of their ‘euthanasia’ programmes. Foot insists that the term 'euthanasia' cannot be characterised solely by the manner of death but must encompass the condition that the death be occasioned ‘for the sake of ’ the one who dies.

In formalising this latter condition Foot considers two possibilities; firstly, that the ‘Death shall be a good’ and secondly, that ‘Death shall not be an evil’ for the one who dies. She argues that the second of these options - although favoured in the current usage of the term ‘euthanasia’ - should be rejected because the condition that ‘A not be an evil for Y ’ does not require that ‘A benefits Y ’ but is satisfied simply by Y being indifferent to A. Current usage would thus cover actions which result in the death of Y even if the motivation for the actions, though not seeking to harm Y, were quite indifferent to Y and to his welfare.

Foot is thus led to define 'euthanasia' not only in terms of the manner of death, but also by insisting that the ‘Death shall be a good’ for the one who dies. She abjures the distinction between 'act' and 'omission' usually made in discussing the moral responsibility for death, insisting that the essential point is the choice of a behavioural strategy - whether act or omission - which is sufficient to result in death, to choose such strategies is to cause the death. Having clarified the meaning she ascribes to the term euthanasia, Foot then considers whether this is just an empty definition or whether actual deaths are capable of satisfying it. The criterion relating to the ‘manner of death’ presents no problem but the stipulation that the ‘Death shall be a good’ for the one who dies, is problematic. She uses the example of a victim of torture, who on the brink of death was always revived so that the torture might continue, to show that in certain conditions death is indeed a good and that for such a person death would be a merciful release.

The role of death in Foot’s argument

One surprising aspect of Foot’s analysis is that, in discussing death and the human situation, the fact that humans are mortal is not mentioned. Imagine a race of demigods who are immortal in all circumstances but one - they can be killed by their fellow beings. Some of these demigods, however, perhaps through misfortune or the caprice of some higher gods, are subject to illness. Conjure up some philosophers to these celestial realms who ponder on the difficulties of these unfortunates and wonders whether it would be moral to kill them; the arguments set out in Phillipa Foot’s ‘Euthanasia’ well express their ethical dilemma! But we do not live in such celestial realms, death is not a contingent event in our lives, each and every one of us must die. It is surely ironic that in Foot’s discussion of euthanasia, the mortality of man not only does not play a central role but plays no role; such would suggest that the original statement of the problem is seriously deficient. One consequence of this omission, which goes some way to explain the tortuous nature of Foot’s analysis, is that by considering death as contingent,[lxvi] the task of showing that there are circumstances in which death is a good can only be satisfied by showing that in these same circumstances life is an evil. This is indeed the direction taken by Foot’s analysis and is exemplified in the torture case discussed above.

Foot’s attempt to explicate the judgement ‘Death is a good’ through an analysis of the judgement ‘Life is a good’ and its exceptions is ultimately unsatisfactory. One reason for her difficulties lies in the fact that her conceptual framework is too abstract for her discussion. By beginning with the polarities ‘Life is a good’ and ‘Death is an evil ‘, she is forced to find grounds to justify these general propositions and she is not wholly successful in her search. The canvas she has chosen on which to paint her picture, is too broad; furthermore, she is forced to treat these propositions - i.e. ‘Life is a good’ and ‘Death is an evil’ - as logically equivalent; thus implying that once an exception to the proposition ‘Life is a good’ is found this establishes that ‘Death is not evil’ is not universal. Certainly ‘death’ and ‘life’ are opposites in the trivial sense that what is alive is not dead but to suggest that the assertion that ‘My life is not good’ logically implies ‘My death is a good’ is not only a logical error[lxvii] - in the sense that one cannot deduce one from the other - but is also a linguistic error in that it overlooks the range of subtle psychological meanings implicit in the use of such propositions. The fact that the propositions ‘My life is a good’ and ‘My death is a good’ are not generally perceived to be incompatible - as is seen in the quotation following - makes this abundantly clear:

“The more positively one evaluated life the more positively one tends to evaluate death; the less positively one views life, the more negatively one views death. An acknowledgement of our finiteness intensifies our awareness of life and acts as a force, propelling us towards the realization of our desires.” [lxviii]

Thus, there is a fundamental flaw at the heart of Foot’s analysis. Had she disavowed the general proposition ‘life is a good’ and ‘death is an evil’, and restricted her analysis[lxix] solely to a consideration of the situations when death could be considered a good, her analysis might have been more fruitful. A further problem hovers in the background which seems to be a problem entirely caused by language. In asserting that ‘Death is a good for X ’, this ‘good’ cannot wander about in a dissociated fashion but must be ‘owned’ - there is however no one to ‘own’ the death, for the X - for whom death is a good - when he receives the death, no longer is; one longs for the insights of a Wittgenstein to disentangle such a problem; however, it is clear that an initial step might be towards decreasing the level of abstraction so that propositions like ‘Death is an evil’ and ‘Life is a good’ are avoided.

Another peculiarity of Foot’s analysis - and which I believe to be her most valuable contribution to the debate on euthanasia - is that the conclusion that ‘X is a ‘good’ for Y ’ (which she defines in terms of X being done ‘for the sake of’ Y) and the moral obligation to do X are separated; the first does not imply the second which must be independently established; this is necessitated by her definition of ‘good’ and is embodied in her conclusion that:

“It is important to emphasise that a man’s rights may stand between us and the action we would dearly like to take for his sake” [lxx]

This aspect of her argument is developed in Chapter 10.

In contrast to Foot’s approach, this chapter seeks to place man’s mortality centre stage. If death must happen to man, then the description of ‘a good death’ - and the moral obligation to seek it for another - arise out of the fact that, of all possible deaths for this other, this particular one is the best.

Scruton

Roger Scruton in his Modern Philosophy, argues[lxxi] that when judged from a third person perspective, death is not always an evil and that it is sometimes a good.[lxxii] He gives as examples:

* Death as a rightful punishment

Though he comments, somewhat unphilosophically:

“Think of Hitler or Stalin: not only were their deaths good in themselves; more miserable deaths would have been even better.” [lxxiii]

* Death as a fitting end to a life of great undertakings

* Death as a liberation from suffering

His first category requires no further comment. His second category appears to be a use of the term ‘good’ in an aesthetic sense in that it does not imply a moral obligation on others to ensure its achievement, an implication which is usually[lxxiv] implicit in the concept ‘good’ when used in its moral sense (as in his third category).[lxxv] Scruton’s discussion of death is ultimately unsatisfactory, never transcending the fear of death and the possibilities of immortality:

“... the feeling persists that my own death is not, and cannot be, the end of me. What is the source of this feeling? ... The arguments are not conclusive, ...” [lxxvi]

Conclusions

The philosophers just considered fall into three groups in their attitude to death.

The first group, represented here by Foot and Scruton, conceive of circumstances - such as torture or severe illness - where death may be a good; this view conceives of death as a friend enabling escape from suffering; it is, however, set against a background of uncritical acceptance of the proposition ‘Death is an evil’ and is tantamount to a denial of death.

The second group, represented here by Plato and Spinoza, recognise that we each fear death and may not wish to die but they argue that we must restrain our desires and fears in order that we become attuned to the facts of the universe. Human mortality is part of the innate structure of the world and to pretend or to hope otherwise - as happens when we speak of death as evil - is destructive of a harmonious life. Our mortality must be willingly accepted; death and life transcend the categories of good and evil.

The third group represented by Jaspers, Heidegger and Derrida, assign a positive role to death, crucial to the development of individuality[lxxvii] and personal responsibility. The knowledge that I must face my own death and that, at the moment of death I will be the judge of how I have lived my life forces a recognition that this - and not the conventionally accepted social norms - is the standpoint to be adopted in deciding all important questions that arise in my life: I must choose so that when on my deathbed and reviewing my life, I will be proud of my choice; these choices must not be made using the norms of others as such would be an abdication of individual moral responsibility. It is from this viewpoint that Heidegger sees death as forcing a cleavage between the ‘I’ and the 'they', thus giving birth to a true individuality with its own tasks distinct from the tasks that ‘they’ consider of importance. It is from this same standpoint that Derrida argues that individual moral responsibility flows from, what he calls, ‘the gift of death’.

Others (whose views have not been discussed in this Subsection) have argued that many of the qualities that are considered to be quintessentially human - such as creativity[lxxviii] and spirituality[lxxix] - flow from the conscious acceptance of our own mortality: our death being the very salt of our lives; the prospect of immortality, a tedium removing all sense of urgency. Judged from this perspective it is imperative that our mortality - this most fundamental of facts - must not be evaded or denied but be willingly accepted; we must, as it were, consent to our mortality.

Conclusion _{9 - 4} : The arguments against the proposition ‘Death is an evil’ (simpliciter) are varied:

(i) that, in times of suffering, death can be a friend. (Foot, Scruton)

(ii) that human mortality is a fact of the universe and, as such, must be accepted. (Plato, Spinoza)

(iii) that the gateway to an ‘authentic’ life which embodies individual moral responsibility, lies in the willing acceptance of our individual mortality; it is incompatible with the denial of death implicit in the proposition ‘Death is an evil’. (Jaspers, Heidegger, Derrida)

(iv) that the gifts of creativity and spirituality flow from, and are sustained by, a full intellectual and emotional acceptance of our individual mortality. (Becker,[lxxx] Koestler)

Subsection 4: Philosophical arguments asserting that death is an evil.

Thomas Nagel’s arguments are here taken as being representative of philosophical arguments to the effect that ‘Death is an evil’. Nagel sets out his arguments in The View from Nowhere[lxxxi]and in Mortal Questions;[lxxxii] these arguments, and Mary Mothersill’s critical response, are considered in this Subsection; for convenience, they are considered separately.

Nagel: The View from Nowhere.

The problem at the core of the chapter entitled ‘Birth, Death, and the Meaning of Life’ is the disparity between the subjective view of a life - in which the individual is at the centre of the world, supreme in his importance - and the objective view - in which his being is utterly contingent, he is of no great moment to the wider community and of even less importance to the universe seen as a whole. From the subjective viewpoint, death is an affront, a total catastrophe; from the objective viewpoint, death is as inconsequential as the falling of a leaf.

Nagel has set himself the task of reconciling these viewpoints and of finding a philosophy which he can live by and in this he is unusual, certainly amongst English speaking philosophers. The problem he sets himself is more often considered in a religious context, it is a central theme of Eastern religions especially Buddhism; it is also the focal point of philosophies such as Spinoza’s. Nagel is aware of these contributions, both of which, he believes, deny the claim of the subjective world; the Buddhist view has been commended to him by Parfit, but Nagel feels that the contemplated loss of ego would be an “... amputation of so much of oneself ... [with] some of these cures more absurd than the disease.” [lxxxiii] Spinoza’s solution - of attempting to see all sub specie aeternitatis - leads, suggests Nagel, to nihilism because from such an elevated perspective, nothing that an individual can do matters - our life and our efforts seem absurd. Nagel also rejects the opposite solution - the ‘denial of the objective unimportance of our lives’.[lxxxiv]

Nagel’s difficulty arises because he seeks a conceptual answer rather than an experiential answer to the problems which he has posed. Buddhism, and to a lesser extent Spinoza’s philosophy, are lived philosophies in the sense that they offer the expectation that by living in a certain manner, contentment - the resolution of the problem of the ‘meaning of life’; the release from being in thrall[lxxxv] to the emotions - will follow; it is not suggested that such results will flow from an understanding of particular intellectual arguments.[lxxxvi] Such arguments are offered only to whet the appetite, they cannot satisfy the thirst; the traditional Buddhist metaphor is that one must not mistake the finger pointing at the moon for the moon.

It is certainly true that, as Nagel argues: ‘The external standpoint and the contemplation of death lead to a loss of equilibrium in life.’ [lxxxvii] but it is a loss of equilibrium which is necessary because adherence to solely the subjective viewpoint is based on an unsustainable fiction. The growing child, in shedding its innocent belief that ‘God’s in his heaven and all is right with the world’, also suffers a loss of equilibrium but it is a loss which is equally necessary; out of this loss a new point of balance can be achieved and a new equilibrium developed but based this time on more secure foundations. To argue otherwise is to constrict our consciousness and our intellectual, and ethical, development.

Nagel is finally driven to believe that there is no credible way of resolving the inner conflict.[lxxxviii] However, - as in an afterthought - he finds a resolution in the ‘nonegocentric respect for the particular ’ [lxxxix] as occurs, for example, when one loses oneself in music, in art, or in the simple pleasure of life; as Nagel says “One can simply look hard at a ketchup bottle ...” [xc] The huge irony is that this resolution of Nagel’s - i.e. the immersion in the ‘particular’ or, in an alternative formulation, an immersion ‘in the present moment’ - is, unknownst to Nagel, precisely the core Buddhist practice of ‘mindfulness’; the ability to rest in this state, is ‘egolessness’.

For Nagel, however, this is only a temporary respite; in discussing ‘death’[xci] the conflict between ‘subjective’ and ‘objective’ views re-emerges in full vigour:

“... death is nothing, and final. I believe there is little to be said for it: it is a great curse, and if we truly face it nothing can make it palatable except the knowledge that by dying we can prevent an even greater evil.” [xcii]

He then explains that ‘death is a bad thing’ because

“Life can be wonderful, but even if it isn’t, death is usually much worse. If it cuts off the possibility of more future goods than future evils for the victim, it is a loss no matter how long he has lived when it happens. .... death is a misfortune even when life is no longer worth living.” [xciii]

On these grounds Nagel asserts that death is worse than unconsciousness because the latter ‘includes the possibility of experience’. [xciv] It is difficult to fully disentangle Nagel’s reasons for regarding death as an evil. One reason lies in the suggestion that the possibility of experience is an unconditional good and death in destroying this possibility is an evil - but what about the practice of anaesthesia? A second reason is that death shatters the subjective view of the world and creates a disharmony - but does the fact that maturity shatters the illusions of childhood imply that maturity is evil? A third reason - though hardly distinct - is that ‘for each person his death is awful’ but this seeks to prove the evil of death from the desire for immortality:

“ ... given the simple choice between living for another week and dying in five minutes I would always choose to live for another week; and by a version of mathematical induction I conclude that I would be glad to live for ever.” [xcv]

To seek to prove from the existence of desire, the goodness of that which is desired seems fatuous. Is my lack of unlimited wealth an evil? Surely a more subtle analysis is required.

Toward the end of this essay Nagel does acknowledge that:

”... human death itself is a given which like the fact that hawks eat mice, it makes no sense to deplore.” [xcvi]

But this is dismissed as it offers no consolation to one about to die. Nagel concludes his essay on a note of abject defeat:

“When we acknowledge our containment in the world, it becomes clear that we are incapable of living in the full light of that acknowledgement.” [xcvii]

Certainly, if this essay has been a walk around ‘Mount Nagel,’ the most charitable thing to be said is that the mountain has been covered in mist.

Nagel: Mortal Questions.

Nagel’s treatment of the proposition ‘Death is an evil’ in Mortal Questions is not dissimilar from the earlier discussion in The View from Nowhere; though more rigorous and focused, it is none the less equally unsatisfying.[xcviii] He first considers why death is an evil, then turns to address some of the logical problems associated with his suggested solution, before finally dealing with the problem of whether it is meaningless to speak of death being evil in view of its biological inevitability.

In order to simplify the problem when discussing ‘Death is an evil’ Nagel only considers the individual’s attitude to his own death, not the suffering it may cause to others. He does not believe in any after-death existence so the evil of death must be accounted for, not in terms of its positive features, but in terms of what it deprives us of i.e. life. Nagel draws further support for suggesting that the core meaning of ‘Death is an evil’ is to be found not through a contemplation of death but through an analysis of life, by observing:

* that in judging that ‘life is a good’, it is not the state of life that makes it a good but what that state 'contains'. Equally[xcix] the assertion that ‘death is an evil’ is not because of any properties of the state of death but because of the absence of goods, and the absence of life which is their precondition.

* that life, ‘like most goods’, follows the principle that ‘more is better’.[c] In contrast to suggest that, of death, ‘more is worse’ [ci] is meaningless.

The first of these observations implies that ‘good’ does not attach to ‘mere organic survival’ as:

“... almost everyone would be indifferent (other things being equal) between immediate death and immediate coma followed by death twenty years later without reawakening.” [cii]

So life is a good, Nagel argues, not because of life, qua life, but ‘life as possibility’ to permit the experiencing of the ‘goods’[ciii] of life. The ‘good of life’ is not, however, to be identified with the possession of the ‘goods of life’ because these ‘goods of life’- though normally thought of as conferring benefits - may cause misery, thus raising the question as to whether there may be a net balance of evil in a life and thereby threatening the universality of the proposition ‘Life is a good’. Nagel resolves this problem by arguing that experience itself ‘is emphatically positive’ and thus, though undergoing terrible experiences, it is still ‘a good’ to be alive.

Nagel’s conclusion at this point is that ‘Death is an evil’ because of ‘the desirability of what it removes’ [civ] which is not life, as such, but the possibility of experience. Nagel then turns to examine some problems associated with his proposed solution. He identifies three such problems:

(i) Since death (as distinct from dying) is not unpleasant, how can it be accounted as bad for someone?

(ii) There is no subject to whom the misfortune can be assigned.

(iii) There is an unaccounted for, asymmetry[cv] between attitudes to posthumous and prenatal existence.

Nagel’s account of death has problems of such a magnitude that to inquire into the difficulties posed by the asymmetry between attitudes to pre-birth and to post-death is not only an indulgence but a presumption; they will not be discussed further. Nagel attempts to resolve the other difficulties by insisting that the judgement of good or evil must not be restricted to immediate circumstances but must be judged relationally, i.e. in relation to the history and alternative possible developments of the individual concerned. Nagel takes the example of an intelligent and successful person who suffered severe brain damage in an accident; nonetheless he is now happy in his present, but simple, circumstances; can we say that the accident was for him an evil, and if so why? Nagel’s solution is that the accident was an evil because it deprived him of what he could be, it is an evil in relation to his possible life. Nagel concludes that we are justified in calling death an evil in relation to the possibilities which might have been had death not existed; furthermore, the evil does not need a ‘current owner’ to be so described.

Nagel finally turns to consider the objection that it is meaningless to speak of death being evil in view of its biological inevitability:

“Blindness or near-blindness is not a misfortune for the mole nor would it be for man, if that were the natural condition of the human race.” [cvi]

Nagel attempt to counter the objection by saying :

“A man’s sense of his own experience ... does not embody this idea of a natural limit. His existence defines for him an essentially open ended possible future ... Viewed in this way, death, no matter how inevitable, is an abrupt cancellation of indefinitely extensive possible goods.” [cvii]

To pursue Nagel’s analogy, imagine an Adrian Mole born with a talent far outstripping his fellow moles. He takes to writing and in one of his novels, by a huge leap of the imagination, he succeeds in conveying the idea of farsightedness. This idea fascinates his fellow moles and they deeply desire such a gift. Is there lack of farsightedness to them now a misfortune and their near-blindness now an evil simply because they now desire it?

The banality of Nagel’s reasoning is also made clear by imaging that one is sitting at a sumptuous banquet, gorging on the finest of foods which are presented course upon course in seemingly never-ending variety, must one conclude that the fact that a banquet has an end, is evil?

Summary of Nagel’s Arguments

There are two limbs to Nagel’s argument that ‘Death is an evil’ :

(i) That in establishing ‘Life is a good’, he determines ‘Death is an evil’.

