Correspondence
Death and the Research Imperative
N Engl J Med 2000; 343:223-225July 20, 2000
- Article
To the Editor:
In his thoughtful and provocative essay, Callahan (March 2 issue)1 suggests that modern medicine may feel itself compelled “to overcome death itself” rather than to follow the humanistic logic of accepting death (when appropriate) in order to make dying as tolerable as possible. Callahan's concept of a research imperative, or even the technological imperative to which he alludes, may not be as responsible as the current “treatment imperative” for influencing modern health care. Many physicians are made to feel that the death of a patient represents a failure on their part. “Report cards” and other consumer health-outcome reports equate death with poor care. If the procedural care provided by a surgeon or interventional physician is associated with a high mortality rate, poor quality of treatment is assumed.
It may be wrong to suggest that we limit future research efforts to the avoidance of premature death or to palliation of the consequences of aging. Death is inevitable, but life expectancy improves with each generation of physicians. Do we dare believe that finally, in this year and place, we have achieved the ultimate in well-being and longevity for humankind?
1 ReferencesTimothy J. Gardner, M.D.
University of Pennsylvania Medical Center, Philadelphia, PA 191041
Callahan D . Death and the research imperative. N Engl J Med 2000;342:654-656
Full Text | Web of Science | Medline
To the Editor:
Callahan's belief that 65 years is a sufficient life span to experience “the typical range of human possibilities and aspirations” brings to mind Sir William Osler's “two fixed ideas”: that one's best work is done by the age of 40, and that one should retire at the age of 60. Osler humorously referred to Anthony Trollope's novel The Fixed Period, in which “the plot hinges upon the admirable scheme of a college into which at sixty men retired for a year of contemplation before a peaceful departure by chloroform.”1 These remarks drew such criticism that Osler tendered his “heartfelt regrets” in the preface to the second edition of Aequanimitas. Osler repeated, however, his original belief that “the real work of life is done before the fortieth year and after the sixtieth year it would be best for the world and best for themselves if men rested from their labours.”1
Of course, healthy human longevity has increased since Osler's day. However, Callahan correctly suggests that the current research imperative to eradicate death at all ages should refocus on the promotion of health and the prevention of disease. For no disease is this strategy more appropriate than it is for atherosclerosis.
The “bright line” between the living and the dying is not bright too often in my practice; nearly half of my patients who have undergone coronary bypass are at least 65 years of age. My colleagues and I fight death to the end, even in elderly patients with severe atherosclerosis. But I also agree with Callahan that these patients should be allowed to consider carefully, and without reproach, a peaceful death with noninvasive care.
1 ReferencesCharles S. Roberts, M.D.
University of North Carolina, Chapel Hill, NC 27599-7065To the Editor:
Callahan's perspective is interesting but is exceedingly imprecise in the attribution of these problems to a “research imperative.” Research is defined as studious inquiry having the aim of discovery of new facts, and an imperative is an obligation.1 In most cases, medical interventions performed at the end of life are not carried out because the patient is part of a research program designed to prolong life or cure disease. In fact, if more patients were part of such a program, we might do a better job of addressing the problem of the overuse of technology at the end of life, which Callahan laments.
1 ReferencesRobert J. Wells, M.D.
University of Cincinnati, Cincinnati, OH 45221To the Editor:
Although Callahan notes the absence of a “bright line” between living and dying, he fails to acknowledge a similar gray area between youth and age and does not support his age-based definition of premature death. Both biologic criteria and quality-of-life criteria can define premature death, but neither of these alternatives supports a precise age cutoff. Although some authorities may offer the age of 80 as a natural time of death from old age,1 there is no scientific evidence of the existence of a biologic clock that goes off at any particular year of human life. Quality of life is inherently subjective, based on a person's own assessment of his or her existence.
Many people over the age of 65 have overcome life-threatening illness and consider life still worth living, and others live with severe impairments, even in great pain, yet get tremendous joy from life. Some elderly people accomplish “young” feats: witness a 90-year-old woman's recent walk from California to Washington, D.C.
