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This is part of the background information by Sylvia Engdahl for her science fiction novel Stewards of the Flame. If you don't see a menu on the left, please click here and then on "Natural death."

Natural Death Seldom Occurs in Today's Society

What is natural death? Most of us have a good idea of what we mean by it, yet the term has become somewhat difficult to define. According to pathologists, "A natural death is a death that results from a natural disease process, distinct from a death that results from accident or violence." But nowadays death from disease is rarely allowed to be natural; it is artificially prolonged by drugs and/or machines and in the eyes not only of medical professionals but of most patients and families, it results from medical measures' failure. It can hardly be said that someone who has spent his or her last hours in an ICU, as pictured at right, has died naturally.

The fundamental premise of Stewards of the Flame is that the logical culmination of this trend would be to deny death entirely, assuming that the machines were "improved" to the point of keeping mindless bodies functioning indefinitely -- and that this would be a very bad thing. Natural death, in my opinion, is death resulting from the normal shutting down of the body when the unconscious mind is ready to die. It happens to everyone, if no accident or acute disease strikes prematurely, as long as the process is not thwarted by interference with the body in the way all too common today. I am aware that this view is termed "deathism" by the proponents of technological life extension, some of whom fervently believe that physical immortality is just around the corner. I should make plain here that I don't oppose research aimed at achieving this. If such research eventually leads to it, then my whole conception of human life is mistaken, and I am not unwilling to be proven wrong; if humans are destined to become immortal, then that's the reality honesty would require me to accept. But I don't think it's going to turn out that way. I think people will go on dying in old age (older than the present maximum) no matter what technology does to repair their bodies. We don't know what death brings, but it surely brings something, or else everyone who has ever struggled through life has done so to no purpose. The purpose of life is a mystery in the first place, but I cannot conceive of living indefinitely without conviction that the effort leads somewhere; I am sure I would grow weary and long for something our present existence cannot provide.

The life-extension enthusiasts admit that people might get bored in time and say that in that case, they could kill themselves. I have personally known people who say this. And of course, the issue of assisted suicide for the terminally ill is a major controversy today. I live in Oregon, where assisted suicide is legal, so I hear a good deal about that. I am opposed to it. Originally, though I was personally opposed, I believed the law should allow individuals to make their own choice. Now I realize that if this choice is legitimatized and becomes common, some people will choose to hasten death merely to spare their families the physical and financial burden of caring for them, and eventually those of us without families may be subtly discouraged from continuing to receive care at the expense of the taxpayers. This situation would not exist if high-tech intervention were not automatically employed early in the course of illness which, in the case of an elderly person, is inevitably going to be fatal. The choice to live or die should never have to be conscious; it is matter properly left to the unconscious mind or, metaphorically speaking, to God. Suicide is wrong because it is a violation of one's own deepest inner determination, just as the artificial maintenance of the aged body is a violation. As Richard Bach has written, "Here is the test to find whether your mission on Earth is finished: if you're alive, it isn't." When, and only when, the unconscious mind is ready to die, natural death occurs -- provided that medical treatment isn't getting in the way of nature.

There has been a lot of discussion in the past few decades about the pointless and often cruel way in which people are routinely treated in their last months of life, and many calls for reform. But though the solution -- hospice care -- is now available, comparatively few people take advantage of it. Many are simply unaware that it exists. Others, or their families, are so conditioned by our culture's denial of death that they believe rejecting futile treatment is tantamount to suicide, or at best an abandonment of "hope." In my novel, the forced prolongation of pseudo-life is not arbitrarily imposed by the medical authorities that run the planet; it is a law supported by the people, who do not want to admit that they are mortal. I suspect this is a realistic assumption about what would happen. The vast majority of Americans polled say that they want to die at home, not in a hospital; yet they end up in hospitals all the same. Continuation of treatment is not compulsory, yet most don't contest the medical establishment's imposition of it, perhaps because don't know that they can -- that there are better alternatives -- or perhaps because society as a whole offers no support for the idea that the natural ending of life need not involve suffering. Unfortunately, the only thing likely to bring about widespread change is the financial impossibility of providing high-tech terminal care to an aging population. Individuals, however, can improve their own future prospects by familiarizing themselves with some of the material listed below.

Links to Articles About Better Care of the Dying

How Not to Die by Jonathan Rauch. The Atlantic, April 24, 2013. "The most urgent issue facing America today is people getting medical interventions that, if they were more informed, they would not want. It happens all the time.”

Final Independence by Jean Erdmann. Aeon, December 15, 2014."Nobody wants a protracted, dehumanised death: why is it still so easy for doctors to ignore a dying patient's wishes?"

‘Warehouses for the Dying’: Are We Prolonging Life or Prolonging Death? by Peter Whoriskey. Washington Post, December 12, 2014. “I think if someone from Mars came and saw some of these people, they would say, what have they done to deserve this punishment?”

How Doctors Die by Ken Murray. Zócalo Public Square, November 30, 2011. "The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist."

Helping Hands (Review of Being Mortal by Atul Gawande). The Economist, October 4, 2014. “Our most cruel failure in how we treat the sick and the aged”, says Dr Gawande, “is the failure to recognise that they have priorities beyond merely being safe and living longer.”

Dying in America: Improving Quality and Honoring Individual Preferences Near the End of Life, Institute of Medicine, September 14, 2014. Report of a study by the National Academies' Institute of Medicine on the current state of care for people approaching death.

Personal site of Dr. Ira Byock, author of Dying Well and The Best Care Possible. Many articles and links. "The medical profession most commonly approaches dying as if it were solely a problematic medical event. From the first day in medical school, doctors are taught to approach patients by defining a set of medical problems to be solved."

