Book Review

The Troubled Dream of Life: Living with Mortality

N Engl J Med 1993; 329:2042-2043December 30, 1993

Article

The Troubled Dream of Life: Living with Mortality
By Daniel Callahan. 255 pp. New York, Simon and Schuster, 1993. $21. ISBN: 0-671-60830-9

Daniel Callahan is well known for his support of age-based rationing of health care resources, a position that has sparked public and professional debate on how best to spend limited health care dollars. In this new book, he cuts through the policy arguments on rationing to what I believe is the problem at the heart of this controversy: our failure as a society to come to terms with the reality of death and the finite place of people in nature. He argues that we are a nation obsessed with trying to control and defeat the chaotic forces of nature; that this has resulted in the unconscious belief that medical technology will, with enough miraculous breakthroughs, overturn the dominion of death; and that as a result, the meaning and value of life are lost in a misguided conflation of the length of life with its meaning or sanctity. He proposes as an alternative “nothing less than a reconstructed view of the self,” which incorporates a social and personal acceptance of the inevitability of death and promotes the moral and practical value of a peaceful death.

An obsession with control over nature does seem to characterize our responses to a whole range of disasters, from climatic changes to disease. This summer's Midwestern floods were accompanied by repeated efforts to blame the devastation on human failures in judgment that were probably irrelevant. Advocacy groups often blame inadequate research funds for the deaths of patients with AIDS or breast cancer, as if enough research would surely eliminate the problem. A poll of attitudes toward new technological developments, published recently in The New York Times, found that although few respondents expected to be affected by advances in communications, 42 percent believed that the largest effect of technology on their lives would be in health and medical care, appearing to believe that “some high tech magic in the sky will help them live longer.” The logical conclusion of this type of thinking is the spreading belief in “successful aging” -- that living properly with the help of modern medicine will prevent decline and disease and, by extension, death. The converse, blaming patients for their “unsuccessful” aging, illnesses, and death (which must, by this distorted logic, be due to their bad habits, bad genes, general sloth, and poor diet), has become commonplace. Thus, illness, decline, and death have become marks of shame, of the failure to age successfully. This is a bizarre state of affairs that Callahan links to a deep fear of death and a powerful desire to avoid it.

What else results from this focus on illusory control? In the effort to eliminate disease and prolong life, we have come to define death as a failure of medicine, as something that should eventually be overcome with enough research, enough technical breakthroughs. If humans can ultimately prevent death, then they are somehow responsible for it -- a line of thought that confuses human agency with the natural inevitability of death. Thus, the technological imperative (whereby the existence of a technique with any possibility of benefit, no matter how small or how limited, mandates its use) has painted us into a corner: any acceptance of death is tantamount to rejecting the sanctity of life. The socialization process of the teaching hospital promotes this deep confusion about the goals and capacities of medicine; in my experience, doctors who pursue the maximal possible prolongation of life (whether by means of feeding tubes and antibiotics or by last-ditch surgical efforts) are in the mainstream. Their efforts are not questioned; the tide of the hospital culture is with them, and they will not be taken to task by the quality-assurance people. In contrast, the doctors who try to avoid subjecting their patients to, in Callahan's words, a “violent and deformed death by technical attenuation” may find themselves labeled “the grim reaper” by colleagues, have difficulty justifying continued hospitalization for those patients under Medicare (because no short-term treatments or diagnostic procedures are needed), and must contend with a regulatory apparatus that assumes a decision not to use a feeding tube or not to treat a fever must be a mark of incompetence or abandonment. Thus, as Callahan describes it, priority is not given to a peaceful death, at least not in most American teaching hospitals, and there are plenty of incentives (from peer pressure to peer review to financial and legal incentives) not to promote the idea.

