The Plain View, Spring 1958, No. 1, Vol. XII, May 1st
Delivered by Dr. Eliot Slater, M.A., M.D., at the 1958 annual public lecture of the Euthanasia Society.
A LITTLE while ago a friend of mine suffered a bereavement. He had living in his home his mother‑in‑law, an old lady of seventy‑six who enjoyed only very feeble health, owing to chronic kidney and arterial disease, and had been in hospital a number of times in recent years. One day this lady was taken suddenly ill with a stroke. She called to her family from the bathroom and when they arrived they found that she was paralyzed down the right side and was unable to speak. There seems to have been some panic in the home. One might have thought that the lady could have been put quietly to bed to wait for the doctor. Instead of that, when the attention of a doctor could not be obtained immediately, first the hospital and then the ambulance service were contacted. The old lady was put in the ambulance and, sinking fast, was driven to one of our most famous London teaching hospitals. By the time she was wheeled into the casualty ward, she had breathed her last. The young and efficient casualty officer was far from being dismayed. All the resuscitation services that the hospital could provide were mobilized, with doctors, nurses, and technicians, and for eighteen hours the patient's heart was kept beating and the elaborate and beautiful apparatus for artificial respiration did her breathing for her.
Mercifully enough, this determined battle was fought in vain. When at a later time my friend asked the doctor what had been the point of it all, he received a very significant reply. The casualty officer admitted that, even if it had been possible to preserve the patient's life, only the shell of a human being, speechless, paralyzed, and demented, would have remained. Yet, he maintained, it was not within his discretion to think of what the ultimate issue would be. He had one duty, and one duty only, to do all that lay within his powers to ward off death.
This is not quite the teaching which I enjoyed when I was a medical student. I was then taught "thou shalt not kill, but needst not strive Officiously to keep alive"; and the effort made by the hospital doctor in my friend's case seems to me to be officious in the extreme. Nevertheless, the point of view expressed by the young doctor is one which in this age is probably beginning to gain ground; and if this is so, then we shall need to examine again the basic principles on which we face these primary issues of life and death.
A friend of mine, who was brought up in a Catholic school, warmly supported the doctor's view in argument with me. Anything less than that, he felt, would be liable to grave abuse. Who is the doctor to assume the responsibility of letting a patient die? Even if the most energetic treatment is only likely to secure a few more days of life, it should not be spared. Now, of course, there is no logical limit to this line of argument. If the duty of the medical man is to be assessed in this way, then he must disturb the dying man to provide him with a few more hours, indeed a few more minutes or even moments; and the last injection of coramine will take precedence over the wish of the wife to say farewell. On the other hand, if the process is not pushed to its last absurd limits, then, wherever else the line is drawn, the doctor cannot evade the responsibility of saying that now the time has come when we must let death take its course. This, surely, is one of the natural and inescapable responsibilities which the doctor has to take as part of his duty.
I have discussed the same story with another acquaintance, a doctor engaged in busy general practice. He took a rather different view to my Jesuitical friend. He thought that an older and more experienced man would have probably refrained from doing all that the casualty officer did; but he thought that what was right for the older man was not necessarily right for the younger. Until one had learned the limits of one's craft, one should seek to push it to its limits. Unless one fought for every patient with all the power at one's command, one would be only too liable to take on a defeatist attitude, to the point of even failing of one's obvious duty. Time and again, the apparently useless life one had saved had subsequently shown itself full of value and meaning.
This attitude is less dogmatic and more reasonable. But if we are to bring a rational approach to the problem, we must abandon the absolute imperative for such considerations as a balance of probabilities. If there is a chance, however small, of saving not only life but health, that must be placed on a higher scale of values than the mere prolongation of the automatic action of heart, lungs, and bowels. A few more hours of mental lucidity and capacity to communicate are in a different dimension from months of coma, dementia, or idiocy. Death performs for us the inestimable office of clearing up a mess too big to mend; if we are going to intervene, then we must have at least some hope of doing this ourselves.