This is an error that Nagel shares with Foot. That it is an error can be seen be noting that one can simultaneously assert that ‘Life is a good’ and that ‘Death is not an evil’ without breaching any rule of logic. Unlike Foot, Nagel at least recognises this and offers the principle that, of a ‘good’, one can say ‘more is better’ which - if true - would be logically sufficient, in conjunction with ‘Life is a good’, to establish ‘Death is an evil’.

But the principle is not true. Pleasure is indeed a good, but one can have a surfeit of pleasure which quickly turns to pain.[cviii] Thus, at best Nagel establishes that ‘Life is a good’ unconditionally; but to do this he has had to assert that all experience - even that of the terminally ill man wracked by pain - is a good.

(ii) That because death offends our deepest desires it must be an evil.

The barrenness of this argument can be readily seen by slightly transposing it. Consider a youth who wanted to be the greatest philosopher who ever lived. Middle age brings him up against the hard realisation that this is not to be. He has two options. He can try to accept the reality of the situation and acknowledge that his talents are quite limited, or he can insist that his not being acknowledged as the greatest philosopher the world has ever known is an evil. The second path is hardly to be commended.[cix]

Mothersill: Death [cx]

Mary Mothersill’s argument is a three-pronged attack on Nagel’s analysis of the evil of death.

Mothersill first considers Nagel’s assertion that ‘death is a misfortune for the one who dies’ and seeks to disentangle its sense. In furtherance of this she attempts to use the tools of formal logic. Because Nagel’s formulation of his argument was, at best, tentative and not expressed with a precision sufficient to even contemplate it’s being formalised, Mothersill’s response is inappropriate and unhelpful.

Mothersill then turns to Nagel’s question “Is it a bad thing to die?” Nagel had radically distinguished between the propositions “I am going to die” and “They are going to die” and concluded that they belonged to irreconcilable perspectives: from the objective perspective we could readily accept the death of another, judging even that it was a good thing; from the subjective viewpoint, however, our own death is unacceptable, an unparalleled disaster. Because these viewpoints are so disparate, Mothersill concludes that, not only can there be no general answer to Nagel’s question, but “... there can be no general question: ’whether it is a bad thing to die.’ ” To Mothersill, the very posing of the question is but an interesting psychological aberration.[cxi]

However, she does accept that some individuals, through confronting their own death, transcend this ‘conjunction of callousness and self-pity ’[cxii] and are able to extend deep compassion to others who are dying. They have already faced their own death and, having recognised the truth of Donne’s “Ask not for whom the bell tolls, it tolls for thee”, can speak from within that wisdom.

Mothersill’s redirection of the discussion is useful as it suggests that the question “Is it a bad thing to die?”, rather than being posed in the expectation of a factual answer, is really an injunction to come to terms with one’s own mortality.[cxiii]

Mothersill’s third point of criticism relates to the inference that Nagel draws from the existence of a ‘fear of death’, and this will be considered in the next section. She concludes her article by giving her own thoughts on whether ‘Death is an evil’: death is not subjectively inconceivable and the ability to face death with equanimity is a trait ‘useful to oneself and others;’ [cxiv] she allows that in certain circumstance ‘it may be a good thing to die’. [cxv]

Conclusions

Nagel’s argument that ‘Death is an evil’ reduces either to the assertion that experience is unconditionally a good (which is difficult, if not impossible, to sustain) or to the assertion that death is an evil because we have the desire for immortality. Spinoza, who also believed that the good is that which is desired, tempered this definition with the realisation that, in order to live a harmonious life, desires must be tempered to accord with reality. Considering for a moment, the equation:

‘the good’ º (df.) ‘that which is desired’ [cxvi]

Spinoza does not consider that his insights apply to the left hand side of the equation - which would have the result that he was offering intellectual arguments for a redefinition of ‘the good’ to coincide with ‘that which is desired and is attainable.”; [cxvii] rather his insights are directed at the right hand side of the equation and are in the nature firstly, of a recognition that desires are of their nature limitless and unbounded and (because of this) secondly, of an injunction that they must, for our own sakes, be restrained at least to the extent that the impossible is not desired. The achievement of whatever freedom there is lies in a fettering of desire because desires are the creators of the ‘human bondage’ of which Spinoza speaks. It is important to recognise that Spinoza offers a programme to be lived and not just a rational argument to be apprehended.

Conclusion _{9 - 5} : Arguments, such as Nagel’s, that ‘Death is an evil’ because we desire immortality gives precedence to desire over reality; as such they are hardly to be commended on rational grounds.

Subsection 5: The Fear of Death

The concepts of 'fear' and 'death' are connected in traditional philosophical discourse in two ways:

(i) in the assertion that the fear of death is irrational.

(ii) in the assertion that the very existence of the fear of death implies that ‘Death is an evil’

The fear of death is irrational

The argument that the fear of death is irrational is exemplified in the following excerpts from classical literature:

Epicurus:	“That most frightful of evils death is nothing to us, seeing that when we exist death is not present, and when death is present we do not exist.” [cxviii]
Lucretius:	“So, if we are to experience sadness and pain in the future our true selves must exist at that time for such thing to befall us. Death, however, rules this quite out and prevents there from being ever the person again who can feel this complex of suffering. Therefore we know for sure that death can bring us no terrors, ...” [cxix]
Bacon:	“Men fear death, as children fear to go in the dark ... [but] there is no passion in the mind of man, so weak, but it mates, and masters the fear of death; and therefore death is no such terrible enemy, ...” [cxx]

Mothersill considers the argument of Epicurus - and other similar arguments - to be nothing other than a rhetorical device to console the minds of those who, not only anxious about death, were also overtroubled by the fear of an afterlife. She suggests that to regard it as logical argument - as Nagel did - is a mistake because: “It is a textbook example of the Fallacy of Equivocation.” [cxxi]

It is certainly true that some fears can be dispelled by the giving of information; for example, in explaining to one that a blemish which he fears is cancerous, is merely benign, his immediate fear of dying of cancer is dissipated. However, this dispelling of fear by information or argument is as immediate as is a lighted torch in expelling the dark; it does not occur by act of will. Consequently the argument that, in face of certain information, a fear is ‘irrational’ is as beside the point as is the argument to a hungry teenager that they cannot be hungry because they have just eaten: the child is hungry and his hunger will not be fed by information. The conclusion to be drawn from the continuance of the fear is that the information or argument, is not apposite to the fear, not that the fear is somehow ‘irrational’. The arguments on the irrationality of fear presuppose that fear can be removed by act of will and that a rational argument to the effect that the fear is inappropriate is the sole precondition for this act of will - but fear is not removable by act of will.

The arguments that the fear of death is irrational, face a much more powerful challenge from a distinction made by the Existentialists, than from formal logical analysis. Heidegger’s distinction between ‘anxiety’ [cxxii] and ‘fear’ - anxiety connoting a fear without a specific object - allows the ‘fear of death’ to be seen as but the mask for the anxiety or ontological insecurity which is the lot of all humans in the face of existence. If ‘fear of death’ is really ‘anxiety in the face of being’ then appeals to rationality and proportionality are obviously vacuous.

Conclusion _{9 - 6} : Arguments that the fear of death is ‘irrational’ presume that, for a fear to exist, it must have rational grounds and that, once the ‘irrationality’ of the grounds are demonstrated, the fear can be vanquished by an act of will. Fear is not removable by an act of will and the distinction made by the Existentialists between ‘anxiety’ and ‘fear’ show that questions of rationality are inappropriate in discussing the fear of death.

The existence of the fear of death implies that ‘Death is an evil’

The principal underlying this implication is that

‘It is a sufficient condition for something to be an evil to X, that it be feared by X.’ [cxxiii]

Thus, for example, punishment is an evil to the criminal because it is feared by him. Can we say that all events which are feared are evil? Getting old (disassociated from all ideas of death) is feared, it is an evil?[cxxiv] From such a perspective the rites of passage of many societies would be judged to be evil because they are greatly feared by those who must undergo them; the fact that, in retrospect, these rites are considered to have been beneficial appears to be of no relevance to the conclusion.[cxxv]

To equate evil with that which is presently feared removes the possibility of finding a secure stable foundation on which to build ethical values; furthermore, in recognising that fear can be a chimera which quickly vanishes of its own accord, and that that which is feared can - once it has occurred - be seen to have been of benefit,[cxxvi] it is clear that fear is not a reliable indicator of the presence of evil. To overcome the problem of fear without harm, it is possible to amend the principle:

‘It is a sufficient condition for something to be an evil to X, that it is feared by X and that it may probably harm X’.

Though such a usage of the terms ‘good’ and ‘evil’, where their meaning is strictly circumscribed by narrow self interest, is counter to traditional ethical understanding, it is certainly logically possible. Indeed, Spinoza used the terms in just such a sense, Lloyd comments:

“Self-preservation becomes for Spinoza the foundation and end of virtue. The continuation of existence ... becomes ... the good itself. The dichotomy between self-seeking and altruism here falls away. Self-seeking - traditionally opposed to rational virtue - now becomes its foundation.” [cxxvii]

However, to Spinoza, the judging of ‘good’ and ‘evil’ in terms of narrow self interest was a provisional position. The practice of philosophy, he suggested, leads one to conceive of the interconnectedness of all, and to understand that the only tenable perspective from which to act in seeking a harmonious life was not that of a narrow self interest but that of the universe sub specie aeternitatis. Thus, in accepting ‘self interest’ as the basis for ethics, one was lead away from construing this self interest in a narrow individualistic fashion - simply because to act in such a fashion was destructive of one’s inner harmony - and towards a more all embracing interpretation.[cxxviii] Using Nagel’s terminology, Spinoza’s argument is that the subjective perspective can only find its full expression within the objective framework. Attempts to insist on the primacy of the subjective perspective - being nothing but presumption doomed to failure - are ultimately destructive of self interest.

Conclusion _{9 - 7} : Arguments which seek to establish deduce the evil of some particular occurrence from the fact that it is feared, trivialise the concept of evil.

Section 2: Manifestations of the denial of death.

In Section 1 it was argued that the proposition ‘Death is an evil’ is, if unqualified, untrue; the goal of this Section is to establish the same conclusion though working this time from a psychological, rather than philosophical, direction. It is argued that to assert ‘Death is an evil’ is to be involved in -what Ernest Becker terms - the ‘denial of death’ and that such a denial is no less injurious to the human spirit than the denial of sexuality. This implies that there is not only a philosophical necessity, but a psychological necessity, to reject the proposition ‘Death is an evil’.

Medical attitudes to death are of particular relevance in the making of ‘end-of-life’ decisions, indeed they are often determinative of such decisions. Because physicians are more intimately connected with matters of life and death than members of any other profession, it seems strange to suggest that death denial might be prevalent in clinical medicine; yet Elisabeth Kübler-Ross and Daniel Callahan[cxxix] have persuasively argued that the ‘denial of death’ is not only prevalent but a well nigh universal phenomenon of clinical medicine. J. D. Morgan who is an academic and medical doctor, suggests as a possible reason, the hubris often found amongst medical clinicians which, he argues, is not unconnected with certain religious attitudes:

“Medicine and religion have much in common. Both address the fears of humanity and the meaning of events surrounding life and death. Religion has responded to these needs by constructing theologies; medicine, by providing a scientific theory of health and sickness. Labelling a biological state as a disease is akin to declaring that there is an evil that ought to be eliminated. The rescue fantasy, that one can ‘snatch the patient away from the jaws of death’, is an important part of medical culture and the popular folklore about physicians. As Becker has pointed out, all power is ultimately viewed as power over death; thus the conceptions of the physician's powers flow from the view that medicine is a priesthood with power over evil. Cardiopulmonary resuscitation is an example of the rescue fantasy becoming a reality.” [cxxx]

It is clear that the medical attitude to death as portrayed by Morgan finds its intellectual underpinning in the proposition ‘Death is an evil’, precisely the same proposition that, as we have seen,[cxxxi] underlies the Christian attitude to death. Because of this coincidence, the medical attitude appears to have a familiarity and naturalness which successfully masks the poverty of the intellectual foundations on which it rests. Morgan also suggests that the contemporary view of death in the West is that every death is contingent, a matter of chance, and that, in principle, there is no reason why any particular injury or disease cannot be overcome. An extreme example of such an attitude is found in the World Health Organisation's refusal to admit ‘death by old age’ as a category in its medical statistical analysis into the causes of death.[cxxxii] These attitudes are not confined to a medical elite but are common throughout society; Ernest Becker - the most influential writer on this subject[cxxxiii] - has called this cluster of attitudes[cxxxiv] the ‘denial of death’.

To simplify presentation of theories concerning the denial of death, I will first consider the ‘denial of death’ as a phenomenon found in society as a whole [in Subsection 1]; and then the denial of death as manifested in clinical medicine [in Subsection 2]. The concept of ‘a good death’ will arise naturally from attempts to incorporate the inevitability of death into clinical medicine.

Subsection 1: What is the ‘denial of death’?

Freud recognised that any explanation of the human condition must take account of both sexuality and death as these are the very poles around which the constellation of life revolves. As a consequence of Freud’s work it has now become a commonplace to talk of the repression, or denial, of sexuality. Furthermore it is possible to examine both the manifestation of a denial of sexuality - as in the refusal to acknowledge female sexual desire in Victorian society - and the consequences of such denial - as in the inappropriate ‘resolution’ of some social problems.[cxxxv] However, Freud’s insights into the importance of death have not received the same attention, particularly from lay audiences.

Jung, even more so than Freud, recognised the most profound consideration that must be paid to the ‘irresistible approach of King Death’:

'As a physician I am convinced that it is hygienic to discover in death a goal towards which one can strive; and that the shrinking away from it is something unhealthy and abnormal which robs the second part of life of its purpose.” [cxxxvi]

Anthony Clare goes even further and suggests that death, rather than sex, is the fundamental concept of modern psychology:

"Sex and death are seen in many cultures as rites of passage of equal importance; psychology is conventionally associated in the public mind with an openness, even a preoccupation, concerning sex whereas in truth the whole of modern psychology could be said to arise from thoughts about death." [cxxxvii] .

Clare notes that this is the reverse of current lay perceptions where not only is ‘sex’ given a preeminent position as an explanatory concept for analysing modern society but discussion of ‘death’ is considered to be either an embarrassment or morbidly unhealthy.[cxxxviii] Such attitudes are not universal; other cultures (such as Buddhist and monastic Christian) hold the belief that it is through the perpetual awareness of death - not death in some abstract sense but our own individual death - that life finds its true value; such cultures believe that such an awareness fosters a respect for the fragility of life and its transience, and turns the focus of life towards living the present moment to the full.

If, as is suggested, the role of death as an explicatory concept is unacknowledged in our culture, then we are no less involved in a denial of death than was Victorian society in a denial of sexuality.[cxxxix] Recognising that the Victorian denial of sexuality led to the inappropriate treatment of certain problems, we may well ask what are the inappropriate patterns of behaviour which now occur because of our ‘denial of death’; the area of ‘treatment withdrawal resulting in death’ is an obvious candidate for exploration. In attempting to answer this question the views of Becker and Kübler-Ross are of considerable assistance; however, because both Becker and Kübler-Ross explain the denial of death by situating it within a wider theoretical framework, it is convenient to consider their views separately.

Becker and the denial of death

Ernest Becker argues that death is a symbol for the entire spectrum of adult anxiety and that our unwillingness to fully accept our mortality is the fundamental problem of human psychology. [cxl] Becker, in the preface to the work for which he is most famous, wrote:

“ ... the idea of death, the fear of it, haunts the human animal like nothing else; it is a mainspring of human activity - activity designed to largely avoid the fatality of death, to overcome it by denying in some way that it is the final destiny for man.” [cxli]

Becker does not mean by this that we are directly motivated by the fear of death and that in consequence we consciously adopt stratagems to avoid facing this fear; quite the contrary, he believes that the fear of death is so shattering to human pretensions that it cannot be acknowledged; his argument is that the postulation of such an unacknowledged fear makes many human actions wonderfully clear. This is precisely the approach adopted by Freud who did not suggest that the Victorians wilfully denied the sexual content of certain experiences, but rather that the hypothesis of sexual repression was a powerful unifying explanatory mechanism for aspects of Victorian society which were otherwise left without adequate explanation. It is Becker’s thesis that awareness of death, the anxiety that this provokes and the strategies that people devise to deal with the anxiety are at the very core of why we act the way we do.[cxlii]

Becker sees the fear of death as being closely connected to man’s unwillingness to accept his ‘creatureliness’ :

“... his abject finitude, his physicalness, the likely unreality of his hopes and dreams.” [cxliii]

He sees the beginnings of this in the child’s awareness that it cannot have complete control over its body. Liechty describes the child’s situation:

“In the course of the oedipal transition, the child comes to see the body as an object to be controlled in the interests of symbolic modes of self-esteem maintenance. ... But [the body] also represents the major and primary threat to the child’s sense of ego mastery. ... [leading to] The self scolding of a child for temporarily losing control of the body ... The child is horrified by its own animal condition and in scolding this animal part ... regains the sense that the symbolic self, the ‘true me’, will have mastery over the animal.” [cxliv]

Becker - in portraying the mental torture of man unable to accept the ‘grotesque contradiction’ between his view of himself as a spiritual being and the hard fact of his animality - humorously quotes a poem by Swift about a young man and his beloved who was named Caelia:

“Nor wonder how I lost my Wits;

Oh! Caelia, Caelia, Caelia shits!” [cxlv]

To Becker, the refusal of man to accept his basic animal condition - and the mortality that is the necessary corollary of such an acceptance - is, rather than sexuality, the primary repression. The death denial - like Victorian sexual repression - is an ineffective strategy in that the unacknowledged problem does not disappear but reappears in another guise (as has been well documented in cases of repression of sexuality). This immediately raises the question: What are the manifestations of ‘denial of death’ ?

The most concrete manifestation of the denial of death is either ‘frenetic activity’ [cxlvi]- actually a physical flight from death - or the insistence that one be ‘in control’’ of one’s life. Becker also suggests that the answer lies in - what he terms - ‘causa sui projects’ : those strategies which man uses to deny his mortality by seeking an identification with something - such as nation, religion, work or children - which will permit a continuation of some replica of himself. Liechty calls these ‘immortality strategies’ [cxlvii] and suggested that Becker viewed ‘such immortality striving as the very source of human evil’ [cxlviii] although Liechty himself took a less extreme position. What then is to be done?

The most obvious response is to recognise that it is not death, but the denial of death, that is an evil.[cxlix] On a more personal level, Becker argues for the necessity for ‘self mourning’ and for resigning oneself to one’s creatureliness;[cl] Liechty - drawing on the work of Kübler-Ross - urges that one should ‘make awareness of death an ally in life’;[cli] he quotes Becker as stating:

“The incorporation of death into life enriches life; it enables individuals to extricate themselves from smothering trivialities, to live more purposefully and more authentically.” [clii]

This is a perspective which finds support from psychologists such as Stanislav Grof:

"Once people confront death and the impermanence of everything on an experiential level they frequently start seeing all of their present life strategies as being erroneous ... The experiential encounter with death often amounts to a true existential crisis that forces people to re-examine the meaning of their lives and the values they live by." [cliii]

Kübler-Ross and the denial of death

Elisabeth Kübler-Ross is widely known for her pioneering work with the dying. She attempted to give a direct voice[cliv] to the terminally ill, one which was not mediated through the medical profession. Her aim was to subvert the conventional wisdom as to the needs of the dying - which defined these needs solely in terms of medical treatment - and to discover, through countless interviews with the terminally ill, what they themselves saw as their requirements. She has urged through her teaching and writings over many years, that in the medical treatment of those who are terminally ill, their voice must be listened to and their interests must be centre stage and that the interests of the medical professionals - which exist despite their protestations of disinterest - must not be allowed to predominate.