What is to be done? In this regard, Callahan's proposals are more circumspect, respectful of the scope and depth of the problem of our fear of death. This book does not overtly advocate age-based rationing, perhaps because the author now recognizes that a simple cutoff for health care services that is based on age does not address the fundamental problem -- that of reestablishing a sense of ourselves as part of nature and thus as inevitably subject to decline and death. He argues that we must promote the value of a peaceful death as one of medicine's most important goals and that we should depend less on the notion that control over the circumstances of death will ensure a dignified death, going so far as to challenge the notion that such control (through living wills, for example) is really possible. Some things in life, he argues, are not in our control. The trick, then, is to “choose our interior stance,” to maintain courage and integrity whatever life brings, a stoical philosophy of life best described in Victor Frankl's extensively cited chronicle of his concentration-camp experiences in Man's Search for Meaning (Boston: Beacon Press, 1963).

Putting into practice Callahan's proposal for “nothing less than a reconstructed view of the self” will take some doing. Public education on the limits of medical technology and the desirability of a peaceful death, combined with the establishment of a communally based standard of futility (for example, one that would set limits on the long-term use of a feeding tube and on the use of antibiotics in patients with severe dementia) and equitably applied caps on spending, would all contribute incrementally to the goal of achieving a common meaning, an acceptance of death. Contrary to Callahan's assertion, more widespread participation in the process of completing advance directives could have an important effect both on the public's willingness to accept the reality of death and on the inappropriate use of life-prolonging techniques. It is too early to assess the efficacy of advance directives; their true effects will not be measurable for decades. Callahan also rejects the usefulness of medical education in promoting a greater acceptance of death, arguing that it has clearly failed to stem the tide of the technological imperative. In this he is wrong: only 3 of our 126 medical schools require a course on death and dying, and surveys show that doctors in training are still not adequately taught how to care for their dying patients. Death must be brought out of its hiding place in the back room on the wards, in the intensive care unit, on rounds. Information is available in the literature on how to help patients die peacefully, but more than knowledge is required: a willingness to accept the need for this kind of expertise, to learn it, use it, and teach it, is necessary to come to terms with the place of death in the practice of medicine.

Work is also needed on the influence of the fear of death on those who choose to become doctors -- the psychiatric and transference issues surrounding death for doctors -- so that we can help our patients more forthrightly and with less conflict. Only when education on the medical and emotional aspects of care of the dying is mandated (for example, by residency-review committees and specialty boards) and implemented at all levels of training will medical education have begun to address the task in a serious and effective manner.

Callahan rejects any role for physician-assisted death in the care of the dying, arguing that it reflects a dangerous extension of our obsession with controlling nature. As a recent letter to The New York Times poignantly illustrates, there are some patients for whom the goal of a peaceful death cannot be accomplished in any other way. Ronald Dworkin argues (in Life's Dominion, New York: Knopf, 1993; see review below) that respect for autonomy mandates flexibility in the care of suffering, terminally ill patients: “Whether it is in someone's best interests that his life end in one way rather than another depends on so much else that is special about him -- about the shape and character of his life and his own sense of his integrity and critical interests -- that no uniform collective decision can possibly hope to serve everyone even decently.” Callahan's condemnation of physician-assisted death is a good illustration of how a personal philosophy of stoicism in the face of life's blows can be presumed to be universally relevant to the suffering of others. Not all of us are willing or able to bear the cruel ravages of age and illness, and thus, the goal of a peaceful death may require a greater acknowledgment of the limitations of comfort care for some.

In its personal voice and impassioned call for fundamental changes in how we value life and approach death, Callahan's book is both disturbing and moving. He holds our faces to the mirror and makes us look. His observations on the denial of death transcend age and age limits on health care, but they do force us to confront and question what we are doing to many of our patients, old and young alike, in the name of the sanctity of life. This book is important reading for clinicians and policy makers, but it is required material for those of us who teach medical students and house staff -- young people surrounded daily by deaths that are seldom discussed, that they are not trained to ease, and that, according to the example set by their teachers, they are usually encouraged to ignore and repress. We should not go on this way, and Callahan's book is a much-needed signpost to a better road.

Diane Meier, M.D.
Mt. Sinai Medical Center, New York, NY 10029