Thinking about the way we think of these things, the psychiatrist inclines to the view that, for many of us, our attitude to death is neurotic. Not only are we moved by emotional and non‑rational motivations, but we do not face the issue squarely. We push uncomfortable ideas out of our minds. It has been said that, just as people's minds were in a bad way on the subject of sex at the beginning of this century, until Freud let some light into a dark cupboard, so now we have the same kind of attitude towards death. It would hardly be in better taste today to enquire of an elderly man whether he was afraid of dying and how he felt about his approaching end, than, in the days of Victoria, to have opened a conversation with a young lady on the subject of the physical relations of the sexes. Indeed, the possibility of a fatal outcome is hardly ever discussed between doctor and patient, even when illness has set the plainest signpost. Most doctors feel it is kindest to refrain from telling the patient of the facts and the probabilities, and sometimes tell lies about them.
It may be that they are justified; though they should surely regard themselves in honour bound to give a plain and honest answer to a straight question, if it is ever put. In this, however, the patient himself very frequently fails. Even the greatest are affected by the weakness. When Johannes Brahms, the composer, a man of great energy of personality, was an old man he developed a cancer of the jaw. For a time he interested himself in the progress of medical investigations; but when these failed to reach any satisfactory conclusion, his curiosity grew less. Finally, he gave explicit instructions that under no circumstances was he to be given any news about his health which might be unpleasant. And in fact he was able to conceal from himself to the last, that he was a dying man.
Medical men themselves are not immune. When I was a young man, I had a colleague of my own age, who had suffered a number of attacks of rheumatic disease of the heart. As a result, the valves of the heart had become scarred. One of the unpleasant possibilities which may arise in such a state is that a germ settles down on the diseased valve where, because of the scarring and the inadequate blood supply, it is beyond the reach of the normal defence processes of the body. Ulceration of the valve may then cause a chronic state of blood poisoning or septicmia. My colleague once confessed to me that it was his one great fear that he might develop bacterial endocarditis, as this disease is called, small though the chance might be. With this fear he had to live every day of his life. It would assail him if he ever had a sore throat. At his last attack of rheumatism he had been in a state of panic until his temperature settled down. Yet with all this he lived an active and ostensibly happy life.
The time came when he had yet another attack of rheumatism, and was admitted to one of the London teaching hospitals, where he could get the most skilled help. Once or twice a week his friends would go to see him. At first he eagerly discussed his illness and the progress of investigation. But his temperature refused to settle, and gradually took on the ominous swinging curve from morning to evening. The temperature chart was removed from his room. Investigations ceased and were replaced by a uniform nursing regime. His comments on his own state ceased too. His mental horizon came nearer, so that he seemed to look at no future beyond the next few days. After about three months of illness he died, as far as I know without ever making any reference to the possibility of his death. Certainly he never spoke of it to any of us, and, I was told, not to any of his doctors.
A neurotic attitude to death is no fault exclusively of our present age, and has been stronger than it is now. Epicurus, in the third century before Christ, offered his consolations to the Greeks in words of sense and reason:
"The other thing which invades, and strikes the Minds of men with extream Fear and Terror, is Death; and this, because of we know not what Everlasting Evills, that are expected immediately to ensue thereupon . . . they being ignorant, that all those solemn stories, that are commonly told of Hell, Rhadamanth, the Furies, &c. are the mere Fictions of Poets: and that if they contain any thing of truth in them, they are but cunning allusions to the miseries, which many men suffer during life, since those, who are uncessantly vexed with vain Fears, superfluous Cares, insatiable Desires, and other violent Passions, lead lives so truly miserable, as that they may well be said, to suffer the torments of Hell …
“We said, that Death (accounted the King of Terrors, and most horrid of all Evills) doth nothing concerne us, because, while we are, Death is not; and when Death is, we are not; so that he, who profoundly considers the matter, will soone conclude that Death doth concerne neither the Living, nor the Dead; not the living, because it yet toucheth them not, not the Dead because they are not.