Kübler-Ross’s writings[clv] can best be analysed as addressing two concerns:

(i) the meaning of ‘a good death’, and how to best help the individual dying patient achieve it;

(ii) current medical practices in relation to terminally ill patients and how these not only hinder, but often prevent a dying patient achieving ‘a good death’.

The ‘denial of death’ is central to both of these questions and it is the first of the four stages of the schema, used by Kübler-Ross, to describe the individual patient’s ability to cope with their impending death.[clvi] The stages, according to Kübler-Ross, are:

Denial	The patient considers that their impending death is unreal and impossible. Such a denial may be more apparent than real in that the patient may not deny their impending death to themselves but to those around them, such as family and carers, who need the denial in order to remain present;[clvii] the patient’s apparent denial being in reality a fear of being abandoned in the face of death. However, Kübler-Ross believes that at least partial denial is used by all patients at some stage where it may act as a useful - and hopefully temporary - buffer in dealing with that which is too threatening.[clviii] She considers attempts to ‘forcibly’ subvert such a denial as unjustifiable.
Anger	The patient rages at their impending death and its perceived unfairness. Such an attitude is exemplified in Dylan Thomas’ poem written on the death of his father: "Rage, rage at the dying of the light, Go not gently into that good night."
Bargaining	The patient accepts that they will die but attempts to postpone it until some project - such as a family wedding, birth of a child or piece of work - is completed.[clix]
Acceptance	Some patients consider their impending death as a defeat, a battle lost. For them the best that can be hoped for is acceptance, in its negative sense, as resignation. However, others can see death, not an alien intruder, but as part of life’s natural cycle and they can achieve a positive acceptance. It is, however, a mistake to assume such a positive acceptance to be a happy stage, as it is almost devoid of emotion and feeling.[clx]

The focus of Kübler-Ross’s writings is on how best to bring a dying patient to a full acceptance of their dying. She sees this as an essential constituent of what I have called ‘a good death’.[clxi] Kübler-Ross sees the medical attitude to death - based she argues on a denial of death - as one of the main obstacles to a patient who is dying in a hospital environment, achieving ‘a good death’. We next consider Kübler-Ross’s views on death and its supposed evil.

Kübler-Ross: Is death to be considered an evil?

Kübler-Ross begins ‘Death - The Final Stage of Growth’ by saying:

“Death is a subject that is evaded, ignored, and denied by our youth-worshipping, progress-oriented society. It is almost as if we have taken on death as just another disease to be conquered. ... Death is as much a part of human existence, of human growth and development, as being born. ... Death is not an enemy to be conquered or a prison to be escaped. It is an integral part of our lives[clxii] that gives meaning to human existence. ... Whatever the things that would make your life more personally meaningful before you die - do them now, because your are going to die.” [clxiii]

Death, she argues, has in our modern society become a dreaded and unspeakable issue to be avoided by every means possible; all the more so because - despite our technological advances - it reminds us of our human vulnerability. This is especially so for those who put a high value on being ‘in control’ of their lives and who are deeply offended by the thought that they, too, are subject to the forces of death[clxiv] but who, if they can no longer deny death, attempt to master it.[clxv]

To Kübler-Ross, the denial of death is pervasive in modern Western society as is the view that death is an evil. It has been argued earlier[clxvi] that the assertion that death was an evil logically implied a denial of death. Kübler-Ross argues[clxvii] the converse: that our denial of death, i.e. the belief in the contingency of our own death, means that in our unconscious mind we believe that we can only be killed - our dying of natural causes or old age being inconceivable to us - so that we associate death with a bad act and thus, an evil. Kübler-Ross argues that death - far from being an evil - is a positive good; speaking of the bereaved, she says that most of them have found that the year following the death of a loved one has been an opportunity for growth; of her own life, she says:

“... these experiences with the reality of death have enriched my life more than any other experiences I have had. Facing death means facing the ultimate question of the meaning of life.” [clxviii]

To Kübler-Ross, death is a highly creative force from which the highest spiritual values of life can originate.[clxix] It does not have to be a catastrophic destructive thing, indeed it can be viewed as one of the most constructive, positive and creative elements of life.

It is interesting to compare the insights on death and dying of a practitioner - such as Kübler-Ross - with some of her contemporaries who approach similar questions from a more philosophical direction: for example, it is quite astounding to see how closely her views correspond with those of the existentialists;[clxx] the following passage, for example, could be a direct quotation from either Heidegger or Jaspers:

“Death is the key to the door of life. ... It is the denial of death that is partially responsible for people living empty, purposeless lives; ... For only when we understand the real meaning of death to human existence will we have the courage to become what we are destined to be. ... You must give up ‘their’ approval whoever they are, and look to yourself for evaluation of success and failure, in terms of your own level of aspiration that is consistent with your values. Nothing is simpler and nothing is more difficult.” [clxxi]

It is no less astounding to see how little these insights have in common with Nagel’s arguments given earlier.[clxxii]

Conclusion _{9 - 8} : The proposition ‘Death is an evil’ considered simply as a proposition of psychology, i.e. as a maxim for living, should be rejected; it is the denial of death, rather than death, that is an evil.

Subsection 2: Medical manifestations of the ‘denial of death’

We will first consider Kübler-Ross’s pioneering contribution to this debate and then the contributions of more recent commentators.

Kübler-Ross

Although, when first attempting to commence her project, Kübler-Ross had considerable support from hospital administrators, she faced considerable opposition from the medical staff who:

“ ... reacted with great resistance, at times overt hostility, to our seminar.” [clxxiii]

In contrast, her patients responded with enthusiasm. She found doctors to be very defensive when discussing death[clxxiv] and unwilling to consent to their patients being interviewed; these refusals were ostensibly to protect their patients but, as Kübler-Ross comments:

“... doctors who need denial themselves will find it in their patients ...”.[clxxv]

She found that:

“Approximately nine out of ten physicians reacted with discomfort, annoyance, or overt or covert hostility when approached for their permission to talk to their patients.” [clxxvi]

Early in her work she observed “... the desperate need of the hospital staff to deny the existence of terminally ill patients on their ward.” [clxxvii] Some of the nurses referred to their colleagues - who had attended Kübler-Ross’s seminars - as 'vultures';[clxxviii] only 8% of nurses felt that dying patients needed their care;[clxxix] most responded to their dying patients “... with a sense of anger, as if these patients committed an angry act against them by dying in their presence.” [clxxx]

The patients, in contrast:

“... responded favourably and overwhelmingly positively to our visits. Less than 2% of questioned patients flatly refused to attend the seminar, ...” [clxxxi]

Kübler-Ross’s does not present a systematic theory as to the reasons for the reactions of the medical carers which have just been described, though she does consider that death denial on the part of the carers, plays a central role. This denial of death is best considered in terms of its manifestations, the primary one being an overestimation[clxxxii] of the power of clinical medicine so that death is considered to be a contingent, rather than a necessary, eventuality. A corollary of this attitude is that when death does occur, it is considered to be a failure either on the part of the medical carers, or of medicine itself. Such a framework explains the ‘rescue fantasy’ [clxxxiii]and the frantic medical activity[clxxxiv] which often occurs when death is seen to come close.[clxxxv] Kübler-Ross asks:

“Is this approach our own way to cope with and repress the anxieties that a terminally or critically ill patient evokes in us? ... [because they] remind us once more of our lack of omnipotence, our own limitations and fallibility and, last but not least perhaps, our own mortality?” [clxxxvi]

Such a framework also explains the responses of nurses when faced with an unavoidable death:

“They sensed their own impotence in the face of death and when they became aware of the doctor’s similar feelings it angered them out of proportion.” [clxxxvii]

It also explains the avoidance and neglect of such patients by the medical staff under the excuse that ‘nothing can be done’. This belief that ‘nothing can be done’ to help a dying patient is reinforced by the ideology that underlies modern medicine - i.e. that of a discipline defined by its ‘curative’ rather than its ‘caring’ role.[clxxxviii] The regarding of medicine as a curative discipline is intimately connected with its being identified as a scientific discipline. Because science is regarded as the locus of power and prestige in modern society; the regarding of clinical medicine as primarily a scientific discipline actively encourages the overestimation of the power of physicians and also exacerbates those clinical attitudes to patients which have just been discussed because the patient, who is seen by the carer ‘as a person’, appears, to the scientist, ‘as an object’.[clxxxix] Kübler-Ross described such attitudes:

“Slowly but surely he is beginning to be treated like a thing. He is no longer a person. Decisions are made often without taking his opinion. If he tries to rebel he will be sedated.” [cxc]

“The dying patient is not yet seen as a person and thus cannot be communicated with as such.” [cxci]

Conclusion _{9 - 9} : In clinical medicine, ‘death denial’ is manifested in:

* a refusal to fully acknowledge the inevitability of death..

* inappropriate medical activity in the face of death.

* the belief that when death occurs it is due to a failure of medicine.

* the belief that ‘nothing can be done’ to help a dying patient.

* a refusal to talk to patients about their dying.

Kübler-Ross’s recommendations

Because Kübler-Ross regards the denial of death as the central problem connected with the medical management of death, it is no surprise that she sees the solution as lying in more education and better communication: education in death and dying[cxcii] for the medical carers and better communication especially between doctors and their patients:

“The fact that we don’t use denial, that we are willing to use the words death and dying, is perhaps the most welcomed communication for many of our patients.” [cxciii]

“If this book serves no other purpose but to sensitise ... to the implicit communications of dying patients, then it has fulfilled its task.” [cxciv]

She speaks of one of her patients who:

“ ... was sad that he was forced to struggle for life when he was ready to prepare himself to die. It is this discrepancy between the patient’s wish and readiness and the expectation of those in his environment which causes the greatest grief and turmoil in our patients.” [cxcv]

Communication is the only solution in such cases, and the obligation to communicate with patients is - as is argued in Chapter 10 - nothing other than a primary constituent of the obligation to treat the patient as a person.

Conclusion _{9 - 10} : Kübler-Ross’s principle recommendations involve:

(i) the necessity of combating ‘death denial’ - which she regards as endemic amongst medical professionals, and

(ii) the primacy of the obligation on medical professionals, to communicate with their patients.

More recent commentators

Kübler-Ross’s main work was done in the 1970’s and the themes that she identified have in the intervening years been explored by many others of whom Daniel Callahan is particularly notable for the incisiveness of his analysis. The themes identified by Kübler-Ross were:

* the pervasiveness of death denial amongst medical carers, and

* the ambiguous nature of the role of medicine: Is the role of medicine primarily a caring one, or is it essentially curative, life preserving, and ‘scientific’?

Though recent developments, commentaries and studies in these areas are interconnected, it is convenient to consider both them, and the work of Callahan, separately.

The pervasiveness of death denial amongst medical carers

The recommendations of a recent report issued by the US Institute of Medicine[cxcvi] give few grounds for believing that there have been radical changes in recent years in either medical attitudes to death or in the aggressive medical interventions which are a consequence of these attitudes. The report notes that the education and training of physicians “... fails to provide them with the knowledge, skills, and attitudes required to care well for the dying patient;” [cxcvii] and does not equip them to “... understand and manage their own emotional reactions to death and dying.” [cxcviii] The recommendation that:

“Textbooks ... need revision to reflect the reality that people die ...” [cxcix]

is startling in its implications and makes abundantly clear the magnitude of the task required. These deficiencies in medical education are further highlighted by a recent statistic that, of 126 medical schools in the US, only 5 have an obligatory course on death and dying.[cc]

The Institute of Medicine’s report believes that the denial of death is not confined to medical professionals but is widespread throughout society:

“ ... this nation has not yet discovered how to talk realistically about the end of life, nor has it learned to value the period of dying ...” [cci]

The continued prevalence of death denial in medicine is conceded in a recent research project under the auspices of ‘The Hastings Center’; this project proceeded on the premise that:

“... modern medicine is, at its core, ambivalent and even schizoid on the problem of death, uncertain whether to accept death as a necessary part of life and medicine, or to see death always as the enemy, to be vanquished.” [ccii]

However, the denial of death is not solely an American phenomenon: a recent BMA report notes:

“...the unrealistic expectations in society about the extent to which it is possible to postpone death such that death is sometimes seen not as a natural, inevitable event but as a failure of medicine. Societal perceptions need to shift away from the view that life can be prolonged indefinitely back towards a realistic acceptance of the inevitability of death.” [cciii]

Conclusion _{9 - 11} : Recent reports from the US Institute of Medicine (1997) and the BMA (1999) indicate that ‘death denial’ is a widespread phenomenon of modern life; the US report found considerable evidence of it’s prevalence in clinical medicine.

The role of medicine: to cure or to care?

The Institute of Medicine’s report concluded that there are very serious problems in ‘end-of-life’ medical care and identified two areas of particular concern:

(i) the management of pain (and, in particular, the ungrounded fears of opiate addiction), and

(ii) the widespread belief that dying people are patients for whom ‘nothing can be done’. [cciv]

The report is scathing in its criticism of clinical practice in relation to pain management:

“Indeed, in this committee’s view, if physician and hospital performance in infection control were as poor as it is, for example, in pain management, the ensuing national outcry would create an immediate demand for responses ...” [ccv]

It is no less forgiving in its criticism of over-intrusive medical intervention:

* “ ... too many people suffer needlessly at the end of life both from errors of omission - when care givers fail to provide palliative and supportive care known to be effective - and from errors of commission - when caregivers do what is known to be ineffective and even harmful.” [ccvi]

* “Medical culture still tolerates and even rewards the misapplication of life-sustaining technologies while slighting the prevention and relief of suffering.” [ccvii]

* “... the aggressive use of ineffectual and intrusive interventions may prolong and disfigure the period of dying.” [ccviii]

This last conclusion is eloquently supported by a research study (which the report quotes) showing that of a group of patients reviewed, nearly half received mechanical ventilation during the last 3 days of life.[ccix]

Conclusion _{9 - 12} : The Institute of Medicine’s 1997 report clearly shows that, of the alternative philosophies of medicine i.e. ‘curative’ or ‘caring’, it is the curative that, at least in the US, is in the ascendant.

Many writers on this subject have pointed out that medicine has its historical origins in ‘caring’ rather than ‘curing’ and that the latter that should always be to the fore. William Ruddick,[ccx] for example, quotes the Prayer of Maimonides ‘never to forget that the patient is a fellow creature in pain, not a mere vessel of disease.’[ccxi] Leo Alexander notes:

“The original concept of medicine and nursing was not based on any rational or feasible likelihood that they could actually cure and restore but rather on an essentially maternal or religious idea ... motivated by the compassion in alleviating suffering.” [ccxii]

Alexander has written on how the medical ideology which was prevalent in Germany in the 1930’s actively assisted the Nazi’s in their implementation of the so-called ‘euthanasia programmes’. This ideology was one where the ideals of compassionate caring were being supplanted by those of scientific medicine with its emphasis on cure and rehabilitation:

“However, with this increased efficiency based on scientific development went a subtle change in attitude. Physicians have become dangerously close to being mere technicians of rehabilitation.” [ccxiii]

He also saw this trend developing in the US.[ccxiv] This trend, he argues, results in those less likely to be rehabilitated:

“... being looked down upon with increasing definiteness as unwanted ballast. A certain amount of rather open contempt for those people who cannot be rehabilitated with present knowledge has developed. This is probably due to a good deal of unconscious hostility, because these people for whom there seem to be no effective remedies have become a threat to newly acquired delusions of omnipotence.” [ccxv]

Alexander insists that the so called ‘euthanasia programmes’ of Nazi Germany were not solely the responsibility of the Nazi state[ccxvi] but to a considerable extent predated Nazism.[ccxvii] Furthermore, they drew considerable support from the medical ideology then becoming prevalent in Germany, an ideology which defined medicine in terms of its curative role. This is an invaluable insight because, without it, it has been all too easy to assign full responsibility for such programmes to Nazism,[ccxviii] thus permitting the comforting - but unjustifiable - belief that, in the absence of Nazism, such practices could not recur. Alexander’s argument that there are pressures, independent of Nazism and implicit in certain medical ideologies, which tend to foster such practices suggest a re-examination of the reasons currently offered for the withdrawal of life-sustaining treatment particularly in the area of disability. Two recent examples from the medical literature are instructive:

* The criterion of ‘clinical advantage’ has been used in deciding whether or not to administer treatment. The Bland case interpreted this criterion to mean ‘recovery’. Andrews criticises this and comments:

“This has serious implications for many other disabled people. ... There is, therefore, no clinical advantage in much of the rehabilitation for patients with disabling disorders since there is no recovery.” [ccxix]

* Gillon is scathing of the efforts of those, such as Andrews’s, who classify as successes those patients who:

“ ... recovered sufficient consciousness to smile at cartoons, to show pleasure when his wife was present, and to show distress when she was absent.” [ccxx]

He argues that even if funds were unlimited it is not incontestable that such treatment should continue; but he continues ‘resources are severely limited’.[ccxxi] Such attitudes to disability are not wholly removed from those portrayed by Alexander.

The issue of treatment withdrawal on the grounds of disability will be further considered in Chapter 11 in discussing the conceptual framework used in making ‘end-of-life’ decisions for Down Syndrome infants, and in Appendix E.

Conclusion _{9 - 13} : A medical ideology which defines the medicine’s role as being fundamentally curative and which minimises its caring role, tends to foster death denial.

Callahan [ccxxii]

Daniel Callahan’s book The Troubled Dream of Life is:

* firstly, a critique of current medical attitudes and practices in relation to death and dying,

* secondly, an analysis of the beliefs which, either explicitly or implicitly, underpin such attitudes,

* thirdly a way out of (what Callahan sees as) the present impasse.

I will consider these aspects separately.

Callahan: Current attitudes to death and dying

In describing death in a modern medical setting Callahan contrasts, what he calls, the ‘tame death’ of our forefathers - where death though perhaps no more welcome was more tolerable and familiar - with the ‘wild death’ of modern times.[ccxxiii] This ‘wild death’ is characterised by a ‘medical brinkmanship’ where, although there is a recognition that a person can be harmed by the overuse of medical technology, the intent is to go as close as is possible to this line;[ccxxiv] the presumption being that treatment must be given if it preserves life even if doing so enhances the likelihood that a later death will be worse than the one averted.[ccxxv]

Callahan suggests that in modern Western society, it is remarkably difficult to talk about death and its meaning.[ccxxvi] Discussions about dying quickly become debates about law, not about death itself. Whereas an earlier generation sought (by, for example, the use of funeral parlours) to put death out of sight; modern society - in its attempt to restrict discussion of death to issues of rights and choices - is guilty of an even greater evasion.[ccxxvii] He sees the concept of 'control' - in the sense of being ‘in control’ of one’s life - as being central to any discussion and interpretation of the role of death in modern society:

“Everyone will want some degree of control. ... My target has been the mistaken belief that a necessary condition of our self-worth is our control of our lives. ... Choice - and the control over life and death that is its necessary condition - has come to be understood as the final meaning of human existence: the capacity to make of ourselves what we want to be. ... To make our sense of wellbeing and dignity dependant on a capacity to control and manipulate our circumstances is already to have set ourselves up for a fall. ... It is precisely the brute force, the external and unavoidable nature of illness and death that makes them so intolerable.” [ccxxviii]

The euthanasia movement seeks to persuade us that we can die as we choose and in that they peddle an illusion.[ccxxix] Callaghan argues that to seek to come to terms with our own death through the medium of legal rights - so that having consulted a lawyer and armed with suitable advance directives we can then believe ourselves adequately prepared for death - is an act of the greatest folly.[ccxxx] Such attempts ensure that the inevitable loss of control experienced in dying is perceived as ‘an intolerable insult to a patient’s sense of dignity’;[ccxxxi] they are, ultimately, destructive of a peaceful death.

