A Good Death?

"Heart attacks are the number one killer of middle aged men!"
"20,000 people per year die needlessly because of the lack of effective treatment for this disease."
"20% of eighty-year-olds who will die this year will die of complications from Alzheimer's."
"Pancreatic cancer accounts for only 1% of the annual cancer diagnosis rate, yet 15% of the annual cancer death rate."

Fundraising for scientific charities or research, advocacy for federal funding, and bioethical arguments concerning medical technologies or public policy goals will often quote statistics concerning the death rate for a particular condition or set of circumstances.

(I just made all those statistics up, by the way. This is not the blog to read for accurate scientific data.)

These statistics are deployed in order to convince the listener/reader of the urgency of the need for donations, funding, excellent students to enter the field, policy changes, or whatever is being sought. "20,000 people per year? Oh, that's terrible." "What? The number one cause of death? That's where our research dollars need to go!!" "Such a high proportion of deaths? We must do something about that."

Because the answer to the implied question--"How many people per year should die of this or that condition?"--must, of course, be, "None, if we could prevent it!"

30,000 children under the age of 5 die every day from starvation-related causes. (That's one statistic I didn't make up, actually.) How many children should die every day from starvation-related causes? If your answer is not a resounding "NONE!" you are an inhuman monster.

How many people per year should die of pancreatic cancer? None, if we can prevent it.
How many people per year should die of AIDS-related illnesses? None, if we can prevent it.
How many people per year should die of MRSA? of heart disease? of leukemia? of renal failure?

None. Of course.

But the argument takes a different turn when you begin to ask a different question. Of what should people die?

What should be the number one killer?

In some cultures and in some times, the answer to this question was more clear. People should die in battle, if they could arrange it. Or they should die while on the hunt, or with their families, or in service to the gods. When one acknowledges that one must die, it is not too difficult to imagine better and worse ways to die.

Francis Bacon changed the course of history when he challenged the world to "call no disease incurable." Medical sciences--indeed, all the sciences--were given free reign. Any stricture, any obstruction, any challenge to biotechnological progress began to be considered an unfair or irrational or superstitious refusal to save people that could be saved.

After Bacon, the answer (largely implicit) to the question (largely unasked) "What should be the number one killer?" is a resounding, "Nothing." There are only bad and worse ways to die.

For the braver among us, those willing to conjecture about our own deaths, the answer might be "Old age." When pressed, most of us would like to die peacefully in our beds, having been cogent and independent up until the very end, with a minimum (if not a complete absence) of any kind of suffering or disability.

In its more temperate moments, that is the (more likely to be stated) goal of medicine, as well.

But as Joel Shuman notes in the essay "The Last Gift," the WHO and the Department of Health and Human Services do not recognize "old age" as a cause of death. Something specific must be named.

Thus every recorded death in the United States must have a medical condition, problem, or failure as its cause. And when every death is a medical failure, there is no death that might not be prevented or forestalled with technological improvement. Heart failure is a condition, a problem--not a natural terminus. Liver failure is not what happens when one's body has reached its natural capacity to filter its blood--it is the result of specific medical processes, any of which might be susceptible to our control.

There is, then, no natural limit to the reach of medicine. There is nothing that might not be prevented with a little more research, and thus there is nothing that should not be prevented. Any impediment to progress is morally equivalent to a death sentence for those suffering from whatever ailment may be helped by a proposed course of action.

It is appalling that 30,000 children per day die of starvation related causes. It should prompt urgent and concerted effort on behalf of the world's governments and NGOs against immediate and emergent causes (drought, crop failure, natural disaster, war), as well as against more subtle and possibly intractable causes (tyranny, poverty, greed).

But it is appalling not because all deaths are appalling. It is appalling because this earth provides more than enough food for us all, and because technology permits us to transfer the fruits of this abundant patch of earth to that distressed patch of earth, and because international diplomacy gives us the chance to convince even the worst tyrants to allow emergency aid to the starving. These deaths are appalling. These deaths are a result of human sin, or at the very least, of human inertia.

But is it possible to conceive of medical causes for death that are not appalling? not urgent? not inhumane?

There will always be a "top ten list" of causes of death. There will always be a top ten list of causes of death. Is it possible to conceive of a list that will not be a list of looming enemies?

If it is not possible, if there is no death from which we do not look to medicine to save us, we are in grave danger, though we do not know it.

Medicine becomes, in such a case, our god, and there is no end to the sacrifices it may demand of us.