"And, as the assurance of this that Death nothing concernes us, doth exempt us from the greatest of Terrors, so also doth it make us to enjoy life to the most advantage of pleasure, not by adding thereunto any thing of uncertain Time but by Detracting all desire of Immortality. For, in life there can be nothing of Evil to him, who doth perfectly understand, that there can be nothing of Evill in the privation of life." (translation of 1656)
A lively idea of the fears of a somewhat later age is given by a walk around the gallery of Nôtre Dame in Paris, and a view close up of the gargoyle statuary. These horrible monsters, engaged even in devouring each other, were carved by devout hands. They were the creatures who, as Martin Luther believed, attended the Christian's death‑bed, who lurked in the shadows behind the bed‑curtains, to spring out and seize the unshriven soul. They are the obscenities we see, painted as from the life, in the pictures of Brueghel and of Bosch. The spiritual comforters of that age, unlike those of Greece, did their utmost to inspire and intensify these terrors, for only by such means was the sinner to be made aware of his condition and brought to repentance. Hear the witness of John Sym in the year 1637:
"Whereby, wee may see in part the miserable state of the damned in hell, whose living there is a second death, farre exceeding the first in misery . . . First, the measure of hells misery upon a man in it; being even as if a man, in his perfect strength and senses, were struggling, and in the very pinch, and agonie of the last and fiercest act of death, labouring under the unspeakable horror, and unsupportable, and untolerable paine of it, and in kinde and degree much more … Secondly, wee may see here, the everlastingnesse and endlesse continuance of that death in hell, which shall be as long as the damned shall have being, which shall be ever; that they may be capable of suffering to the utmost of their capacity; so that, their being gives neither ease nor comfort; but they shall ever be in the same extremity of death, for evermore; without any relaxation, or abatement; which fills them with utter desperation, and unexpressible woe."
So sensible a man as Francis Bacon was convinced that death was wholly horrible, though his description is that of the natural philosopher:
"The immediate proceeding signs of Death are, great unquietness and tossing in the bed, fumbling with the hands, catching and grasping hard, gnashing with the teeth, speaking hollow, trembling of the neather lip, paleness of the face, the memory confused, speechless, cold sweats, the body shooting in length, lifting up the white of the eye, changing of the whole visage, (as the nose sharp, eyes hollow, cheeks fallen) contraction and doubling of the coldness in the extreme parts of the body; in some shedding of bloud or sperm, shrieking, breathing thick and short, falling of the neather chap, and suchlike."
It was Bacon, also, who suggested a rational approach to these anxieties, and, in the year 1605, seems to have been the first to use the word Euthanasia:
"Nay further, I esteeme it the office of a Physitian not onely to restore health, but to mitigate pain and dolors, and not onely when such mitigation may conduce to recovery, but when it may serve to make a faire and easy passage: for it is no small felicitie which Augustus Caesar was wont to wish to himselfe, that same Euthanasia . . . in my judgment they ought both to enquire the skill, and to give the attendances for the facilitating and asswaging of the pains and agonies of death."
Looking back from our present viewpoint, we see generation after generation of the Dark Ages sunk in a state of miserable mental enslavement. Passing the centuries under review, we see the black shadow lift only slowly. If the fears of Hell receded, those of death with its funereal pomps retained their place. The physical aspects of bodily decay kept their morbid grip on the imagination. It needed a robust spirit to overthrow them:
"The knell, the shroud, the mattock and the grave;
The deep damp vault, the darkness and the worm;
These are the bugbears of a winter's eve,
The terrors of the living, not the dead."
Poor Edgar Allen Poe remained obsessed throughout his life by the stink of death and the fear of premature burial, a quite particular phobia which Epicurus never thought it necessary to deal with.
"It may be asserted, without hesitation, that no event is so terribly well adapted to inspire the supremeness of bodily and of mental distress as is burial before death. The unendurable oppression of the lungs‑the stifling fumes of the damp earththe clinging to the death garments‑the rigid embrace of the narrow house ‑ the blackness of the absolute night ‑ the silence like a sea that overwhelms‑the unseen but palpable presence of the conqueror worm‑these things, with thoughts of the air and grass above, with memory of dear friends who would fly to save us if but informed of our fate, and with consciousness that of this fate they can never be informedthat our hopeless portion is that of the really dead‑these considerations, I say, carry into the heart which still palpitates a degree of appalling and intolerable horror from which the most daring imagination must recoil."
These fears too have now become old‑fashioned. One wonders how much the practice of cremation has done to strip Death of one of his more unsightly trappings.
One may observe how the preacher and the poet, in order to bring out the horror of dying, draw a picture in which the assault of death is made on the vigorous and intact personality. This is, in fact, most unusual, though it may occur. When the young man in all his vigour and love of life sees the close approach of death, it is not surprising that he recoils with a cry of dismay, even panic. This was the case with James Elroy Flecker, who died of tuberculosis while still in his prime. You may remember his lines:
"I am afraid to think about my death;
When it shall be, and whether in great pain
I shall rise up and fight the air for breath,
Or calmly wait the bursting of my brain."