Callahan: The beliefs underlying current attitudes to death and dying

To Callahan, the great lesson taught us by death is that we cannot be totally ‘in control’; to presume so is an act of hubris - a setting of the stage for the inevitable nemesis. However, to come to terms with the medical and ethical issues associated with death it is necessary to leave the periphery and head straight to the heart of the matter - death. Callahan, speaking of Becker and Aries, says “Correctly and with profundity, they said that death itself is the issue.” [ccxxxii]

As a first step in the task of confronting death it is necessary to reassess our relationship to nature. The distinctions and differences between man and nature have been stressed both in religion (especially by Christianity with its doctrine of the soul) and in philosophy (especially by Cartesianism and Existentialism). This one-sidedness has fostered the modern belief that man is a self-created creature somehow outside of nature and exempt from its laws. To Callahan, man is ineluctably embedded in nature and subject to it laws; one such law is that all that lives, dies,

“To think that we can bend nature wholly to our will ... is nothing less than foolish. In the fact of human mortality, nature retains its own imperial independence.” [ccxxxiii]

A recognition of the mortality of man is crucial to any reassessment of the problems associated with death.[ccxxxiv] Such a proposition has the appearance of a vacuous truism yet so many of the practices of modern medicine are explicable only in terms of its denial:

“Medicine, I believe, has implicitly defined its central purpose as an all-out fight against death. ... It has declared war on death, ... [it] has come ... to look upon death as a correctable biological deficiency.” [ccxxxv]

Certainly the biological necessity of death is understood but the cause of every death is taken to be contingent because:

“ ... in principle and in medical theory there is no reason why any particular disease cannot be overcome.” [ccxxxvi]

The belief is, because the diseases which cause death can be cured one by one, that death itself can be dismantled (since death is caused by disease).[ccxxxvii] Medicine thus confuses its power to alter disease with its power to banish mortality.[ccxxxviii] Callahan notes the:

“... subtle, tacit distinction that runs through scientific medicine, that illness, and the diseases that cause it, can be distinguished from ageing, mortality and death. Death can only be brought back within medicine by a repudiation of the mythical line between illness and death.” [ccxxxix]

Attitudes such as Callahan depicts are exemplified by the refusal of the WHO to consider that old age could possibly be a cause of death.[ccxl] In a memorable phrase Callahan describes life and death as a ‘zero-sum game, the causes of death can only be moved around,’ [ccxli] to presume that they can be eliminated, is folly.

Callahan’s proposals

Callahan‘s main proposal is that the goals set by medicine for itself should not just relate to life, its enhancement and extension[ccxlii] but should, in a full acceptance of the inevitability of death, also recognise that the achievement of a ‘peaceful death’ is an objective worthy of its efforts:

“The goal of a peaceful death should be as much a part of medicine as that of the promotion of good health. That means that medicine must abandon the modern cultic myth that in the cure of disease lies the cure of death.” [ccxliii]

This aspect of Callahan’s analysis will be considered in the Section 3 which deals with ‘a good death’; two other aspects - his treatment of the question ‘Death is an evil’, and his discussion on suffering and loss of dignity - will be discussed here; the latter aspect is best considered in terms of the distinction between ‘being’ and ‘doing’ which, though not used by Callahan, is helpful.[ccxliv]

Death is an evil

Though Callahan acknowledges the centrality of the proposition ‘Death is an evil’, his analysis lacks the rigour[ccxlv] and clarity shown in the rest of his discussion. Much like Philippa Foot, he - by choosing categories more abstract than is required for his analysis - impales himself on the horns of a (self-imposed) dilemma: for example, in considering ‘life is a good’ he takes life in the abstract, i.e. unrelated to death, as the primary idea thus obliging his to treat ‘Life is a good’ as synonymous with ‘Death is an evil’; in consequence, he is forced into precisely the same difficulties as was Foot.[ccxlvi] This is all the more inexcusable in that, in doing so, he is ignoring his very own strictures not to treat death as contingent. Had he followed his own advice and considered death as a necessary part of life - there is no life that does not end in death - it would have been clear that to ask is ‘life a good’ and ‘death an evil’ (simpliciter) is as meaningful as to attempt to cleave to the concept ‘left’ without immediately recognising that the concept of ‘right’ is it’s necessary companion.[ccxlvii] Despite these criticisms Callahan does arrive at the conclusion:

“... our moral judgement should focus on the timing and circumstances of death, which we can to some extent manage and control, not on the existence of death, which we cannot.” [ccxlviii]

In the end he does break free of the stranglehold imposed on his analysis by his acceptance of the duality ‘life is a good / death is an evil’; and he finds a new way to view death which he calls the ‘inside’ view:

“There is a way of interpreting life that can give an integral place to death. I will call it the ‘continuous’, or ‘inside’, view, to distinguish it from the ‘fragmented’ or ‘outside’, view. It begins with a different kind of question. We should not ask whether death is an evil (for this already fragments death), but whether a life course that includes death at its end is an evil. And the answer ... is: not necessarily ... life and death are inextricably intertwined, and that much of the value of life comes because of this relationship, not despite it. In this view, life itself requires, for its meaning and piquancy, death as its necessary complement. Life cannot be life as we understand it without death’s being integral to it. ... One reason for accepting it, perhaps unpleasantly realistic, is this: that is the way things are, and you had better accept it.” [ccxlix]

‘Being’ v ‘Doing’

In using this polarity I am attempting to bring into focus a view of man and of his place in the world that is so prevalent in the West that the possibility of any alternative view is often not recognised. In the West, man is primarily conceived as one who acts on his environment; his definition - to himself and to others - is in terms of the changes that he has wrought on the world; a life lived without the possibility of making such changes would be widely considered as being a useless life.[ccl]

Westerners who visit the East often comment on the ‘passivity’, or ‘fatalism’, of those peoples; by this is meant that, in the face of circumstances deemed to be unsatisfactory, two responses are possible:

* one can attempt to change the circumstances or

* one can attempt to accommodate oneself to the circumstances - to change one’s inner attitude so that one can accept the existing circumstances.

Eastern responses to problems are sometimes ‘inner directed’ so that by meditative, or other such spiritual practices, it becomes possible to live in harmony with, what was previously considered to be, an intolerable situation. To the Westerner such responses are categorised as passive and fatalistic; his response, in contrast, is ‘outer directed’ or ‘active’ - a solution being seen in attempting to find harmony by changing the outer environment.

However, it is in facing that which cannot be changed - our mortality being the supreme example - that the typical ‘outer directed’ response accentuates the original disharmony. It is in facing death that the hitherto successful strategy of ‘activism’ becomes a frantic activity,[ccli] a panic in the face of the impending ‘loss of control’. This is the perspective from which Callahan’s thoughts on ‘suffering’ and ‘loss of dignity’ are best understood.

Callahan distinguishes between ‘pain’ and ‘suffering’; ‘suffering’ relates to a person’s psychological or spiritual state[cclii] and occurs at some impending destruction of the person[ccliii] or their self-image. Suffering is the response to threats to the ego, pain being the response of the body. Often the only path available to deal with suffering is through a changing of the attitude[ccliv] adopted towards that which appears to be threatening. As a preliminary to such a change it is often necessary to adopt a stance more akin to 'being' than to ‘doing’:

“Facing up to terror is something we do entirely with and within ourselves ... It is the mastery of self,[cclv] not of the outside world, that brings the deepest satisfaction, and in the end it is the only mastery that is proof against what the world brings.” [cclvi]

Callahan sees the solution to the perceived loss of dignity (often spoken of in relation to dying) as flowing from the same source:

“One has no more right to dignity - and hence to dignity in death - than one has to beauty or courage or wisdom, desirable though these may be. However much we work to control the circumstances of our dying, its essence is loss of ultimate control, the final disenfranchisement of the controlling self. Our dignity will stem from the way we come to understand and master that loss, not from the loss itself.” [cclvii]

The distinction between the attitudes ‘being’ and ‘doing’ (and the different values which society associated with them) is of considerable importance when discussing ‘end-of-life’ decisions. The all-too-common assumption that only active responses are of worth and that only those who consistently manifest such responses, have value, needs to be critically examined; otherwise it becomes all to easy in looking at, for example, inactive old people in a nursing home, to judge that such lives are useless and without value. Furthermore, if the ‘being’ response is undervalued and if there is nothing that we can actually do for a dying person then - as Kübler-Ross has well documented - it becomes all to easy to leave them to face their dying alone. In such circumstances it requires a degree of courage to face and acknowledge one’s impotence and to remain and simply be with another in their suffering:

”Then we discover something at once humbling and appalling. We can be with another in his suffering, and we can try to share it, but we cannot relieve it.” [cclviii]

The inability to sit with such feelings of impotence is, perhaps, the cause of many of the inappropriate medical interventions that occur in end of ‘end-of-life’ situations.[cclix] Furthermore, it is at the root of the conflict in medicine between the activism of those who adhere to a ‘scientific medicine’ - who believe medicine to be solely a rehabilitative discipline - and those who, like Callahan, see caring - which may often be just a ‘being with’ - as the most basic value in medicine:[cclx]

“It should be understood that caring is the most basic value in medicine ... the same cannot be said of cure, which is not always needed.” [cclxi]

Conclusion _{9 - 14} : Callahan in The Troubled Dream of Life concludes that death denial pervades Western society and its medicine. He recommends that:

* medicine must fully acknowledge that death is intrinsic to the human condition.

* the presumption that it is possible, either on an individual or social level, to be in control of nature - and in particular of death - must be jettisoned.

* the caring aspect of medicine - and in particular the goal of a peaceful death - must be reintegrated into, and given an honoured role in, medical practice.

Section 3: The moral obligations implied in stating a death is ‘a good death’.

In Section 1 of this chapter it was argued that the proposition ‘Death is an evil’ could not be justified on logical grounds; in Section 2 it was contended that it could not be justified on psychological [cclxii] grounds. Thus, the proposition ‘Death is an evil’ (simpliciter) is not sustainable. From this it follows that some deaths are a ‘good’.

Conclusion _{9 - 15} : As the proposition ‘Death is an evil’ (simpliciter) cannot be justified on either logical or psychological grounds, it is not sustainable. It follows that some deaths are a ‘good’.

What characterises such deaths?

One possible avenue of investigation is to pose the question[cclxiii] ‘How would you wish to die?’ A person who fully (i.e. not just intellectually but also emotionally) accepts their mortality, will not respond to such a question by refusing to contemplate such an eventuality - for such evasion would be a denial of death - but will have certain preferences. Some deaths will be desired and these could be termed ‘good deaths’ - for example death ‘without pain’, or ‘not alone’, or ‘at peace with myself’. There will be others that would be regarded with loathing and these could be termed ‘bad deaths’ - for example death ‘by violence’, or ‘prolonged painful death’, or ‘death where one was treated as an object’. However, before pursuing this analysis a possible ambiguity first needs to be resolved.

A possible ambiguity

It may be that the term ‘good’ when used in the context of ‘a good death’ is not being used in its ethical sense but in a vernacular or aesthetic sense. It seems best to (at least temporarily) distinguish between two senses of the term ‘good’ (an aesthetic sense and a moral sense) and to correspondingly distinguish between two senses of the term ‘a good death’: the moral sense denoted by ‘Good_M Death’, and the vernacular sense denoted by ‘Good_V Death’. Our first task is to consider the import, if any, of this distinction.

Imagine a mountaineer whose greatest love was to climb and who had spent his life scaling the highest mountains in the world. In attempting one such mountain - which he had always found particularly challenging - his rope gave way, he fell and was instantly killed. Colleagues could, perhaps, call such a death ‘a good death’ in the sense of it being a fitting or apt or appropriate end to a career spent climbing. Would their use of the term be in the sense of a ‘Good_M Death’, or in that of a ‘Good_V Death’?

Ethical propositions are often characterised as being ‘ought-type’ statements (in contrast to, for example, scientific propositions which are ‘is-type’ statements in that they describe an existing situation and connote no sense of obligation). Applying this to our example would suggest that (because in saying that the climbers death was ‘a good death’ there is no connotation of ‘oughtness’) the sense is that of ‘Good_V Death’. But is this a premature conclusion? Is the calling of such a death a ‘Good_V Death’, devoid of ethical significance?

If it transpired that the climbing partner had cut the rope, thus causing the death, the phrase ‘a good death’ would seem highly inappropriate; however, if it then became apparent that the climber had been suffering from a terminal illness, had not long to live, had wanted to die whilst climbing and had asked his partner to help him die on the mountain and the rope had been cut in response to this, the balance again changes and the phrase may again become appropriate. Such considerations show that the phrase ‘Good_V Death’ is not independent of ethical considerations. The problem then is to determine the nature of this dependence.

One method of resolving this difficulty is by using the concept of ‘aptness’. It was mentioned earlier[cclxiv] that both uses of the term ‘good’ could perhaps be subsumed under the one concept of ‘aptness’ or ‘fitness for purpose’ or ‘appropriateness’, and that this appears to have been the practice in Greek philosophy. However, to say of a response that it was ‘appropriate’ requires an examination of more that just the circumstances which were responded to, it also requires consideration of the ‘responder’. Certain responses to circumstances may be appropriate responses for one person to make but not for another: to chastise a misbehaving child may be an appropriate response from a parent but not so from a stranger. Thus, in considering whether a response is apt, not only the circumstances but also the status of the responder must be taken into account - a complication that is often neglected in considering whether an action is ethically a ‘good’. Thus, to say of the death of the mountaineer that it was a 'good' means that considering all the circumstances it was an apt end to the climbers life - but apt in the sense of apt for ‘the gods’ to decree, not for man; (‘the gods’ knowing that this man must die and aware of all the possibilities, may decree that his death on the mountain is the most fitting end). However, for any ‘mere’ human to lay claim to such knowledge and thus appropriate the role of ‘the gods’, would render his involvement in the death of the climber inappropriate; this is most especially so if such action was done without the knowledge and consent of the one for whom it was supposedly performed.

A second method of resolving the difficulties is to use the device adopted by Phillipa Foot in her discussion of euthanasia;[cclxv] Foot, in discussing whether an action was, or was not, a 'good', separated the ‘goodness’ of the action from the ‘oughtness’ of the action. A (contemplated) action could be considered a good if, in so far as it affected X, it was being done ‘for the sake of’ X. Such (contemplated) actions were a good because they sprang from the virtue of Charity. The judgement that a (contemplated) action was a 'good', although a necessary condition was, however, not a sufficient condition for its being performed; for not only had the (contemplated) action to be in accord with Charity, it must also accord with Justice. Foot’s principle is that ‘Where Charity and Justice conflict, Justice must prevail’. The principle of ‘Justice’ that Foot has in mind, is the right to non-interference - ‘to be let alone’ - so that no person should be subjected to interference against his will even if this be done with the ‘best’ of motives. To return to our mountaineering example, although the knowledge of a fellow climber that his companion was suffering from a terminal illness, and that dying on the mountain would be ‘a good death’ for him, he is prohibited by the virtue of Justice from attempting to achieve this unless done at the request of his fellow climber. However, even if his friend requests help in dying - thus removing the objections flowing from considerations of Justice - Foot is of the view that the wider interest of society may still prohibit such actions.

To summarise: to Foot, a (contemplated) action is a good if it flows from the virtue of Charity, it should not, however, be performed unless it satisfies the requirements of Justice; this however may not be a sufficient condition as it may also be required that the action be not detrimental to the interests of the wider society.[cclxvi]

Returning to the distinction made earlier between a ‘Good_V Death’ and a ‘Good_M Death’, the import of the distinction seems to lie in the fact that in discussing a ‘Good_V Death’ the unqualified sense of ‘oughtness’ - usually implicit when something is described as being a 'good' - is not present. Once it is accepted, in stating ‘a good death’ is a ‘good’, that the ‘ought’ implications are strictly circumscribed, then the distinction between a ‘Good_V Death’ and a ‘Good_M Death’ can be dropped.

Conclusion _{9 - 16} : In stating that ‘a good death’ is a good, the obligations imposed on third parties must be strictly circumscribed.

‘A good death’ is not ‘a least worse death’

Margaret Pabst Battin has used the concept of ‘The Least Worse Death’ [cclxvii] in her analysis of ‘end-of-life’ decisions:

“The crucial point is that certain conditions will produce a death that is more comfortable, more decent, more predictable, and more permitting of conscious and peaceful experience than others. Some are better, if the patient has to die at all, and some are worse. ... What the patient who rejects active euthanasia or assisted suicide may realistically hope for is this: the least worse death among those that could naturally occur.” [cclxviii]

The phrase ‘the least worse death’ - as is emphasised in the phrase ‘if the patient has to die at all’ - is irretrievably embedded within the framework of death denial, of believing that death is contingent and that it is an evil. The use of such a phrase, whilst it may arrest the greatest excesses of interventionist medicine, still validates the philosophical principles which underlie such procedures and thus reinforces the denial of death.

The connotations of suggesting to medical professionals that they help a patient achieve ‘a good death’ are quite different to those implicit in helping a patient achieve a ‘the least worse death’. The former implies some positive obligations on carers, the latter suggests a duty of non-intervention: imagine a recently bereaved family discussing the death of a beloved with the deceased’s medical carers; for the family to congratulate the carers for helping their relative achieve ‘a good death’ though, perhaps, not common would be unremarkable; however, for them to congratulate the carers for their loved one’s ‘least worse death’ would surely be bizarre; this clearly shows the magnitude of the difference between the connotations of the different terms. Callahan is also of the opinion that a ‘lesser evil’ standard is not appropriate.[cclxix]

In stating that ‘a good death’ is a ‘good’, what obligations are implied? [cclxx]

General considerations

In saying such a death is a ‘good’, obligations might arise in two ways;

* in relation to occasioning[cclxxi] the death itself, and

* in relation to occasioning the ‘goodness’ of the death.

In relation to occasioning the death itself

A consideration of the question ‘How would you wish to die?’ makes clear that to be killed in the face of one’s direct protestations could never be considered to be ‘a good death’, whereas to be killed at one’s request might well be so considered. This might suggest that if the death - as distinct from the nature of the death - was being occasioned, that consent was a requirement; however, there are circumstances - such as irreversible coma or PVS - where many might consider that even to be killed without one’s consent was a ‘good’. As is evident from the continuing debate on assisted suicide and euthanasia the question is contentious, however, some assistance can be derived from a consideration of the requirements of Justice which are considered below and (in more detail) in Chapter 11.

However, one conclusion can be unequivocally stated:

* To occasion the death of another in the face of their objections could not be considered to be ‘a good death’

In relation to occasioning the ‘goodness’ of the death

In recognising that an intervention in a person’s dying which was contrary to their wishes would be destructive of the goodness of the death, it is clear that the primary obligation is to attempt to communicate with the patient in an effort to determine their wishes. Kübler-Ross has suggested that the obligation on the carers to communicate with the dying patient is perhaps the greatest obligation at this time - the important thing being simply to ask the dying person “What do you want?” [cclxxii] She has described[cclxxiii] the typical medical practice in relation to a severely ill patient as beginning by considering him as a ‘person with no right to an opinion’ [cclxxiv] and progressing to treating him as an object. [cclxxv] This permits the conclusion:

* The primary obligation on the medical carers of a patient who has entered onto the threshold of death is to attempt to communicate with the patient.

