A National Hospice Foundation survey some years ago found that Americans are more inclined to discuss safe sex and drugs with their children than they are to talk with their terminally ill parents about preparing for death. Although this may sound reasonable—unsafe sex and illicit drugs pose a threat more immediate than death—the consequences of avoiding talk of human finitude have been disastrous.
As a medical doctor, I have cared for countless patients who have approached life’s end without giving it much thought. Such patients often wind up dying highly medicalized deaths. They approach their graves having exhausted limitless technologies and therapies, including those unlikely to help. They don’t die the way that most of us hope for—at home, in bed, surrounded by family. And those they love are often left reeling from the experience.
With COVID-19 upon us, the threat of mortality is very real, even for the young. Yet preparing well for death is not what occupies the news. Instead, the conversation is focused on minimizing spread, treating disease, and amassing personal protective equipment—all necessary measures to safeguard public health. But the fallacy here is that all of these efforts are mobilized in opposition to death when the reality is that many will die—from the infection, its complications, or something else. Pandemic increases the odds of dying imminently, but mortality has always been 100 percent.
So what are we to do? Of course it is prudent to avoid crowds, wash hands, and call your doctor if you’re sick. But this is the domain of prevention, of thwarting death. These are short-term actions that we hope have long-term consequences. But they offer no cure for what ultimately ails us. They do not solve the problem of our mortality, nor do they provide the tools to prepare for it.
From the late Middle Ages until about a century ago, preparation for death was part of life. In order to die well, one had to live well, and this was worked out in communities over a lifetime. It wasn’t random or subjective. Rather, it was profound and coherent. Daily life itself was interwoven with the practices, rituals, catechisms, prayers, and beliefs concerned with preparing for death. Society today may have lost some of that coherence, but religious traditions continue to offer the tools for wrestling with human finitude, if we’re willing to consider them.
Will COVID-19 change the way we think about our mortality? It should. And it could start on a personal level. Do you know anyone of retirement age or anyone with a compromised immune system? Most of us do. What sorts of conversations have you had with them about human finitude?
When I ask this, people often counter that they don’t even know how to begin. Here’s a start: “Mom, Dad, if you caught the coronavirus and became so sick that you couldn’t make your own medical decisions, who would you want to make them for you?” Although this question is intended to establish a legal health care proxy, it leads naturally into questions about life support and end-of-life wishes. You can ask for their thoughts about “breathing tubes” and mechanical ventilators and whether they would want cardiopulmonary resuscitation or “CPR” if their hearts were to stop. You can rehearse the arguments against the efficient elimination of human life, against the misleadingly-named but increasingly vocal “death with dignity” movement. You can promise your presence. You won’t abandon them.
If this sounds too medical, numerous resources exist to assist the non-clinician. The founder of the nonprofit Aging with Dignity published a document called Five Wishes based on his work with Mother Teresa’s homes for the dying. Five Wishes gently guides the reader through five domains relating to decision-making authority, end-of-life wishes, comfort-related care, treatment with regard to personal matters, and how the dying wish to be remembered.
These sorts of discussions do much to mitigate dread of an isolated death in an anonymous intensive care unit. But their real value lies in their ability to pivot the conversation to what really matters, the so-called “big questions”—questions of human existence and of ultimacy. Why am I here? What is life for? What happens when I die?
Of course philosophers, priests, and rabbis have been wrestling with these topics for millennia. And they’ve written intelligently and persuasively about how to make sense of them. The work has been done; we don’t need to recreate it. But we do need to stop ignoring it. We must start to face our finitude and rehearse for death.
COVID-19 is giving us another chance.
L. S. Dugdale is a physician and medical ethicist at Columbia University and author of the forthcoming The Lost Art of Dying.