And the concluding lines:
"I know dead men are deaf, and cannot hear
The singing of a thousand nightingales.
I know dead men are blind, and cannot see
The friend that shuts in horror their great eyes.
And they are witless. Oh, I'd rather be
A living mouse than dead as a man dies."
It is, perhaps, one particular type of temperament that is more than normally susceptible to the fear of death, presenting itself simply as an inevitable end. These are the ruminative obsessionals, of whom a great example was Dr. Johnson. They are the people who suffer under a sense of external compulsion; they know the irrationality of the ideas which afflict them, but are still unable to resist them. Many of them are weighed down by the oppressive sense of the ineluctable passage of time. The ticking of the clock reminds them that an end is approaching them in measured, unvarying steps. Death hovers over them, casting a shadow that is felt even in youth, and deepens always as time advances. Everything that is ephemeral is a reminder, and spring is more painful to bear, with its promises doomed to extinction, than are autumn and winter. Only the great enduring things, the mountains, the sea, the stars, perhaps the thought of God, can console.
These people are exceptional; and though most of us have feelings like this at some times, the moments of oppression are usually short and infrequent. It is not easy to say how far the average man has faced the issue and adjusted to it, or how far he has merely succeeded in pushing it out of his mind. As a rule, I think, he refuses to give any thought at all to his ultimate end. He accepts it, but turns his back on it as something wholly unpleasant, inevitable but requiring no mental preparation. It is only those whose lives have become ones of active suffering who can come to think of death as a blessing and a release. The greater the comfort and the pleasantness of our days, the sharper and more distressing the contrast between the time now and the time to come. With what terrifying speed, as one grows older, do the years slip by! How intolerable to think that one day our prized identities must cease to be, that the sun will rise on a world which knows us no more!
These thoughts are natural enough; but how often do we look at the opposite side of the picture? Do we ever consider the appalling alternative, if, like the struldbrug, we were condemned to live for ever? Would the thoughtful man really welcome the elimination of all possibility of ever ceasing to be, even if he were endowed with perpetual youth? One steps back from the thought as from the abyss, and the mind reels as it does when called to contemplate a universe without beginning and without end.
On some such lines will run the thoughts of the average man, who is not endowed with a religious faith which professes to provide the answers to this dilemma, who is unread in the stoic philosophers, and who has little idea of the part that death plays in nature's economy. On this last aspect, the biologist has something significant to contribute.
In an interesting essay, P. B. Medawar has considered what the consequences would be if we had a race whose individuals were indeed potentially immortal, but subject to the normal accidents of existence, such as being afflicted with disease or being devoured by predators. They would, of course, need to reproduce themselves, and we may suppose that reproductive life once entered on would be continued indefinitely at a uniform rate. Now as the individuals grow older their numbers grow uniformly less. When the population is in equilibrium, it shows the usual pyramid, with each age group outnumbering the next older. Each new generation must be recruited preponderantly from the germ cells of the younger members of the community, and there would be more offspring who were born of young than of old parents. This race would, of course, be subject to the impact of forces of natural selection. Environments would change, and genetic adjustments would have to take place. In such a process, genes which added to the vigour of the young would have much more value than genes which benefited the older age groups. Indeed, if any gene appeared which caused an increase of vigour in youth at the cost of an increasing decrepitude at a later age, it would be favoured by selective forces, and would rapidly spread through the species. In other words, despite the potential immortality of the individual, and his equal vigour at all ages, an advantage which took effect early in life would always outweigh one that came later.
It follows that though such a race might begin its existence with all individuals, of whatever age, showing an equal vigour and fecundity, the mere continuance of racial existence would cause a change by which vigour became concentrated in the young, while disease and relative incapacity was postponed to later ages. The phenomenon of senescence would enter the picture; and the natural conclusion of senescence is so‑called natural death.