Obligations flowing from Justice

The obligation to communicate flows not only from the obligation to ensure ‘a good death’, it is also a direct consequence of the requirements of Justice. Foot considers that the requirements of Justice can, in the present context, be crystallised in ‘the duty of non-interference’. Justice could thus be infringed either by interfering to cause the death of a person unless at the request of that person, or by interfering with the death of a dying person in a manner contrary to their wishes; the first, obviously, being the more serious infringement. In considering a medical intervention, the primary duty on carers - as seen from the perspective of Justice - would be to attempt to communicate with the patient so as to establish their wishes, the secondary obligation would be to desist from such a proposed intervention if it were contrary to the patient’s expressed wishes. This permits the conclusion:

* Medical carers should desist from a proposed intervention if contrary to the patient’s expressed wishes.

The last three conclusions can be amalgamated:

Conclusion _{9 - 17} : The primary obligation on the carers of a patient who has entered onto the threshold of death is to attempt to communicate with the patient. Medical carers should desist from a proposed intervention if contrary to the patient’s wishes and, in particular, the occasioning of the death of a patient in the face of his objections could not be ‘a good death’.

What if communication is not possible?

What of those patients with whom it is not possible to communicate so that it is not possible to ascertain whether they wish to be helped to die, or, if dying, how they should be assisted?[cclxxvi]

There are two situations to be considered:

firstly, where it is believed that communication, although not possible at present, can be re-established; and

secondly, where it is believed that the loss of the ability to communicate is permanent.

In the first case the requirement is that all effort should be directed towards re-establishing communication and that such attempts should only be stopped if they appeared to be destructive of a peaceful death. The questions to be asked are ‘If this immanent death be prevented:

(i) Is it likely that communication can be re-established? and

(ii) Is it likely that a later death will be a better death?

In such cases much depends on the individual circumstances and, in particular, on whether the patient was aware that death was immanent and has settled his affairs or whether ‘unfinished business’ remains. Such cases raise their own complication and, as they are not within the ambit of this thesis, they will not be considered further. The second type of case will be considered in the Chapter 11.[cclxxvii]

The conclusion to be drawn is that:

Conclusion _{9 - 18} : In considering whether a prospective death is ‘a good death’ for a patient who has entered onto the threshold of death (i.e. one for whom death is an immanent possibility) it is important to distinguish between those patients who have the present ability to communicate, those with whom communication may be established and those who have permanently lost the ability to communicate.

Callahan’s position

As has been discussed,[cclxxviii] Callahan believes that in discussing death, dying and the appropriateness of medical intervention, the most crucial step is the acceptance of the inevitability of death. Once this is recognised then any medical decision to intervene to postpone death must weight the possibility that the later death may be worse than the one avoided. To Callahan:

“Death is acceptable ... when it comes at a point in life when

(i) further efforts to defer dying are likely to deform the process of dying, or when

(ii) there is a good fit between the biological inevitability of death in general and the particular timing and circumstances of that death in the life of the individual.” [cclxxix]

A death in such circumstances is not only morally acceptable but is a moral good.[cclxxx]

Callahan argues that:

”It is a moral evil to distort death negligently by human intervention just as it is a moral evil wilfully to allow death to occur when the timing[cclxxxi] and circumstances are wrong.” [cclxxxii]

Furthermore, it is imperative that:

“... once a potentially fatal illness appears, it be considered seriously as the candidate for the cause of death, if other conditions of the timing and circumstance of death are acceptable.” [cclxxxiii]

Callahan suggests two additional tests to determine whether a death is opportune:

* The ‘historical mourning test’ - ‘Would such a death have been greatly mourned a generation ago as unfair?’ [cclxxxiv] and

* The ‘treatment invention test’ - ‘If such a treatment had not yet been invented would we wish for it?’ [cclxxxv]

For example, in relation to PVS patients, the ‘historical mourning test’ would pose the question as to whether, a generation ago the death of such a patient would have been considered as unfair. The ‘treatment invention test’ would pose the question as to whether, in the absence of such as ANH, we would have hoped for its invention for use with PVS patients.

Callahan believes that the ‘location of the gate between life and death’ is becoming increasingly more indeterminate so that now it is:

“ ... increasingly useless to base decisions concerning whether to terminate treatment on some medical determination that the patient ‘is dying’.[cclxxxvi] ... The old question was: when is a patient dying, and thus a candidate for the abatement of lifesaving treatment? The new question should be: at what point, or within what range, should lifesaving treatment be abated to enhance the likelihood of ‘a good death’?” [cclxxxvii]

Callahan’s emphasis would be on the moral obligation on carers, [cclxxxviii] if the timing and circumstances are opportune, to ensure the best death possible for their patient. The conclusion to be drawn is that:

Conclusion _{9 - 19} : The acceptance of human mortality implies that medical carers must, in treating a patient who has entered onto the threshold of death, consider whether - in postponing the particular death - a ‘better death’ is more likely. The particular circumstances of the patient and their family are of crucial importance to any such evaluation. If it is deemed that a better death is unlikely then the immanent death (termed ‘a good death’) is a positive good in the sense that there is a moral obligation[cclxxxix] on the medical carers to attempt to achieve that death for their patient and to do so in a manner that is in as harmonious as is possible with the patient’s interests. ‘A good death’ is to be distinguished from a ‘a least worse death’ which connotes no such positive moral obligations.

Some further characteristics of ‘a good death’

I believe that to attempt to define ‘a good death’ - in the sense of attempting a comprehensive list of necessary and sufficient conditions - would be counterproductive. Although it - like the concepts of ‘a happy childhood’ or ‘a good birth’ - escapes any attempt at exhaustive definition some general characteristics can be enumerated and some of the threads that might help to create that tapestry that is a good death will be suggested in what follows.

Kübler-Ross, as has been mentioned, is highly critical of inappropriate ‘life sustaining’ medical intervention:

“This man was ready to separate himself from this world. ... many such patients have been given an additional ‘lease on life’. I have heard more curses than words of appreciation for the gained time, and I repeat my conviction that a patient has a right to die in peace and dignity. He should not be used to fulfil our own needs when his own wishes are in opposition to ours.” [ccxc]

Kübler-Ross believes that the greatest effort should be directed towards keeping open the possibility of communication with the dying person:

“All too often families ... and even medical staff assume that all a dying person wants is to be comfortable. ... We are terribly anxious about pain and seek the latest medications, most of which deaden the mind as well as the body. I am not prepared to say that this is all wrong. But I do believe that we have our priorities confused. Someone’s life is about to end. Surely, there are important things for that person to say and do before he dies!” [ccxci]

In order to clarify the issues involved, the two extremes of ‘conscious dying’ and ‘sedated dying’ can be contrasted. Kübler-Ross would err in favour of the conscious dying because it would allow matters of ‘unfinished business’ [ccxcii] to be resolved for both the patient themselves[ccxciii] and for the patient’s family. Erring on the side of ‘sedated dying’ may indeed be just a further manifestation of death denial on behalf of the carers, in that they themselves can be shielded from the more distressing aspects of death and dying. A move towards ‘sedated dying’ may be the unintended consequences of the recommendations made by the Institute of Medicine, discussed earlier,[ccxciv] and the judgement of the US Supreme Court against the right to assisted suicide and in favour of extended palliative care.[ccxcv]

Callahan also favours ‘conscious dying’ over ‘sedated dying’; in discussing his concept of a ‘peaceful death’[ccxcvi] he says:

“What must a peaceful death encompass? There is need to fashion a notion of the self that has, in some sustaining way, come to accept death, a self that understands that control over fate will pass from its hands, that this is precisely what biological death means and must mean. It should also be a death marked by consciousness, by a self awareness that one is dying, that the end has come - but, even more pointedly, a death marked by self-possession, by a sense that one is ending one’s days awake, alert, and physically independent, not as a machine-sustained body or a body that has long ago lost its mind and self-awareness.” [ccxcvii]

Callahan’s view is that the achievement of a peaceful death should not be a goal sought only when nothing more can be done, but should be central to the mission of medicine.[ccxcviii]

Conclusion _{9 - 20} : ‘a good death’ - as in a leavetaking - should as far as is possible be marked by a conscious awareness of parting; for this reason excessive sedation (which is often administered for reasons of death denial on the part of family or medical carers) should be avoided.

Kübler-Ross has spoken about some people having a wilfulness about their deaths in that they showed a remarkable power of personal choice in their dying; they intuitively sensed:

“... that meaningful life was drawing to a close and [were] able to enter the final phase easily and naturally.” [ccxcix]

Kübler-Ross was discussing American Indians; the same wilfulness and composure in the face of death is also a mark of the Japanese Zen Buddhist, seen particularly in the tradition of writing death poems[ccc] shortly before the moment of death. It is also found in Hindu culture: Werner Menski comments on traditions of death in Hinduism:

"Yet again, the individual conscience of the terminally ill individual allows for radical solutions. The Hindu concepts of 'a good death' and 'a willed death' are relevant here. In the former, a person prepares for death, having finished all earthly business. In 'a willed death' people who are old and weak, but not terminally ill, may virtually wait till death arrives, refusing to take any food or drink." [ccci]

This is of particular interest in relation to ‘end-of-life’ decisions for PVS patients in that withdrawal of food (in the form of ANH) - though often categorised disparagingly as starvation and thus carrying the implication that it is an evil - is yet the preferred method of those who ‘will’ their own deaths; these are said to die with such a composure that the conclusion might be drawn that deaths by food withdrawal is not necessarily destructive of ‘a good death’.

Conclusion _{9 - 21} : Death by withdrawal of food - and a fortiori withdrawal of ANH - is not necessarily destructive of ‘a good death’.

A contrary view is that the practice of withdrawal of ANH from sedated patients, or the use of ‘double effect’ drugs, is inhuman and could not constitute ‘a good death’. It is often suggested that the killing of such patients might, in certain circumstances, be both more honest[cccii] and more humane.

More honest, in that reliance is not placed on doctrines of indirect effect which many consider to be intellectually dishonest.[ccciii]

More humane, in that the action of ‘double effect’ drugs[ccciv] is unpredictable. Dr. Bert Keizer[cccv] considers that morphine - when used as a ‘double effect’ drug - is barbaric; he states that such procedures are banned in Holland because they are slow and uncertain.[cccvi] Professor O'Shea, a neuroscientist, in discussing the painful death of his 11 year old daughter from an inoperable brain tumour, testified to a similar effect: his daughter had been given a ‘double-effect’ drug which, he had been told, was likely to stop her breathing; the hope was that she might die gently and without stress yet:

“It took nearly 24 hours for Linda to succumb. During that time she was going through complete arrests of breathing for several minutes, then the nervous system would kick in and she would start breathing again. It was extremely distressing: she died several times ... ”

A mother, whose 4 year old son’s feeding tube was removed, states that his death:

“... was a long drawn out process in our home that took 17 days.”

These testimonies show the importance, when discussing ‘a good death’, of considering the effect of a death of a patient on their family - the more harrowing and distressing the less ‘good’ the death.[cccvii] The necessity of considering the effect on the family is all the greater when considering patients who are believed to have permanently lost consciousness as there the greater quantum of the good in ‘a good death’ will come, not from the patient, but from the family and the wider society. However, many would argue that there are no circumstances where a direct killing could be considered to be either ‘a good death’ or a 'good'. Yet to harbour only feelings of compassion towards another and to do them an evil would also seem to be contradictory; unless, of course, there was an infringement of the obligations of Justice. It will be argued in Chapter 11 that, in relation to PVS patients, the obligations of Justice, as to non-interference, are in abeyance; this will leave open the possibility that to kill such patients, if motivated solely by compassion, might not be an evil and might in the circumstances constitute ‘a good death’. This does not imply that such killing should be legalised.

Conclusion _{9 - 22} : It is possible that, in certain cases - such as when requested to do so by a patient or in cases where the ability to communicate is irretrievably lost - a killing might be constitutive of ‘a good death’. However, there may be important social reasons why such a killing should be prohibited.

Section 4: Conclusions

In Section 1 of this chapter, it was established that the proposition ‘Death is an evil’ could not, if unqualified, be justified on logical grounds; in Section 2, it was established that it could not be justified on psychological grounds; hence, the proposition ‘Death is an evil’ (simpliciter) is not sustainable. Consequently there are some deaths that may be spoken of as being ‘good deaths’. Whilst recognising that such deaths cannot be precisely defined, Section 3 sought to outline their broad characteristics.

The greatest hindrance to a good death is caused by the denial of death; such denial is prevalent throughout society but is particularly acute in clinical medicine. The primary manifestation of death denial is the belief that death is contingent and that it is possible to be ‘in control’ of one’s death; the view that the primary role of medicine lies in the cure of disease rather than in the care of patients exacerbates the worst effects of death denial.

The resolution of the problem of death denial lies through a full acceptance of human mortality, through a recognition that death is intrinsic to the human condition and that medicine cannot attempt to control death but can, at most, influence the circumstances or the timing of an individual death. This limited control should only be exercised in the knowledge that (in the light of all the circumstances of the particular case) if the ‘present’ death is, in fact, postponed a ‘better death’ is more likely. If it is deemed that a ‘better death’ is unlikely then the immanent death is a positive good[cccviii] in the sense that there is a moral obligation[cccix] on the medical carers to attempt to achieve that death for their patient and to do so in a manner that is in as harmonious as is possible with the patient’s interests. ‘A good death’ is to be distinguished from a ‘a least worse death’ which connotes no such positive moral obligations.

In considering whether a perspective death is ‘a good death’ for a patient who has entered onto the threshold of death,[cccx] it is important to distinguish between:

(i) those patients who have the present ability to communicate;

(ii) those with whom communication may be established; and

(iii) those who have permanently lost the ability to communicate.

In the first two cases the primary obligation on the patient’s carers is to attempt to communicate with the patient and, having succeeded, to accede as far as is possible to the patient’s wishes; medical interventions contrary to the patient’s wishes are incompatible with ‘a good death’. It is important that, where possible, dying be a conscious experience as only in such circumstances can ‘unfinished business’ - which if it exists is destructive of ‘a good death’ - be resolved; for this reason excessive sedation should be avoided.

In cases where the patient is deemed to have permanently lost the ability to communicate it is important to recognise that it is not only the patient’s interests that must be considered in classifying an immanent death as being ‘a good death’, the interests of the patient’s family and carers are also of importance: for a death to be ‘a good death’ it must cause minimal damage to the surviving community. In certain circumstances it is possible that a killing or that a withdrawal of food or of ANH may be constitutive of ‘a good death’; however, there may be important social reasons why such procedures should be prohibited; these issues are discussed in greater detail in Chapter 11.

____________

The conclusions which were established in this chapter are:

Conclusion _{9 - 1} : The belief in the contingency of X and that the occurrence of X is, to some extent, dependent on human agency are preconditions for asserting either ‘X is good’ or ‘X is evil’.

Conclusion _{9 - 2} : The predicates ‘good’ or ‘evil’ cannot meaningfully be applied to ‘death’ without further qualification. The assertion that ‘Death is an evil’ (simpliciter) implies a denial of death in that it implies a refusal to accept human mortality.

Conclusion _{9 - 3} : Christianity considers ‘death’ to be a punishment inflicted on man and as not intrinsic to the human condition; it - unlike many Eastern religions - subscribes to the proposition ‘Death is an evil’.

Conclusion _{9 - 4} : The arguments against the proposition ‘Death is an evil’ (simpliciter) are varied:

(i) that, in times of suffering, death can be a friend. (Foot, Scruton)

(ii) that human mortality is a fact of the universe and, as such, must be accepted. (Plato, Spinoza)

(iii) that the gateway to an ‘authentic’ life which embodies individual moral responsibility, lies in the willing acceptance of our individual mortality; it is incompatible with the denial of death implicit in the proposition ‘Death is an evil’. (Jaspers, Heidegger, Derrida)

(iv) that the gifts of creativity and spirituality flow from, and are sustained by, a full intellectual and emotional acceptance of our individual mortality. (Becker, Koestler)

Conclusion _{9 - 5} : Arguments, such as Nagel’s, that ‘Death is an evil’ because we desire immortality gives precedence to desire over reality; as such they are hardly to be commended on rational grounds.

Conclusion _{9 - 6} : Arguments that the fear of death is ‘irrational’ presume that, for a fear to exist, it must have rational grounds and that, once the ‘irrationality’ of the grounds are demonstrated, the fear can be vanquished by an act of will. Fear is not removable by an act of will and the distinction made by the Existentialists between ‘anxiety’ and ‘fear’ show that questions of rationality are inappropriate in discussing the fear of death.

Conclusion _{9 - 7} : Arguments which seek to establish deduce the evil of some particular occurrence from the fact that it is feared, trivialise the concept of evil.

Conclusion _{9 - 8} : The proposition ‘Death is an evil’ considered simply as a proposition of psychology, i.e. as a maxim for living, should be rejected; it is the denial of death, rather than death, that is an evil.

Conclusion _{9 - 9} : In clinical medicine, ‘death denial’ is manifested in:

* a refusal to fully acknowledge the inevitability of death..

* inappropriate medical activity in the face of death.

* the belief that when death occurs it is due to a failure of medicine.

* the belief that ‘nothing can be done’ to help a dying patient.

* a refusal to talk to patients about their dying.

Conclusion _{9 - 10} : Kübler-Ross’s principle recommendations involve:

(i) the necessity of combating ‘death denial’ - which she regards as endemic amongst medical professionals, and

(ii) the primacy of the obligation on medical professionals, to communicate with their patients.

Conclusion _{9 - 11} : Recent reports from the US Institute of Medicine (1997) and the BMA (1999) indicate that ‘death denial’ is a widespread phenomenon of modern life; the US report found considerable evidence of it’s prevalence in clinical medicine.

Conclusion _{9 - 12} : The Institute of Medicine’s 1997 report clearly shows that, of the alternative philosophies of medicine i.e. ‘curative’ or ‘caring’, it is the curative that, at least in the US, is in the ascendant.

Conclusion _{9 - 13} : A medical ideology which defines the medicine’s role as being fundamentally curative and which minimises its caring role, tends to foster death denial.

Conclusion _{9 - 14} : Callahan in The Troubled Dream of Life concludes that death denial pervades Western society and its medicine. He recommends that:

* medicine must fully acknowledge that death is intrinsic to the human condition.

* the presumption that it is possible, either on an individual or social level, to be in control of nature - and in particular of death - must be jettisoned.

* the caring aspect of medicine - and in particular the goal of a peaceful death - must be reintegrated into, and given an honoured role in, medical practice.

Conclusion _{9 - 15} : As the proposition ‘Death is an evil’ (simpliciter) cannot be justified on either logical or psychological grounds, it is not sustainable. It follows that some deaths are a ‘good’.

Conclusion _{9 - 16} : In stating that ‘a good death’ is a good, the obligations imposed on third parties must be strictly circumscribed.

Conclusion _{9 - 17} : The primary obligation on the carers of a patient who has entered onto the threshold of death is to attempt to communicate with the patient. Medical carers should desist from a proposed intervention if contrary to the patient’s wishes and, in particular, the occasioning of the death of a patient in the face of his objections could not be ‘a good death’.