Growth House The Internet's leading online community for end of life care -- award-winning international gateway to resources for life-threatening illness and end of life care; also offers RSS feeds and streaming audio. "Our primary mission is to improve the quality of compassionate care for people who are dying." Includes the online edition of the book Handbook for Mortals.

Sick to Death and Not Going to Take It Anymore! Online edition of the book. "People would expect a headline that shouts 'New Drug Prevents Heart Disease in Elderly' to herald a story about something thoroughly laudable. The headline could be equally correct and say instead 'New Drug Promises Major Increases in Dementia.' Saving the lives of children who otherwise faced polio was reasonably understood to be a very good thing. Saving the lives of elderly persons by eliminating one among a group of competing causes of death is more complicated. Eliminating one illness might well change the nature of the death and delay its timing, but the language of saving lives is misleading."

Pallimed. An excellent blog containing information and commentary about hospice and palliative medicine.

Before I Die. PBS Online, April 1997. Many good articles, but some advocate assisted suicide.

On Our Own Terms: Bill Moyers on Dying. PBS, 2000. Accompaniment to the TV series; includes video excerpts.

What Is Hospice Care? American Cancer Society, January 2007. "Hospice is a philosophy of care. The hospice philosophy recognizes death as the final stage of life and seeks to enable patients to continue an alert, pain-free life and to manage other symptoms so that their last days may be spent with dignity and quality, surrounded by their loved ones. Hospice affirms life and does not hasten or postpone death."
Hospice Net. An independent, nonprofit organization working exclusively through the Internet; provides information and support to patients and families facing life-threatening illnesses.

Hospice Foundation of America. Aims to help those who cope personally or professionally with terminal illness, death and the process of grief and bereavement.

American Hospice Foundation. Archived articles from a former organization that worked to improve access to quality hospice care through public education, professional training, and consumer advocacy.

Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO). Advance directive forms for all states are available here for download.

Final Passages. Home care of the dead and home-directed funerals.

Some Books on Reforming Care of the Dying
The Hospice Handbook: A Complete Guide, Larry Beresford, Little, Brown, 1993, 0316091383.

Knocking on Heaven's Door: The Path to a Better Way of Death. Katy Butler, Scribner, 2013, 1451641974.

The Best Care Possible: A Physician's Quest to Transform Care Through the End of Life, Ira Byock, M.D., Avery, 2013, 583335129..

Dying Well, Ira Byock, M.D., Riverhead, 1998, 573226572.

The Troubled Dream of Life: In Search of a Peaceful Death, Daniel Callahan, Georgetown University Press, 2000, 0878408150.

Final Journeys: A Practical Guide for Bringing Care and Comfort at the End of Life, Maggie Callanan, Bantam, 2009, 0553382748.

Unplugged: Reclaiming Our Right to Die in America, William H. Colby, American Management Association, 2007, 0814401600.

Hospice and Palliative Care: The Essential Guide, Stephen R. Conner, Routledge, 2009, 0415993563.

The End-of-Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignified Death, Susan R. Dolan and Audrey R. Vizzard, Outskirts Press, 2013, 1478716509.

Being Mortal: Medicine and What Matters in the End, Atul Gawande, Henry Holt, 2014, 9780805095159. Grave Matters: A Journey Through the Modern Funeral Industry to a Natural Way of Burial, Mark Harris, Scribner, 2007, 0743277686.

And a Time to Die: How American Hospitals Shape the End of Life, Sharon R. Kaufman, University Of Chicago Press, 2006, 0226426858.

The Needs of the Dying: A Guide for Bringing Hope, Comfort, and Love to Life's Final Chapter, David Kessler, Harper Paperbacks, 2007, 0061137596.

Last Rights: Rescuing the End of Life from the Medical System, Stephen P. Kiernan, St. Martin's, 2006, 0312342241,

What Dying People Want: Practical Wisdom for the End of Life, David Kuhl, M.D., PublicAffairs, 2002, 1586481193.

The Hospice Choice: In Pursuit of a Peaceful Death, Marcia Lattanzi-Licht, Fireside, 1998, 0684822695.

Sick To Death and Not Going to Take It Anymore!: Reforming Health Care for the Last Years of Life, Joanne Lynn, M.D., University of California Press, 2004, 0520243005. (Available online.)

Handbook for Mortals: Guidance for People Facing Serious Illness, Joanne Lynn, M.D. and Joan Harrold, M.D., Oxford University Press, 2001, 0195146018. (Available online.)

A Life Worth Living: A Doctor's Reflections on Illness in a High-Tech Era, Robert Martensen, M.D>, Farrar, Straus and Giroux, 2009, 0374532036.

The American Way of Death Revisited, Jessica Mitford, Vintage, 2000, 0679771867.

How We Die: Reflections on Life's Final Chapter, Sherwin B. Nuland, M.D., Vintage, 1995, 0679742441.

What Happens When We Die?: A Groundbreaking Study into the Nature of Life and Death, Sam Parnia. M.D., Hay House, 2007, 01907113.

Death and Dignity: Making Choices and Taking Charge, Timothy E. Quill, M.D., Norton, 1994, 0393311406.

A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life, Timothy E. Quill, M.D., Johns Hopkins University Press, 2001, 0801869781.

Changing the Way We Die: Compassionate End of Life Care and The Hospice Movement. Fran Smith and Sheila Himmel, Viva, 2013, 936740516.

To Die Well: Your Right to Comfort, Calm, and Choice in the Last Days of Life, Sidney Wanzer, M.D. and Joseph Glenmullen, M.D., Da Capo, 2007, 0738210838.

The Good Death: The New American Search to Reshape the End of Life, Marilyn Webb, Bantam, 1999, 0553379879.

It's OK to Die, Monica Williams-Murphy, M.D. and Kristian A, Murphy, The Authors & MKN, 2011, 9780984739318.

Last updated in December, 2014