It is, now, generally agreed among biologists that growth and reproduction on one side and ageing on the other side are intimately bound up together. With many races, deterioration in vigour commences as soon as actual growth ceases. In our own species the running down of all the tissues of the body is well in hand, even before reproductive capacity has come to an end. If we consider merely the capacity for growth, this is greatest at the moment of conception and diminishes rapidly thereafter. By the age of ten, hearing capacity, especially for the higher tones, has reached its peak, and subsequently declines. By the age of twenty, the adaptive capacity of the eyes is growing less. By thirty muscular strength and neuromuscular speed and accuracy of co‑ordination are showing a deficit which spells the end of many athletic careers. At forty the heart and bloodvessels are no longer those of a young man; and many of the chronic killing diseases have taken a hold on the less fortunate members of the population. By fifty, psychologists are measuring intellectual impairment, especially learning ability, in quantitative measurements on standardized tests. Emotional reactions are becoming slack and conventionalized, the imagination is weakening, and the capacity for fresh creative thinking, at least, has gone. By the age of sixty, senility, in greater or lesser degree, has arrived. H. S. Simms has noted that from about ten onwards there is a logarithmic increase in the mortality due to various types of disease process. The mortality from most infections, for instance, rises by about five per cent with every year of age. If mortality could be maintained at the figure for the age of ten, man would have a life expectancy of eight hundred years.
One may ask, is anything known of the basic causes of what we call senescence, or, when it appears as a mental disease, senile dementia? The cells of the body are potentially immortal. They can be removed from the body and maintained in tissue culture practically indefinitely. The changes of senescence are largely in the state of balance between the tissues, in the chemistry of the body and the composition of tissue fluids. There are glandular changes, perhaps particularly involving the suprarenal glands. There is a lower rate of living, and a reduced capacity of adaptation to environmental changes. Reserve capacities have to be called on sooner.
On the psychological side, the old man can still cope with what he is habitually accustomed to, but loses his power of adapting to the new. While his memory store, his vocabulary or store of words, his arithmetical ability, and his power to use stored knowledge, are largely maintained; his ingenuity and his capacity for abstract reasoning drop. The rate of decline in the power to perceive new relations, starting about the age of twentyfive, is such that by the age of eighty he has no more ability of this kind than a child of eight. With the intellectual changes there are changes in temperament. Increasing insecurity and incapacity to tolerate anxiety are compensated for by increasing tenacity and over‑caution. Emotions of all kinds are less easily controlled, and he becomes more irritable. The general level of mood alters too, so that any upset is likely to be accompanied by depression. Above all energy fails, and initiative is replaced by inertia and early fatigue.
The physical changes which take place in the brain are seen mainly in the dying off and dropping out of nerve cells. The dead cells disappear, and their place is taken by gap‑fillers, the cells of connective tissue. Indeed, the whole brain may shrink.
There is no evidence that the process is caused by any specific disease; it is a manifestation of molecular death, of dying, not by inches, nor by millimetres, but by microns. Nevertheless, no clear line can be drawn between physiological and pathological processes in this connection.
The time at which such changes become clinically detectable and the speed with which they proceed vary very greatly from one individual to another. Some part at least must be played by genetical factors, by the hereditary constitution. The tendency to long‑living has frequently been shown to run in families. In his studies of uniovular twins who lived into old age, Kallmann has shown that there is a close resemblance between the members of a twin pair in their degree of preservation at a late age, even when they have lived very different lives. This is most easily explained by the fact that such twins have the same hereditary endowment.
It seems, then, to the biologist that the idea of the medical man that death is the chief enemy is misplaced. The light drains from the sky long before the sun sets. It is at an earlier stage that we should seek out our opponent, before his inroads have gone too far. This is indeed a difficult matter. Senescence is a part of our essential constitution, and is not easily defeated. The processes of natural selection, which over other spans of life tend constantly to keep a species vigorous by eliminating the feeble and the diseased from the reproductive cycle, are here of no assistance. The hereditary constitution which predisposes to a deterioration which occurs only after the end of reproductive life, is at no disadvantage while reproduction is still occurring, and will have its full representation in the next generation. Genes which cause such a constitution are immune to natural selection, and may accumulate indefinitely.
The race itself is potentially eternal; and, sub specie aeternitatis, the senescence of the individual is no disadvantage. Death itself becomes then a boon to the individual and a benefit to the race, by eliminating the worn out and those whose part has already been played. In human communities, if the aged and the sick did not die within no long span after they had ceased to be self‑supporting, the burden on society would become disastrous.