Conclusion _{9 - 18} : In considering whether a prospective death is ‘a good death’ for a patient who has entered onto the threshold of death (i.e. one for whom death is an immanent possibility) it is important to distinguish between those patients who have the present ability to communicate, those with whom communication may be established and those who have permanently lost the ability to communicate.

Conclusion _{9 - 19} : The acceptance of human mortality implies that medical carers must, in treating a patient who has entered onto the threshold of death, consider whether - in postponing the particular death - a ‘better death’ is more likely. The particular circumstances of the patient and their family are of crucial importance to any such evaluation. If it is deemed that a better death is unlikely then the immanent death (termed ‘a good death’) is a positive good in the sense that there is a moral obligation on the medical carers to attempt to achieve that death for their patient and to do so in a manner that is in as harmonious as is possible with the patient’s interests. ‘A good death’ is to be distinguished from a ‘a least worse death’ which connotes no such positive moral obligations.

Conclusion _{9 - 20} : ‘A good death’ - as in a leavetaking - should as far as is possible be marked by a conscious awareness of parting; for this reason excessive sedation (which is often administered for reasons of death denial on the part of family or medical carers) should be avoided.

Conclusion _{9 - 21} : Death by withdrawal of food - and a fortiori withdrawal of ANH - is not necessarily destructive of ‘a good death’.

Conclusion _{9 - 22} : It is possible that, in certain cases - such as when requested to do so by a patient or in cases where the ability to communicate is irretrievably lost - a killing might be constitutive of ‘a good death’. However, there may be important social reasons why such a killing should be prohibited.

---

[i] To obviate the need for a continued repetition of this distinction the term ‘good’ will, in the remainder of this chapter and unless otherwise stated, be used to signify ‘good’ in its ethical sense; though perhaps both uses of the term ‘good’ can be subsumed under the one concept of ‘aptness’ or ‘fitness for purpose’. This appears to have been the practice in Greek philosophy as evidenced in a quotation from Rex Warner who, in his The Greek Philosophers states (p.114):

“There is a sense in which Aristotle does not employ at all our concept of ‘morality’. Here again one is apt to be misled by difficulties of translation. The Greek word arete in this context is usually rendered as ‘virtue’, and we naturally think of virtue as a moral affair. But this implies a restriction that is not present in the Greek. ‘Moral Virtues’ in Aristotle are simply good qualities of character displayed in right conduct; and any good qualities of character may be so called - good manners, affability, wit, proper dignity of bearing, as well as honesty, truthfulness, temperance, or charity. It is not, of course, that Aristotle does not discuss what we should regard as moral questions; it is only that he does not specially distinguish them from other questions of what is good in conduct and character, and indeed he has not the linguistic means of doing so.” [emphasis in the original]

[ii] though Foot’s distinction between the ‘goodness’ and ‘oughtness’ of a proposed action complicates this implication. The implication itself will be discussed later.

[iii] An examination of the concept of ‘good’- and the more basic concept of ‘value’ - would doubtlessly be helpful, but is not possible within the narrow ambit of this thesis.

[iv] The proposition ‘Death is an evil’ is ambiguous in that it may mean ‘(Some) death is an evil’ or ‘(All) death is an evil’. The proposition, as used in this chapter, is used in the second sense,- i.e. as ‘Death is an evil’ (simpliciter); however, the precise meaning can also be captured by the proposition ‘Human mortality is an evil’; this latter proposition not having any of the intuitive plausibility of ‘Death is an evil’.

[v] James Rachels (ed.), Moral Problems, at p. 446.

[vi] It would be a valid reason if only some (including those who were murdered) but not all, persons died.

[vii] One might quibble with the term ‘untimely’ the important point is that it is some types of death - untimely or violent or whatever - that are evil, not death itself.

[viii] In speaking of a proposition as ‘inappropriate’ I wish to refer to the idea that a word structure may have the form of a proposition and yet have no meaning: e.g. ‘Good is yellow’ or ‘All runners in the race were losers’, ‘I am jealous of myself’; the underlying idea is also captured by a question such as ‘What is the universe near?’ I do not wish to argue that ‘Death is an evil’ is not a proposition, as this would have the consequence that its negation was not a proposition and the negation of ‘Death is an evil’ is unproblematic, however stating that ‘‘Death is an evil’ is untrue’ does not appear to be sufficiently strong.

[ix] A more detailed schema for Section 1 is as follows:

Section 1: The proposition ‘Death is an evil’ (simpliciter) is untrue.

Subsection 1: Death being an intrinsic part of the human condition cannot be considered to be an evil.

Subsection 2: Religion and the evil of death.

The Christian attitude to death

Eastern religious attitudes to death

Contrast between Eastern and Christian myths on the origin of death

Christian attitude to killing

Subsection 3: Philosophical arguments disputing the proposition ‘Death is an evil’

Plato

Spinoza

Jaspers

Heidegger

Derrida

Foot -‘Death is an evil’ - The role of death in Foot’s argument

Scruton

Conclusions

Subsection 4: Philosophical arguments asserting that death is an evil

Nagel - Nagel: The View from Nowhere - Nagel: Mortal Questions - Summary of Nagel’s Arguments

Mothersill: Death

Conclusions

Subsection 5: The Fear of Death

The fear of death is irrational

The existence of the fear of death implies that ‘Death is an evil’

[x] The phrase ‘denial of death’ will be discussed below in relation to Ernest Becker’s writings. It means the refusal to fully accept - both intellectually and emotionally - one’s own mortality.

[xi] A more detailed schema for Section 2 is as follows:

Section 2: Manifestations of the denial of death.

Subsection 1: What is the ‘denial of death’?

Becker and the denial of death

Kübler-Ross and the denial of death

Kübler-Ross: Is death to be considered an evil?

Subsection 2: Medical manifestations of the ‘denial of death’

Kübler-Ross

More recent commentators

The pervasiveness of death denial amongst medical carers

The role of medicine: cure or care?

Callahan

Current attitudes to death and dying

The beliefs underlying current attitudes to death and dying

Callahan‘s proposals

[xii] The relevance of the concept of ‘a good death’ to the making of ‘end-of-life’ decisions for PVS patients will be considered in the Chapter 11.

[xiii] A more detailed schema for Section 3 is as follows:

Section 3: The moral obligations implied in stating a death is ‘a good death’.

A possible ambiguity

‘a good death’ is not ‘a least worse death’

In stating that ‘a good death’ is a ‘good’, what obligations are implied?

General considerations

In relation to occasioning the death itself

In relation to occasioning the ‘goodness’ of the death

Obligations flowing from Justice

What if communication was not possible?

Callahan’s position

Some further characteristics of ‘a good death’

[xiv] William James, The Varieties of Religious Experience, p.139.

[xv] It might be contended that this argument also implies that since illness is also an intrinsic part of the human condition it too should not be considered to be evil; the point, however, is that though illness and death are both intrinsic to the human condition (viewed in its generality) only death is intrinsic to the human condition (viewed in its particularity): a particular individual may not experience illness but he will certainly experience death.

[xvi] Quoted in E. M. Cioran, A Short History of Decayat p.63.

[xvii] Spinoza, for example, was considered by many to be a destroyer of morality in that he denied human freedom and considered that human actions were necessary consequences of existing situations.

[xviii] It is ironic that these precise beliefs - i.e. that death is contingent and dependent on human intervention - are, in Elizabeth Kübler-Ross’s view [(1970) p.2], a logical consequence of death denial; furthermore, they imply the logical equivalence of the propositions ‘Death is evil’ and ‘Killing is evil’. This is discussed further in Section 2 of this chapter.

[xix] Wittgenstein Tractatus Logico-Philosophicus 6.4311

“Death is not an event in life. We do not live to experience death.”

see also Brian Magee Confessions of a Philosopher p.584;

“As Wittgenstein so well put it, death will not be an event in our lives ... The limits of our lives will be as un-clear-cut, as unlike a drawn line, as the limits of our visual field (again an analogy drawn by Wittgenstein).”

Steiner (p.105) notes Heidegger’s agreement with Wittgenstein’s observation:

“Thus ‘death is, in the widest sense, a phenomenon of life’; indeed, it may well be the identifying phenomenon, though it cannot itself ‘be lived’ (a point on which Heidegger concurs explicitly with Wittgenstein).”

[xx] The practice or technique of deep-freezing the bodies of those who have died of an incurable disease, in the hope of a future cure.

[xxi] Such a belief is exemplified in a Sunday Times article of 4^th July 1999 the headline of which stated ‘’Immortal’ genes found by science’. The article continued by arguing that it was now possible (by using genetic manipulation) to extend the life of fruit flies threefold and that such technology would soon be available to humans.

[xxii] The interrelatedness of the supposed evil of death and religious belief may also be seen by attempting - with the aid of a thought experiment - to interpret the proposition ‘Death is an evil’ literally; this allows the metaphorical nature of the proposition to quickly become apparent. Imagine that in some imaginary world it was possible to banish death. What then of the incurable cancer victim racked by pain? Is there to be no end to their torment? No hope of merciful release from their suffering? What of the problem of overcrowding in such a world without death? Wherefrom the resources to tend the sick? Could it be said of such an imaginary world that it is unequivocally better than our existing world? Standing behind an imaginary veil - that is, not knowing our own particular circumstance - and acting only from motives of compassion, could we unequivocally say that such a banishing of death was a ‘good’? Does this not imply that when it is said that death is an evil, it is not death, as such, that is being discussed but death as a metaphor for suffering, loss and pain, for the loss of some imagined paradise?

[xxiii] John Milton, Paradise Lost Book 1(i), (the opening lines).

[Available on Internet: http://www.literature.org/authors/milton-john/paradise-lost/chapter-01.html]

[xxiv] The Bible, Book of Isaiah, 25.8 - 26.19.

[xxv] The Bible, The Revelation of St John 21:4.

[xxvi] See, for example,

Thomas Merton, The Way of Chuang Tzu p.88:

“Consequently: he who wants to have right without wrong,

Order without disorder,

Does not understand the principles

Of heaven and earth. ...

They are correlative: to know one

Is to know the other.

To refuse one

Is to refuse both.”

and Thomas Cleary (trans.), Chuang Tzu p.106:

“Death and Life are destiny; the existence of consistency in the night and day is Nature. The existence of that which humans can do nothing about is the condition of things.”

[xxvii] The Bhagavad-Gita Ch. II - 27; included in Radhakrishnan and Moore (eds.), A Sourcebook of Indian Philosophy p.108.

[xxviii] Elisabeth Kübler-Ross is said to have believed that no one had thought more deeply on death and dying than Tagore. (Dutta and Robinson, Rabindranath Tagore at p.88)

[xxix] Included in William Gerber, The Mind of India at p.184,

[xxx] Kübler-Ross (1975) p.63,

[xxxi] James Rachels Moral Problems p.444.

The ethicist Peter Singer has similarly argued that infanticide is permissible for parents of very deformed children during the first few days after birth. (Radio interview on BBC World Service 16.1.00)

[xxxii] The early church was resolutely pacifist; however, on becoming a state religion its attitudes to state violence - such as war and execution - changed. See Rachels, Moral Problems, p.444.

[xxxiii] ibid. p.446.

[xxxiv] Could it be that the injunction was once interpreted as being that extraordinary means should not be used? If so, this would accord with the Taoist perspective where one is also urged to work with, or take advantage of, circumstances but never to attempt to force them.

[xxxv] Jacques Derrida, The Gift of Death.

[xxxvi] Rachels op.cit. p.445.

[xxxvii] Plato, Benjamin Jowett (trans.), Phaedo,

(Section 12):

“ ‘In reality then, Simmias,’ he said,

‘the correct philosophers practice how to die,

and death is less feared by them of all people.’ “

[xxxviii] ibid. (Section 13) which continues:

“ ‘Quite so,’ he said.
‘Then do not the courageous face death
in fear of greater evils, when they do face it?’
‘This is so.’
‘Then by fearing and need are all courageous
except the philosophers.’ “

[xxxix] ibid. (Section 6):

“ ‘But you must be ready,’ said he;
‘for possibly you might also hear.
Perhaps however it will appear strange to you,
if this alone of all the others is absolute
and it never happens to mankind, as in other things,
when it is better to die than to live;
and to whom it is better to die,
perhaps it appears strange to you,
if for these people it is not holy for them
to do what is good for themselves,
but they must wait around for the good work of another.’ “

[xl] ibid. (Section 3):

“ Socrates sitting up on the bed
bent his leg and rubbed it with his hand,
and while rubbing he said, ‘How odd, men,
seems to be this thing, which people call pleasure;
how wonderfully is it related
to what seems to be the opposite, pain,
in that they will not come to a person at the same time,
but if someone pursues the one and gets it,
he usually is forced to get the other also,
as though out of one head the two are joined.’ “

[xli] ibid. Sections 15, 16.

“ ‘is it necessarily so
that the same things born are generated
both out of each other and out of each into the other?’
‘Certainly.’
‘What then?’ he said. ‘Is there an opposite to life,
just as sleeping is to waking?’
‘Certainly,’ he said.
‘What?’
‘Death,’ he said.’ “

[xlii] Discussed in the previous Subsection.

[xliii] Lloyd Spinoza, p.77.

[xliv] ibid. p.118.

[xlv] Karl Jaspers, Way To Wisdom, p.125:

“To philosophise is then at once to learn how to live and to know how to die.”

[xlvi] John Passmore, A Hundred Years of Philosophy, p.467.

[xlvii] H.J. Blackham, Six Existentialist Thinkers, p.52.

[xlviii] George Steiner, Heidegger (p.94):

“Inauthentic Dasein lives not as itself but as ‘they’ live. ... It ‘is lived’ in a hollow scaffolding of imposed, anonymous values. In inauthentic existence we are constantly afraid (of other men’s opinions, of what ‘they’ will decide for us, of not coming up to the standards of material or psychological success …). Fear ... of this order is part of the banal, prefabricated flux of collective sentiment. Angst is radically different. ... Angst is a mark of authenticity, of the repudiation of ‘theyness’.”

[xlix] Reinhard May, Heidegger’s Hidden Sources quotes (at p.84) Heidegger paraphrasing Jaspers:

“There is a general ‘experiential relation to death’, which is not to be confused with a ‘general knowing about death’, only ‘when death has entered into experience as a limit-situation’, ... ”

[l] Joshua Schuster argues that it gives man not only ‘authenticity’ but the very concept of ‘me’ and ‘mineness’:

“ ... for any ‘me’ to exist, one must already have a pre-theoretical understanding of mineness, and of death. There is no death without mineness either. Only a being with mineness can die (much later Heidegger will later remark that animals do not die, they only perish). We cannot ‘give’ someone our death since mineness is not something ‘I’ can exist without; mineness is a given and not giveable.”

‘Death Reckoning in the Thinking of Heidegger, Foucault, and Derrida’ (at p3)

[li] Blackham op.cit. p.96.

[lii] Steiner op.cit. p.105.

[liii] ibid. see also p.102:

“Dasein has access to the meaning of being - this is an immensely important point - because and only because that being is finite. Authentic being is therefor a being-toward death, a Sein-zum-Tode (one of the most often cited, least understood tags in modern thought).”

[emphasis in the originals]

[liv] Compare the quotation from Thomas Merton given earlier in a footnote to Subsection 2.

[lv] May op.cit. p.6.

May discusses the Asian influences on the development of Heidegger’s thought; these influences were substantial and were unacknowledged by Heidegger. May’s principle conclusion is that:

“... in particular instances Heidegger even appropriated wholesale and almost verbatim major ideas from the German translation of Daoist and Zen Buddhist classics.” (p. xviii)

Graham Parkes, in an essay entitled ‘Rising sun over Black Forest: Heidegger’s Japanese connection,’ (published with the translation of May’s work mentioned above) discusses how the Japanese philosopher Tanabe and Heidegger mutually influenced each other. A flavour of the Japanese philosopher’s views - which also shows their similarity to Heidegger’s - is given in the following quotations from Tanabe:

· “In the having of certain death (a having that takes hold), life becomes visible in itself.” [ibid. p.83]

· “Just as life is not merely a passage [of time], so death is not the mere termination or breaking off of such a passage. Rather death stands before Dasein as something inevitable. One can even say that it is precisely in the way life regards death and deals with it in its concern that life displays its way of being. If it flees from the death that stands before it as something inevitable, and wants to conceal and forget it in its concern with the world of relations, this is the flight of life itself in the face of itself ... One must rather emphasise that it is just there, where life voluntarily opens itself to certain death, that it is truly manifest to itself.” [ibid. p.82]

[lvi] Jacques Derrida, David Wills (trans.), The Gift of Death.

[lvii] He uses the term ‘God’ as meaning one’s deepest inner conscience:

“God is the name of the possibility I have of keeping a secret that is visible from the interior but not from the exterior.” [op.cit. p.108]

[lviii] The concept of ‘secrecy’ and its being a precondition to responsibility, plays a central role in the essay.

[lix] ibid. p.68.

[lx] ibid. p.36.

[lxi] ibid. p.36.

[lxii] ibid. p.45.

see also: “... it remains for everyone to take his own death upon himself.” [op.cit. p.44]

Joseph Campbell (in his The Masks of God: Oriental Mythology p.57) quotes an observation by Oswald Spengler to the same effect:

“The child suddenly grasps the lifeless corpse for what it is, something that has become wholly matter, wholly space, and at the same time it feels itself as an individual being in an alien extended world.”

[lxiii] Derrida op.cit. p.41.

[lxiv] ibid. p.51

[lxv] The essay is entitled ‘Euthanasia’ and is included in Foot, Virtues and Vices and Other Essays in Moral Philosophy.

[lxvi] The treating of death as contingent implies a ‘denial of death’; cf. Conclusion _{9 - 1} and Conclusion _{9 - 2} .

[lxvii] ‘X is not-G’ does not imply that ‘not-X is G’

[lxviii] J. D. Morgan, who was commenting on the link between attitudes to death and creativity, draws extensively on the works of Ernest Becker and Daniel Callahan considered later in this chapter; he teaches Thanatology at the University of Western Ontario and has edited Readings in Thanatology. Amityville: Baywood, (1996).

[Internet source: http://www.wwdc.com/death/morgan.html].

See also: Epicurus “The art of living well and the art of dying well are one.” [Quoted in Schuster op.cit. at p.1]

[lxix] This criticism has more validity in relation to the first part of her essay than to the second part; see Appendix D.

[lxx] Foot op.cit. p.49.

[lxxi] Roger Scruton, Modern Philosophy, an Introduction and Survey, p.314.

[lxxii] This is reminiscent of the comment by the American judge (quoted in the Introduction to Part 2) who said:

”There is a strident cry in America to terminate the lives of other people - deemed physically or mentally defective ... “

and also to the comment by Lord Mustill that in discussing such matters, it is essential to have in mind “... the distinction between the right to choose one’s own death and the right to choose someone else’s.” [The Bland case p.886]

[lxxiii] ibid. at p.314.

[lxxiv] though not in Foot’s analysis.

[lxxv] The attitude to death suggested by Scruton’s last category is well captured by the 18^th century German writer Lessing who, writing on the pre-Christian attitude to death, said:

“The ancients did not picture death as the grim skeleton which haunts the danses macabres of the Middle Ages ... but as the brother of gentle sleep, with torch reversed. Death is a friend.

‘Give me thy hand, thou fair and gentle creature.

I am a friend and come not to punish thee.

Be of good cheer! I am not fierce.

