Death and dying, event and process, have always generated personal problems, the physical and emotional agonies of grief. Witness the biblical accounts of David's sorrow at the deaths of King Saul and his son, Jonathan, of his son with Bathsheba and his son, Absalom. Some of the works of the greatest authors in English literature (Shakespeare, Milton, Poe, Frost and many others) cry out in grief.
However, as is true of the rest of life, the way people die has changed in the modern world. Not long ago, death came from a limited number of sources and most of them were little affected by human intervention. Assault, warfare and accidents produced injuries for which medical care was often inadequate. There was no effective cure for many diseases. Repetitive childbirth drained the life out of women. All of these causes of death were viewed as normal, something that happened and could not be avoided. Grief then was no less than that which death brings today, but it was different.
Now, many of the old diseases have been eradicated or controlled. Surgeries have gone from being serious but life-saving to "minimally invasive" events done in the morning and out of the hospital in the afternoon. Victims of injuries are routinely saved. Few women give birth every other year and rarely does one die in childbirth. Death has come to be viewed as unnatural, indefinitely avoidable. This baseless expectation gives rise to a host of issues.
For example, physicians and hospitals are not supposed to let anybody die. They're culpable if they do. They are to be blamed, even sued. There are some lawyers that encourage such action. Physicians and hospitals carry heavy liability insurance, whether it is ever needed or not and the cost for this insurance makes its way into bills that patients pay. This is one part of the problem of health care costs in this country. Beyond that, physicians do not like to bear a burden of blame for death which they are powerless to prevent.
Death is natural. It is the ultimate solution to the great problems of human life. James Weldon Johnson, genius singer of the soul of the South, in his folk opera, "God's Trombones," depicts God summonsing His servant Death to go down and fetch the soul of his suffering child Caroline and bring her to the arms of God.
No matter how fortunate a person's genetic makeup, no matter how marvelous the health care interventions available, there comes a time when every human body wears out, tears up or sickens to death. What happens then?
Physicians by personal code and professional preparation are committed to saving life. Hospitals are founded for that purpose. They don't like to endure the displeasure of patients or their family members. However, sooner or later, patients have terminal conditions. We are all going to die. With the health care system oriented to keeping people alive, what is to prevent the perpetuation of suffering for people who are dying, sometimes over a long time?
Face it. In spite of all of the miracles of modern medicine, there are illnesses that cannot be cured, must be endured for years. Alzheimer's disease, which can take many years to run its awful course, is the most obvious. Its latter stages can entail months in a vegetative state. In fact, there are many others for which there is no cure and little positive intervention. So, one issue - a big one - when is death to be permitted, rather than perpetually postponed, in cases where treatment is in fact cruel?
Of course, there are solutions for some situations. One of the best is hospice care, whether at home or in a facility. Comfort, including unstinting pain management, is the norm. I have nothing but good things to say for this approach to patient care. However, it does not fit every problem, even many serious long-term problems.
In the final analysis, people who want to have a say in how they are allowed to die in such problematic situations should consider carefully their options and document their choices. Those who want to live as long as they can no matter what their condition, have a right to do so and should inform physicians and family. Those who want to set limits on treatment and survival conditions should prepare two enabling legal instruments - a living will and a durable power of attorney for health care.
A living will provides to physicians and other health care professionals specific guidance about the kind of interventions the person permits. Notice the word permits. The patient gets to choose. It is a legal document. It includes a choice of conditions: terminal condition, comatose state, persistent vegetative state. The maker can choose any one or all three. It includes a list of interventions that should be included or excluded. Every physician consulted and every hospital entered should be provided a copy to be scanned into their records.
The durable power of attorney for health care appoints a trusted person who knows the maker well to make decisions about health care when the person is unable to do so. If the patient cannot communicate because of injury or illness, his or her designated representative is given the power to make crucial decisions. The person holding durable power of attorney for health care may not be a close relative or one who might possibly gain if the patient should die. What is important? Intimate knowledge of the mind and wishes of the potential patient and capacity to carry out those wishes.
As in case of a regular will, I recommend the services of a good attorney in drawing up these documents and thoughtful preparation throughout the process. I also recommend that everyone, regardless of age, have these instruments of self-determination. You have a right to make these important choices. Do it ASAP. You have no promise of tomorrow. And as the poet said, "Golden boys and girls all must, as chimney sweepers, come to dust."
Roger G. Branch Sr. is professor emeritus of sociology at Georgia Southern University and is a retired pastor.