1 ReferencesM. Max Quinn, J.D.
Valery A. Portnoi, M.D.
Beth Israel Medical Center, New York, NY 100031
McCue JD . The naturalness of dying. JAMA 1995;273:1039-1043
CrossRef | Web of Science | Medline
To the Editor:
Callahan is eloquent in his arguments for a different emphasis on care in late life. However, a fundamental principle of our society and its health care is that every person has the right to choose the goals of his or her care, within achievable and ethically permissible bounds. Another fundamental principle is the responsibility of good doctors to reflect the chosen goals in their treatment. Although the truth of the eventual inevitability of death is apparent, it is equally true that the timing and mechanism of death may be modified and that there is the possibility of additional, meaningful life in all but the most desperate of illnesses.
When faced directly with the choice between a philosophy of accepting death and one of struggling against long odds for additional time, persons of many ages choose the latter. When this struggle proves futile, human nature presses the argument that the other choice was to be preferred and that the decision process was at fault. However, the Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatment1 provided the most recent confirmation of the lack of effect of process and information on the choices of care near the end of life. It would seem that the philosophy was at fault. A comfortable death was rejected in favor of suffering and struggling against long odds.
The public should select the values from which health care is directed and then reflect this acceptance in the wishes they bring to medical encounters in late life. Until this happens, substantial change in the provision of life-prolonging care to dying persons can come only at the cost of instructing physicians to stop listening to patients, thus eliminating the individual's right to choose.
1 ReferencesBruce E. Robinson, M.D., M.P.H.
Sarasota Memorial Hospital, Sarasota, FL 342311
The SUPPORT Principal Investigators
CrossRef | Web of Science
Author/Editor Response
Dr. Callahan replies:
To the Editor: Let me restate two basic points I tried to make in my article, both of which seem to have been misunderstood by some of the correspondents. One of them is that, for the living of a life, I contended that 65 years is long enough to “experience the typical range of human possibilities and aspirations.” Note that I said “typical,” and not that life is not worth living after 65, or that research to improve the quality of life after that point would not be valuable, or that most of us (including me) do not want to live longer than that. But until someone can prove that there is some correlation between human well-being and a life much beyond that point, I see no compelling reason to spend research money to pursue it; too many people younger than 65 have more compelling health needs that offer worthier research targets.
My other basic point is that one reason why decision making at the end of life has proved to be so difficult is that modern medicine is fundamentally ambivalent about the place of death in human life. The research part of medicine has declared war on all causes of death, while the clinical part is trying to persuade clinicians and patients that death is, after all, part of life. So, to Roberts I would like to respond that although we almost surely have not achieved the ultimate in longevity, I see no reason to believe that human well-being will be much enhanced by longevity past, say, the age of 80 on average.
Contrary to Wells's interpretation, I was not commenting at all on patient participation in research at the end of life, which I support. However, it would not seem wise or humanly beneficial to carry out research designed to extend the life of those who live to the age of 90, for instance, as if that were not a long enough life for most people.
Quinn and Portnoi are surely right in stating that the line between youth and age is gray and that the quality of life is highly subjective. However, those truisms do not mean that research aimed at fighting death itself would do either them, or the rest of us, any good. Like most other people, I will take as long a life as I can get, but that does not mean that I should support a war against death, which is what the research enterprise appears to be pursuing.
Daniel Callahan, Ph.D.
Hastings Center, Garrison, NY 10524-5555- Citing Articles (2)
Citing Articles
1
Rafael Ballester Arnal, Beatriz Gil Juliá, M. Dolores Gil Llario, Sandra Gómez Martínez. (2011) Afrontamiento de la muerte en familiares de pacientes ingresados en una unidad de cuidados intensivos: Valoración diferencial en función de variables sociodemográficas. Medicina Paliativa 18:2, 46-53
CrossRef2
Alan Carver, Kathleen Foley. (2001) Facts and an open mind should guide clinical practice. Current Neurology and Neuroscience Reports 1:2, 97-98
CrossRef