Thou shalt sleep peacefully in my arms.’ ”

[Quoted in Alfred Einstein Schubert the Man and his Music, at p.350.]

[lxxvi] Scruton op.cit. p.311-2.

[lxxvii] ‘individuation’ (as used by Jung) would be a more accurate term.

[lxxviii] See, for example, the writings of Dr. J. D. Morgan (mentioned above) and Arthur Koestler who stated:

"If the word death were absent from our vocabulary, our great works of literature would have remained unwritten, pyramids and cathedrals would not exist, nor works of religious art. ... All art is of religious or magic origin. The pathology and creativity of the human mind are two sides of the same medal, coined by the same mintmaster.”

[Quoted at http://www.trinity.edu/~mkearl/death.html ]

[lxxix] e.g. Joseph Campbell, Historical Atlas of World Mythology. p. xiii

"The mystery of death and the mind's requirement to come to terms with it have been everywhere the prime inspiration of spiritual inquiry and practice, ....”

[lxxx] The writings of Ernest Becker are discussed in Section 2.

[lxxxi] In the final chapter which is entitled ‘Birth, Death, and the Meaning of Life’.

[lxxxii] In Chapter 1 which is entitled ‘Death’ .

[lxxxiii] Nagel, The View from Nowhere. p.219.

[lxxxiv] ibid.

[lxxxv] The ‘human bondage’ of which Spinoza speaks.

[lxxxvi] No more so than a thorough intellectual grasp of the principles of art, makes one into an artist.

[lxxxvii] Nagel, The View from Nowhere. p.210.

[lxxxviii] ibid. p.221.

[lxxxix] ibid. p.222.

[xc] ibid. p.222.

[xci] i.e. as distinct from the conflict between the subjective and objective views of life which was the focus of the earlier part of the discussion.

[xcii] ibid. p.224. That, to which he refers in speaking of the ‘greater evil’, is not clear; it may be dying in the defence of another.

[xciii] ibid. p.225.

[xciv] Such a perspective would imply, for example, that patients who were in severe pain but who were terminally ill, but incompetent to decide on treatment withdrawal, should wherever possible be kept alive.

[xcv] ibid. p.224.

[xcvi] ibid. p.229.

[xcvii] ibid. p.231.

[xcviii] Nagel’s test for a proposed solution to a philosophical problem, actually being a solution is:

“... if a neat solution to a problem does not remove the conviction that the problem is still there ... then something is wrong with the argument and more work need to be done.” (Nagel, Mortal Questions p.x)

Nagel appears to believe that the problems of life (and death!) are resolvable through argument and analysis; presumably, (and apropos Diogenes’ argument mentioned in Section 1) he can satisfy his hunger by rubbing his books!

[xcix] The structure of Nagel’s argument is by no means clear at this point; the argument appears to be that ‘Death is an evil’ is not an independent ethical judgement but a derived proposition, logically equivalent to ‘Life is a good’ ; in short, ‘Death is an evil’ ’ º (df.) ‘Life is a good’

[c] His acceptance of this principle - thought not acknowledged to be so by Nagel - is determinative of death being an evil. See also:

“If death is an evil at all, it cannot be because of its positive features, but only because of what it deprives us of.”

(ibid. p.1)

[ci] e.g. Shakespeare has received a greater portion of death than Proust because he is dead longer. ibid. p.3

[cii] ibid. p.2.

[ciii] Perception, desire etc.

[civ] ibid. p.4.

[cv] No one finds it disturbing to contemplate the eternity before his own birth and to complain about the ‘lack of goods’ in that state. In The View from Nowhere (op.cit. p.228) Nagel mentions that Lucretius found in this asymmetry an argument against regarding of death as an evil; however, it does not convince Nagel.

[cvi] ibid. p.9.

[cvii] ibid. p.9 -10.

[cviii] A comment by Alan Watts (which was mentioned earlier in Chapter 3, Section 2 when discussing pain judgements) may clarify this:

"What we feel is to an enormous and unsuspected degree dependent on what we think, and the basic contrasts of thought ordinarily strike us as the basic contrasts of the natural world. We therefore take it for granted that we FEEL an immense difference between pleasure and pain. But it is obvious in some of the milder forms of these sensations that the pleasure or the pain lies not so much in the feeling itself as in the context. There is no appreciable physiological difference between shudders of delight and shudders of fear ... but the context of the feeling changes its interpretation, depending on whether the circumstances which arouse it are for us or against us."

[Alan Watts, Nature, Man and Woman, p.86]

[cix] A similar point can be made in relation to those dissatisfied with their bodies which, they believe, offend in some way against their ideal of beauty; must one agree that, to them, their bodies are an evil? Is not the ancient wisdom which urges them to learn to accept and love that which you cannot change, to be preferred?

[cx] Mary Mothersill. ‘Death’ included in Rachels (ed.), Moral Problems. (editions prior to 3^rd).

[cxi] ibid. p.377; see also:

“Of course, Nagel’s question - ‘Is it a bad thing to die?’ - is itself rather mystifying. Nagel says it is a question that ‘arises.’ Does it? ... What I think has happened is that Nagel has tried to transform a peculiar and interesting psychological phenomenon into a disputed point of theory.” (ibid. p.375)

[cxii] ibid. p.376.

[cxiii] In Section 2 of this chapter it will be argued that the acceptance of the proposition ‘Death is an evil’ bespeaks a ‘denial of death’, a refusal to fully accept - both intellectually and emotionally - one’s own mortality, thus implying a similar injunction; see also Conclusion _{9 - 2} : The predicates ‘good’ or ‘evil’ cannot meaningfully be applied to ‘death’ without further qualification. The assertion that ‘Death is an evil’ (simpliciter) implies a denial of death in that it implies a refusal to accept human mortality.

[cxiv] ibid. p.379 and which she attributes to Hume.

[cxv] ibid. p.383.

[cxvi] i.e. that they are equal by definition.

[cxvii] This was the argument proposed in Subsection 1.

[cxviii] Lloyd op.cit. p.117.

[cxix] Warner op.cit. p.164.

[cxx] Francis Bacon, Essays: ‘Of Death’

[cxxi] Rachels, Moral Problems, p.379:

“Either, the conclusion ‘Death is nothing to us ... repeats the premise ‘When we are, death is not come ... ,’ in which case there is no inference, or else the conclusion ‘Death is nothing, i.e. a matter of indifference to us’ is a nonsequitor.”

[cxxii] See also Kierkegaard’s concept of ‘dread’:

“One almost never sees the concept dread dealt with in psychology ... it is different from fear and similar concepts which refer to something definite, whereas dread is the reality of freedom as possibility anterior to possibility. One does not therefore find dread in the beast, ...”

[Søren Kierkegaard. The Concept of Dread quoted in Kaufmann op.cit. p.101]

[cxxiii] This is similar to the earlier argument that that which is desired is a good.

William James’ aphorism that ‘fear is fear of the universe’ [quoted in Ernest Becker (1973) at p.145] would, if true, elegantly and effectively dispose of this argument.

[cxxiv] Kübler-Ross (1975) p.27 mentions the Trukese Indians who believe:

“... life ends when you are forty; death begins when you are forty.’”

[cxxv] The relationship between ‘fear’ and ‘harm’ can be made clearer: fear exists because of a challenge to the existing ego; it is nothing but the apprehension felt at the prospect of a change adjudged to be threatening. However, the ego in order to mature must change to accommodate the wider world; to attempt to refuse change would be the road to psychosis; one consequence of this is that events which threaten the ego at one stage - and cause fear - are seen at a later stage - and by a more mature ego - to have been beneficial; the events themselves having been the cause of the maturing of the ego. This would imply that any direct correlation of ‘fear’ and ‘evil’ is simplistic.

The relationship between fear and evil is explored in Buddhism and in the philosophy of Spinoza. The Buddhist belief is that ‘fear’ and ‘ego’ are mutually independent ideas and that with maturity towards ‘egolessness’ fear will necessarily disappear. Spinoza’s philosophy implies that, when all is judged from the perspective of the universe as a whole, neither ‘threat’ nor ‘evil’ nor ‘fear’ nor ‘harm’ can exist as these are, at best, relations between parts of the universe, originating when one part presumes to a preeminence or to an unchanging status; they cannot be meaningfully asserted of the whole.

Taoist philosophy expresses a similar attitude:

“The profound and intelligent man, identifying himself with change itself, would be quiet at any occasion and follow any course. He is at one with evolution; he is everywhere. To him there is neither gain nor loss, neither death nor life. ... Whenever there is attachment, there is bondage.”

[Fung Yu-Lan. Chuang-Tzu: A Taoist Classic. p. 62.] The similarity to the philosophy of Spinoza is clear.

[cxxvi] cf. Kierkegaard’s attitude to despair (elaborated in his The Sickness unto Death):

“ ... despair is that sickness of which it is true that it is the greatest bad fortune never to have had it; ... “ [ibid. p.56]

“The relation between ignorance and despair is like that of ignorance to dread ... the dread in a spiritless person is recognisable precisely in his spiritless sense of security. ... Despair is itself a negativity, ignorance of it a new negativity.” [ibid. p.74]

“A human being is a synthesis of the infinite and the finite ... Looked at in this way a human being is not yet a self. ... That is why there can be two forms of authentic despair. If the human were self-established, there would only be a question of one form: not wanting to be itself, wanting to be rid of itself.” [ibid. p.43]

[cxxvii] Lloyd op.cit. p.9.

[cxxviii] Eastern religions consider the path to truly ethical action as being found, not through acts against self interest - the common Western view - but rather through attempts to enlarge the concept of self. Once the ‘self’ is sufficiently all-embracing (so that the actor sees himself in all others) there is no need for ethical rules: to act out of an enlightened self-interest or compassion, is sufficient. This may help explain the Buddhist emphasis (also found in philosophy of Schopenhauer) on developing compassion rather than on following rules of ‘right’ and ‘wrong’ conduct.

[cxxix] Kübler-Ross and Callahan’s views are discussed in detail in this Section.

[cxxx] J. D. Morgan, Attitudes Toward Death. [Internet source: http://www.wwdc.com/death/attitudes.html.]

Morgan continues:

“Cardiopulmonary resuscitation was developed for a select group of patients with temporary cardiac arrhythmias who would die without resuscitation. The procedure became standard practice and now the presumption is that no one should be allowed to die in a hospital without an attempt at resuscitation even though less than 20 percent survive.”

[cxxxi] Section 1, Subsection 2.

[cxxxii] Mentioned in a Sunday Times Editorial (22-3-98).

[cxxxiii] In speaking of Becker, Kübler-Ross [1975, p.143] says:

“Ernest Becker, the author of ‘The Denial of Death’ died a few weeks after I was privileged to review his manuscript. He finished a true masterpiece a few weeks before he died.”

[cxxxiv] i.e. that ‘Death is an evil’ and that ‘Death is contingent’.

[cxxxv] e.g. the response to pregnancy outside marriage ranged from forced adoption to - for a second 'offence' - incarceration in a mental hospital.

[cxxxvi] Quoted in Joseph Campbell The Masks of God: Volume 1, Primitive Mythology, p.123-31.

[cxxxvii] Anthony Clare, 'Death and Dying’ in Colm Keane (ed.) Death and Dying p.15.

[cxxxviii] Clare, op. cit. p.20:

" Ours is a culture that has been accused of being evasive in the face of death. We use euphemisms for death itself ... The real loss of innocence is not a child's discovery of sex but of death, of his or her own mortality."

see also his comments in The Irish Times [1.7.1998]:

" ... exploration or analysis of death ... was not morbid but was the very essence of life ... to see and face death and to go on living was to live enriched."

[cxxxix] It is indeed ironic that, although discussion of sexuality was a taboo amongst Victorians, discussion of death was not. Callahan refers to an article by Geoffrey Gorer entitled ‘The pornography of death’ (1955) which called attention to the peculiar way in which Victorian sexual constraints were gradually overthrown but those same constraints were subsequently used to suppress the public expression of death.

[Daniel Callahan. The Troubled Dream of Life: Living with Mortality, p.30.]

[cxl] Daniel Liechty. Transference and Transcendence: Ernest Becker’s Contribution to Psychotherapy, p.103.

[cxli] Ernest Becker. The Denial of Death (1973) p. ix.

[cxlii] Liechty, op.cit. p.102.

[cxliii] Becker (1973) p.33. Cartesian dualism is a paradigm of man’s refusal to accept his ‘creatureliness’.

[cxliv] Liechty p.56-7. Becker notes (op.cit. p.37) that “... ‘paradoxically ‘children toilet train themselves’.”

[cxlv] Becker [1973, p.33]; this finds an echo in Montaigne who, in speaking of royalty, observed that ‘even on this highest throne they are seated on their arses.’

[cxlvi] ibid. p.23; Heidegger also considers that one of the manifestations of ‘inauthenticity’ is ‘frenetic busyness’ [Steiner op.cit. p.99]. Kierkegaard’s perspective is similar, he notes, wittily:

“The biggest danger, that of losing oneself, can pass of in the world as if it were nothing; every other loss, an arm a leg, five dollars, a wife, etc. is bound to be noticed.” [The Sickness unto Death p.62]

[cxlvii] Liechty op.cit. p.63.

He continues (p.76):

”... human beings spend most of their psychic energy in the creation of symbols of immortality that allow, at least momentarily, suppression from consciousness the fact of their mortal, animal nature.”

[cxlviii] Liechty op.cit. p.173.

[cxlix] Although Kübler-Ross believes that it is therapeutically unwise and basically unkind to force a patient to give up this denial when it is truly needed.

[cl] Becker (1973) p.217.

[cli] Liechty op.cit. p.165.

[clii] ibid. p.166.

[cliii] Quoted in Fritjof Capra, Uncommon Wisdom, p.109.

[cliv] [1975, p.xv] “For many years I continued to ask terminal patients to be our teachers.”

[clv] The writings that have been consulted are, primarily, On Death and Dying (1970) and Death: The Final Stage of Growth (1975).

[clvi] The schema should be considered as indicating a direction rather than a progression; the stages are not as steps on a ladder but often coexist. The schema is not restricted to death but also encompasses events such as divorce and retirement where essentially the same steps will be traversed; Kübler-Ross expresses this by saying:

“ ... dying is something we human beings do continuously, not just at the end of our physical lives on this earth.”’

[(1975) at p. 145]

[clvii] e.g. People who respond to the patient’s attempts to broach the question of death with total avoidance or false optimism or discouraging comments such as: "Don't be morbid" or "Don't dwell on it".

[clviii] (1970) p.35; she quotes one of La Rochefoucauld’s maxims: “We cannot look at the sun all the time, we cannot face death all the time.’

[clix] She notes that none of the patients who did, in fact, live until their goal was accomplished, ‘have kept their promise.‘ [Kübler-Ross (1970) p.73]

[clx] ibid. p. 99.

[clxi] Her views on this will be considered further in Section 3 of this chapter which deals with the concept of ‘a good death’.

[clxii] She begins the last - as she does each - chapter of On Death and Dying with some lines by Rabindranath Tagore.

‘Death belongs to life as birth does.

The walk is in the raising of the foot as in the laying of it down’.

[clxiii] Kübler-Ross (1975) p. x-xi.

[clxiv] ibid. p. 5.

[clxv] Kübler-Ross (1970) p.11.

[clxvi] in Section 1.

[clxvii] Kübler-Ross (1970) p. 2.

[clxviii] Kübler-Ross (1975) p.126, where she also spoke of her experiences in Nazi Germany.

[clxix] ibid. p.1

[clxx] Discussed in Section 1, Subsection 3.

[clxxi] Kübler-Ross (1975) pp 164-5 [emphasis in the original]; compare with the passage from Jaspers quoted earlier (in Section 1 Subsection 3):

“ ... dead-ends but frontiers where being-in-itself is to be encountered. Death, for example, so long as I am forgetting it or fleeing from it or merely taking note of it as the inevitable end, is just an empirical fact about an empirical object in the world of being-there; it is not constitutive of my life, and in so far as it is not I am not living at the level of being-oneself.” (H.J. Blackham, Six Existentialist Thinkers, p.52)

and (Steiner, Heidegger, p.94):

“Inauthentic Dasein lives not as itself but as ‘they’ live. ... It ‘is lived’ in a hollow scaffolding of imposed, anonymous values. In inauthentic existence we are constantly afraid (of other men’s opinions, of what ‘they’ will decide for us, of not coming up to the standards of material or psychological success …). Fear ... of this order is part of the banal, prefabricated flux of collective sentiment. Angst is radically different. ... Angst is a mark of authenticity, of the repudiation of ‘theyness’.”

The similarity is eloquent testimony to the practical value of Continental philosophy.

[clxxii] Section 1, Subsection 4.

[clxxiii] Kübler-Ross (1970) p.218.

[clxxiv] [Kübler-Ross (1975) p xix]:

“Our main problem was with the physicians.”

[clxxv] Kübler-Ross (1970) p.28; see also p.29:

“The need for denial is in direct proportion with the doctor’s need for denial.”

[clxxvi] ibid. p.220.

[clxxvii] ibid. p.222.

[clxxviii] ibid. p.223.

[clxxix] ibid. p.224.

[clxxx] ibid.

[clxxxi] ibid. p.229.

[clxxxii] The existence of such a hubris amongst physicians is discussed by Hans Mauksch in his essay entitled ‘The Organisational Context of Dying’ which is included in Kübler-Ross (1975); and by Jacob Needleman in an essay entitled ‘The Two Sciences of Medicine’ included in his The Indestructible Question.

[clxxxiii] Kübler-Ross (1970) p.148.

[clxxxiv] Such activism is indicative of death denial cf. James B. McCarthy. Death Anxiety: the Loss of Self.(p.11):

“Perhaps the most widely used security operation that holds the fear of death at bay is the ‘manic defence’, a concept illuminated by Donald Winnicott and derived from the early work of Melanie Klein. ... Winnicott explains that a great variety of activities can provide reassurance against death. ... Being ‘too busy to think’... The need to be constantly occupied, the inability to tolerate aloneness with oneself, the rush to fill leisure time with social activity ... are illustrative of the manic defence against depression and fear of death.”

(Compare also with Becker’s view mentioned in Subsection 1).

[clxxxv] It is also seen in the tendency to speak of death in military terms; one of the most incongruous examples is in the phrase ‘no heroic measures’ when used in relation to the withdrawal of medical treatment thus permitting a person to die; if heroism is to be decreed surely it is to those who, in the face of the current ideology of aggressive medical interventionism, allow a person to die peacefully. On this theme Kübler-Ross notes (in a quotation which I cannot, at present, trace):

“While medicine considers its hi-tech interventions ‘heroic measures’, the real truth is that just being there for the patient is the real measure of heroism.”

[clxxxvi] Kübler-Ross (1970) p.8.

[clxxxvii] ibid. p.223.

[clxxxviii] As will be argued later in this Subsection the distinction between regarding clinical medicine as a scientific discipline and as a caring discipline is of crucial importance to the discussion of death denial.

[clxxxix] Hans Mauksch in his essay ‘The Organisational Context of Dying ’ [included in Kübler-Ross (1975) p.23] refers to Erving Goffman’s concept of the ‘stripping process’ whereby total institutions - such as hospitals, especially mental hospitals, convents and the military - strip the individual of his autonomy and identity, ostensibly for the greater efficiency of the institution. In a hospital this is accomplished by subtle expressions of power e.g. by patients being kept waiting, by the use of plastic name tags, by obligatory hospital clothes; the result is that the ‘personhood’ of the patient is diminished and the objectification of the patient increased.