The death and the removal from the community of those of an earlier generation have another essential part to play in maintaining the adaptability of the species as a whole. Environments are constantly changing‑for the animal world in the changes wrought by climate and by man, for man by the pressure of his own social development. To cope with these changes, the species has to throw up constantly a new team. Even if they retained all their youthful vigour, and kept the advantage of a rich experience, the old would prove defective by being bound by the habits of reaction, the habits of thinking, of the past. Furthermore, new types of individual, new in point of genetical constitution, will be needed. Time and again species have died out on this earth and have become extinct because they became genetically stereotyped, and could not produce a sufficient range of variability. Just as in the mechanical world, advances occur most rapidly where new models are being constantly produced, with consequent rapid obsolescence of the old, so too it is in the world of nature. If we wish the human race to thrive, then we must accept the subordination of individual to racial values; we must acquiesce in the need for one generation to give place to the next.
This does not mean that we should consider that we already have the best of all possible worlds. There are many reasons for thinking that it would be advantageous to man if the rate of exchange of generations were a little slower, and if the mature individual could continue, with the wisdom of accumulated experience and with the vigour that precedes middle‑age, for a longer time than the lustrum or so which we enjoy at present. We are demanding of our youth longer and longer training periods; so that fully active and responsible life is becoming shorter at that end. There would be a great saving of human values if we could extend it at the other. To indulge in a daydream, how many men and women would enjoy the prospect if the life expectation and the vigour were granted them, to change over in their fifties or sixties, go back to university, and train in some slightly or radically different field for another and a different career. Human society, it seems to me, would lose little if, with a higher proportion of mature individuals, it became a little more conservative, a little more insulated from the clamour of the hungry generations pressing on them from the rear.
Such a prospect is likely to remain a day‑dream, for the reasons given, for a very long time. It is impossible to predict what advances in human pathology and physiology will bring us, but from the genetical side the only way I can see towards the extension of man's expectancy of maturity with vigour, would be by a gradual rise in the mean age of mothers at the birth of their children. If we were to marry later, and finish having our families at a later age, then man would be harnessing the forces of natural selection on his side.
To return, now, to the main theme. The position of the biologist when he is asked to contemplate the death of the individual is that this is an end which is devoutly to be wished. Death plays a wholly favourable, indeed, an essential, part in human economy. Without natural death, human societies and the human race itself would certainly be unable to thrive.
This seems to me to put a definite onus on the philosopher, the psychologist, and the educationist. We should train the individual to be able to regard his eventual death with open eyes and equanimity. Death at a ripe age should be i5 occasion for regret or mourning. Illness and accident, not to speak of war, remain the enemies of mankind; but death is not. No life‑story is complete without its end as well as its beginning; and we should hope to face the turning of the last pages with as much interest as any of the intermediate ones. Just what is it, of which death deprives us? We have already said goodbye to yesterday; when we come to die, it is not the past but the future of which we take our leave.
He who regards his own extinction as a personal catastrophe has, I believe, a perverted system of values, one that is based on an excessive egocentricity. Such an extreme valuation of the self may, perhaps, be regarded as a decay product of Christian beliefs. Christianity first taught man the value of the individual human personality, and taught him also to believe in the immortality of the individual human spirit. When belief in personal immortality decays, then the temporal self takes a place in a man's loyalties which it is unable to bear. Something less temporary and less trumpery is needed. What that shall be is for each one of us to choose for himself; but something we must have for which, for each of us, his own self is wholly expendable. I suppose that the way in which the biologist thinks would lead him to regard himself as an infinitesimal unit in a fantastically complex and beautiful web of life, stretching millions of years into the past and on for an illimitable time into the future, growing, changing, and advancing, but constantly under threat. In this progression, each generation occupies the world only on a short‑lived lease; but while that lease endures it has a total responsibility. It is a trustee and a guardian, whose greatest crime would be to sacrifice the future to the present. In such a vista, personal death is seen in proper proportion.
As a conclusion, I should like to end with a quotation from W. B. Yeats, who gives in a few words the pith of all I have had to say:
"Nor dread nor hope attend
A dying animal.
A man awaits his end,
Dreading and hoping all.
Many times he died,
Many times rose again.
A great man in his pride
Confronting murderous men
Casts derision upon
Supersession of breath:
He knows death to the bone.
Man has created death."