[cxc] Kübler-Ross (1970) p.8.

[cxci] Kübler-Ross (1975) p. 25.

[cxcii] [Kübler-Ross (1970) p. vii]:

“Medicine should not confine itself to the prevention of death any more than family planning should confine itself to the prevention of birth.”

[cxciii] Kübler-Ross (1970) p.233.

[cxciv] ibid. p.126.

[cxcv] ibid. p.78.

[cxcvi] Institute of Medicine Approaching Death: Improving care at the End of Life.

[cxcvii] ibid. p.265.

[cxcviii] ibid.

[cxcix] [ibid. p.269]:

“Textbooks and other material likewise need revision to reflect the reality that people die and that dying patients are not people for whom ‘nothing can be done’.”

Callahan recounts a telling anecdote:

“ ‘Death’, Dr Otto Guttentag told me well over two decades ago, ‘has no place in modern medicine. Only pathologists take death seriously.’ I thought at first he was simply making a joke. He was not. Death is for the most part absent in modern textbooks of medicine ...” [The Troubled Dream of Life p. 73]

[cc] Esther B. Fein, ‘Failure to Discuss Dying Adds to Pain of Patient and Family’; New York Times on the Web March 5, 1997. [Internet source: http://nytsyn.com/newsservice/index.html ]

[cci] Institute of Medicine, Approaching Death, pp. 265-271.

[ccii] The Hastings Center Report 1.7 Research, Clinical Practice, and the Care of the Dying. [Internet source: http://www.cpn.org/sections/affiliates/hastings_center.html ]

The project is under the direction of Daniel Callahan and is described as:

”This project proceeds on a somewhat different track from those which have marked the termination of care debate in this country. Its premise is that modern medicine is, at its core, ambivalent and even schizoid on the problem of death, uncertain whether to accept death as a necessary part of life and medicine, or to see death always as the enemy, to be vanquished. Where clinical medicine, at least of the sensitive kind, works hard to find a place for death in the humane care of patients, research medicine still has death as its declared enemy. For researchers, there are no acceptable causes of death. The net result is that medicine is fundamentally torn, unable to decide whether death should be accepted, as clinicians well understand, or rejected, as researchers seem to imply in their agenda of eliminating the causes of death. The aim of the project is to see if medicine can find a better way of conceptualizing its stance toward death, with the hope that the schism within medicine on this crucial subject can be healed.”

[cciii] BMA (1999a) 1.4.1.

The report also notes that:

“Many nurses have reported concern about what they perceive as ‘moral distancing’ on the part of some doctors. They consider that those who make the decision generally delegate its implementation to nurses, who can feel unhappy if they have not been able to contribute in any way to that decision.” [BMA (1999a)3C.18.2]

[cciv] Institute of Medicine Approaching Death at p.269.

[ccv] op.cit. p.263-4.

[ccvi] ibid. p.264.

[ccvii] ibid.

[ccviii] ibid.

[ccix] ibid. p.134.

[ccx] William Ruddick ‘Do doctors undertreat pain?’ Bioethics. (p 3). Ruddick has written about the tendency amongst physicians to ‘psychologically forget the patient’s pain’ and to see it only as a useful indicator of disease. Ruddick’s article was discussed in Chapter 3, Section 5.

[ccxi] op.cit. p.1.

[ccxii] Leo Alexander. ‘Medical science under dictatorship’ New England Journal of Medicine at p.45.

[ccxiii] ibid.

[ccxiv] The fact that the hospice movement with its emphasis on caring rather than curing, developed outside the traditional medical structure is also indicative of how modern medicine defines itself in terms of ‘curing’ rather than ‘caring’.

[ccxv] Alexander op.cit. p.45.

[ccxvi] Alexander argues that such programmes were widely discussed in medical circles before the Nazi’s took charge in Germany:

“Sterilization and euthanasia of persons with chronic mental illnesses was discussed at a meeting of Bavarian psychiatrists in 1931. By 1936 extermination of the socially unfit was so openly accepted that its practice was mentioned incidentally in an article in an official German medical journal.” [op.cit. p.39]

[ccxvii] This topic is considered in more detail both in the next chapter and in an appendix on the development of euthanasia in pre-war Germany (Appendix E).

[ccxviii] For example, the well respected BBC series The Nazis: a Warning from History in its discussion of child euthanasia implied that such programmes originated with the Nazis; it made no mention of the fact that such programmes had been widely discussed in academic circles as far back as 1920 (see the discussion of the proposals by Binding and Hoche in Appendix E).

[The Nazis: a Warning from History; Part 2 (shown on BBC2 29-7-00)]

[ccxix] Andrews (1993a) p.1601.

[ccxx] Gillon (1993) p.1603.

[ccxxi] ibid. p.1603.

Alexander’s riposte (op.cit. p.45) to the scarce resources argument is apposite:

“There has never in history been a shortage of money for the development and manufacture of weapons of war; there is and should be none now”

[ccxxii] I came across Daniel Callahan’s book -The Troubled Dream of Life: In search of a Peaceful Death - by chance, when the main ideas of this thesis, and particularly of this chapter, had begun to take shape. It was a time when my confidence in my approach was at a low ebb and it was most encouraging to find many of the ideas that I wished to elaborate, being shared by such an eminent and experienced commentator and being espoused with such eloquence and conviction. To him, I wish to express my deep gratitude.

[ccxxiii] Callahan [op.cit. p.28] where he notes the insistence of many moderns ”... that death must have been worse in earlier times.” His response is that then people typically died of infectious diseases and that the long and lingering death of modern times was uncommon.

[ccxxiv] op.cit. p.41.

[ccxxv] ibid. p.70.

[ccxxvi] ibid. p.13.

[ccxxvii] ibid. p.35.

“ ... we have discovered in the language of choice and rights still another kind of evasion ... we choose ‘choice’ about death, rather than death itself, as the new, supposedly liberating focus.”

[ccxxviii] ibid. p.153-4.

[ccxxix] ibid. p.92.

[ccxxx] Callahan does not deny the limited usefulness of such as living wills; however when used as a strategy for dealing with death they become implements of death denial. He believes the attempt to exert control over one’s living and dying has having an almost ‘driven quality’ [op.cit. p.16] and that the preoccupation with control has become both subtly demeaning and socially troubling. [op.cit. p.17].

Callahan states [op.cit. p.155]:

“Should I want some control over my life and death? Of course. Should I think that I am somehow less of a person when I cannot have that control? No. Should I have a right to specify conditions for the medical management of my dying? Yes. But if I am thereby led to make myself someone who cannot endure the thought of not having control over death itself, I will have done myself great harm.”

[ccxxxi] ibid. p.101.

[ccxxxii] ibid. p.34.

[ccxxxiii] ibid. p.122.

[ccxxxiv] ibid. p.123-4.

”Our first task at present is to recapture our mortality, to give it once again a meaningful relation in our lives. Death must be brought back to the surface, given its rightful place ... The fact of its inevitable triumph - its ultimate necessity - must be built into the very definition of medicine ... the way of wisdom for the Greeks was the acceptance of necessity ... ”

[ccxxxv] ibid. pp. 74, 57-58.

[ccxxxvi] ibid. p.74 [emphasis in original].

[ccxxxvii] ibid. p.157.

[ccxxxviii] ibid. p.59.

[ccxxxix] ibid. p.198.

[ccxl] referred to earlier (Introduction to Section 2).

[ccxli] op.cit. p.198.

[ccxlii] e.g. Callahan (op.cit. p.211) sees the US health care system as embodying the view that:

“ ... physicians owe it to their patients to provide the most aggressive life-extending treatment, regardless of cost.”

[ccxliii] ibid. p.229.

[ccxliv] It has been mentioned earlier (Chapter 1, Section 3); it will be discussed again in discussing personhood (Chapter 10).

[ccxlv] Such as when (ibid. p.165) he asserts that:

”Only if we understand life to be a good and death to be an evil can it make sense to us to speak of some deaths as more tolerable than others.”

[ccxlvi] See the earlier discussion of Foot’s argument in section 1 subsection 3 and in Appendix D.

[ccxlvii] In an attempt to clarify my suggestion that the problem lies in the level of abstraction, consider the examples of ‘a book’ or ‘a journey’. Both of these are, of their nature, limited - in the sense that a book, to be a book, must have an end and, equally so, a journey. To ask whether it is a ‘good’ for a book, or a journey, to have an end is obvious nonsense. The nonsense can be concealed however by considering a higher level of abstraction. The concept book_U (or equally journey_U) - i.e. an unlimited ‘book’, one not necessarily limited by an end - and the abstract concept of ‘End’ can apparently permit the question of whether ‘Is it a ‘good’ for a book_U to have an End?’ to be posed. This is precisely what is occurring when the questions ‘Is life a good?’ or ‘Is death an evil?’ are asked.

[ccxlviii] ibid. p.178.

[ccxlix] ibid. pp 168-170.

[ccl] To such as Owen Flanagan (in his Consciousness Reconsidered) a life lived without the possibility of ‘life-plans’ would put the very existence of personhood in doubt.

[ccli] see Kübler-Ross’s observations earlier in this section at Subsection 1; see also Heidegger’s view that ‘frenetic busyness’ ‘lust for novelty’ and ‘self-scattering’ are the marks of an inauthentic life lived in a denial of death. [Steiner op.cit. p.79, 99; and the discussion on Heidegger in Section 1, Subsection 3.]

[cclii] Callahan op.cit. p.95.

[ccliii] ibid. p.133. In this context the term ‘person’ is best understood as the social being rather than the physical being; cf. Chapter 10.

[ccliv] ibid. p.128. Callahan refers to Viktor Frankl as saying that the last of the human freedoms is to choose one’s attitude; see also p.142.

[cclv] Callahan makes a distinction between ‘self-mastery’ and ‘self-control’.

[cclvi] ibid. p.131.

[cclvii] ibid. p.147.

[cclviii]Callahan op.cit. p.141; see also p.144:

“I want only to work against the assumption that we cannot possibly do well by others unless we can relieve their suffering, that we must relieve one another’s suffering.” [emphasis in original]

[cclix] Kübler-Ross(1970 p.105) has spoken of the importance of recognising that some patients in their dying want no outside interference, just silent understanding:

“When our patients reached the stage of acceptance and final decathexis, interference from outside was regarded as the greatest turmoil and prevented several patients from dying in peace and dignity.” [ibid. p.237]

[cclx] Sherwin B. Nuland in an essay ‘The Doctor’s Role in Death’ [included in Spiro, Curnen, Wandel (eds.) Facing Death which is a series of essays, by physicians from the Yale Medical School, on attitudes to death] describes the development of his own attitudes to the role of medicine:

“By the time I was senior in medical school, I was no longer someone who thought that the greatest good I could achieve was the relief of human suffering. Instead I had begun to believe that the greatest good I could achieve was the solution to The Riddle of disease “. [op.cit. p.39]

“As physicians, we abandon our patients too frequently, and almost universally. I attribute this failure again to our fascination with The Riddle of disease. It is the riddle of diagnosis and therapy that captivates us. When we realise that there is no longer anything we can do, the very stimulus that has made us excellent doctors in an intensive care unit is lost: we lose interest in our patients as individuals because we have lost our interest in their now insoluble Riddle. We must reorient ourselves to an image of us not only as enemies of disease but also as people who stand by the values that brought most of us into medicine - the values that inform us that our primary mission is to relieve human suffering.” [op.cit. p.42]

[cclxi] Callahan op.cit. p.209.

[cclxii] In the sense of it not providing a viable belief system from which to live one’s life. These are distinct grounds. It was John Dewey, I believe, who suggested that it was not the truth of a belief that was of importance, but whether the belief permitted us to live life well.

[cclxiii] This way of tackling the problem of defining ‘a good death’ was suggested by a comment in Callahan’s book where he spoke of ‘just listening to people talk about the death they would like’. [op.cit. p.195]

[cclxiv] It was mentioned at the beginning of this chapter that the Greek term ‘arete’ - often translated as virtue and which appears to us to be an ethical term - was used by the Greeks to refer to the ability to respond appropriately to the existing circumstances.

[cclxv] Discussed earlier in Section 1, Subsection 2; and in Appendix D.

[cclxvi] It is possible to include this last condition under the ambit of Justice if Justice is considered to have two aspects: an individual aspect ‘Justice_I’ and a social aspect ‘Justice_S’ ; this is discussed further in Chapters 10 and 11. I wish to thank Dr. Dolores Dooley for this suggestion.

[cclxvii] Margaret Pabst Battin, The Least Worse Death.

[cclxviii] Battin op.cit. p.36 [emphasis added]

[cclxix] Callahan op.cit. p.180:

“But is a ‘lesser evil’ standard strong enough? I think not.”

[cclxx] To answer this question fully it is first necessary to clarify the concept of ‘personhood’ and, in particular, the necessary conditions for its ascription (this is done in Chapter 10); this gives us the tools to enable a more rigorous discussion of the nature and limitations of the obligations imposed on medical carers to help a patient achieve ‘a good death’ (this discussion is the focus of Chapter 11).

The discussion which follows sets out the views of Kübler-Ross and Callahan on the obligations imposed on medical carers in relation to ‘a good death’ and seeks to draw some broad conclusions; it is best considered as being preliminary to the discussion in Chapter 11.

[cclxxi] I use the word 'occasioned' rather than 'caused' as the later suggests, in certain contexts, a degree of opprobrium; a (justifiable) withdrawal of treatment which forseeably leads to death would ‘occasion’ that death.

[cclxxii] Kübler-Ross (1975) p. 36.

[cclxxiii] as mentioned earlier in Section 2.

[cclxxiv] Kübler-Ross (1970) p.7

[cclxxv] [Kübler-Ross (1970) p.8]:

“Slowly but surely he is beginning to be treated like a thing. He is no longer a person. Decisions are made often without taking his opinion. If he tries to rebel he will be sedated ....”

[cclxxvi] These categories are distinct: a PVS patient, for example, is not dying yet it can be contemplated that they might wish to die; though see Callahan’s criticism (below) of the phrase ‘is dying’. Perhaps, both cases can be subsumed under the phrase ‘entered onto the threshold of death’ - i.e. where death is an immanent possibility.

[cclxxvii] There the argument will be developed that, in accordance with the necessary condition for personhood to be established in Chapter 10, a permanent loss of the ability to communicate entails a loss of personhood. This loss of personhood in turn entails that the requirements of Justice - in the sense of the obligation of non-interference - lapse. In such situations the requirements of Charity are gainsaid only by the interests of the wider society, if at all.

[cclxxviii] Section 2, Subsection 2.

[cclxxix] ibid. p.180.

He believes that death can be deformed in three ways;

- by ‘deforming the process of dying itself’ - as in technological brinkmanship which can ‘both save life and ruin dying’ as when it results in extended loss of consciousness;

- by ‘deforming the dying self’ - as with obsessions with loss of control or loss of image.

- by ‘deforming the community of living’ as when community life is distorted thorough the denial of death or through doctrines that certain lives are not worth living. [Callahan op.cit. p.192]

[cclxxx] ibid. p.200:

“I call such a death a ‘moral good’ because it allows us to achieve important personal as well as social ends.”

[cclxxxi] i.e. they are premature and untimely.

[cclxxxii] ibid. p.185.

[cclxxxiii] ibid. p.199.

[cclxxxiv] ibid. p.183.

[cclxxxv] ibid. p.184.

[cclxxxvi] I have earlier used the phrase ‘entered on the threshold of death’ - i.e. that death is ‘on the agenda’, a possibility - in place of the phrase ‘dying’; I believe that this meets Callahan’s objections.

[cclxxxvii] ibid. p.44-46.

[cclxxxviii] The BMA, for example, have stated:

“... there are strong arguments for complying with reasonable requests from competent patients for treatment to be continued for a limited period to allow them to achieve a particular goal or to sort out their affairs. What is ‘reasonable’ will need to be judged on an individual basis, taking account of factors such as the patient’s ability to achieve the goal, the time it would take to do so and the potential opportunity costs for other patients who may be denied treatment as a consequence of respecting the patient’s wishes.” [BMA (1999a) 2.11.1 ]

[cclxxxix] By using the concept of ‘personhood’ ( which is discussed in Chapter 10) a more detailed examination of the nature of these obligations is possible; this is carried out in Chapter 11.

[ccxc] Kübler-Ross(1970) p.156, [emphasis added].

[ccxci] Kübler-Ross (1975) p. 36.

[ccxcii] The phrase ‘unfinished business’ refers to any issues that have not been fully dealt with in our lives and for which we feel the need for resolution. Kübler-Ross has commented [Kübler-Ross (1970 p.241] :

“We are always amazed how one session can relieve a patient of a tremendous burden and wonder why it is so difficult for staff and family to elicit their needs, since it often requires nothing but an open question.”

[ccxciii] as, for Roman Catholics, in confession.

[ccxciv] Section 2, Subsection 2.

[ccxcv] The New England Journal of Medicine in its ‘Sounding Board’ of October 23, 1997, Vol. 337, No. 17, says

“By authoritatively pronouncing that terminal sedation intended for symptomatic relief is not assisted suicide, the Court has licensed an aggressive practice of palliative care.”

[ccxcvi] Speaking in the first person, Callahan defines a ‘peaceful death’ by the following criteria:

I want to find meaning in my death or at least be reconciled to it;

I hope to be treated with respect and sympathy;

I would like my death to matter to others;

I do not want to die abandoned;

I do not want to be an undue burden on others;

I want to live in a society that does not shun death;

I want to be conscious;

I want my death to be quick and not drawn out;

I hope that I can bear pain well if it is unavoidable.

[op.cit. p.195]

[ccxcvii] Callahan op.cit. p.54.

[ccxcviii] ibid. p.185.

[ccxcix] Kübler-Ross (1975) p. 36.

[ccc] A few days before his death Kozan Ichikyo called his pupils together, ordered them to bury him without ceremony and forbade them to hold services in his memory. He wrote the following poem on the morning of his death, laid down his brush and died sitting upright:

“Empty-handed I entered the world

Barefoot I leave it.

My coming, my going -

Two simple happenings

That got entangled.”

from Yoel Hoffman (ed.) Japanese Death Poems. [Quoted in the Internet magazine Salon, in an issue devoted to death and dying. Internet source: http://www.salon.com/weekly/intro960805.html]

[ccci] Included in Morgan, Peggy & Lawton, Clive (eds.) Ethical Issues in Six Religious Traditions at p.33.

[cccii] Quill, Dresser and Brock ‘The Rule of Double Effect - A Critique of Its Role In End-of-Life Decision Making’ New England Journal of Medicine 337, 24, (1997) are critical of the doctrine and of attempts to use it to justify the practice of ‘terminal sedation’.

[ccciii] See the earlier discussion in Chapter 6, Section 3, Subsection 1(ii).

[ccciv] i.e. drugs the use of which use can be justified under the doctrine of double effect in that they are painkillers but which can also forseeably result in death.

[cccv] Keizer has written (in his Dancing with Mr. D) on the practice of euthanasia in the Netherlands.

[cccvi] This, and the following testimonies, was reported in an article in the Sunday Times of 27.7.1997.

[cccvii] One of Callahan’s criteria for a ‘peaceful death’ was that it did not deform or distort the dying process; he listed three ways in which this might happen, the third being ‘the deforming of the community of the living’.

[cccviii] then termed ‘a good death’.

[cccix] The nature of this obligation is discussed more fully in Chapter 11.

[cccx] i.e. one for whom death is an immanent possibility.