The Art and Science of Dying
What is death? Is it a process? A state of non-being? A continuum? In researching the science of death, I realized that there is no concrete answer; what’s more, there’s even a blurred line between life and death.
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Death, at the cellular level
We experience death every day. At least our cells do. Take your skin: it’s estimated that roughly 40,000 skin cells complete their life cycle and are shed every hour, floating off as common house dust, completely unbeknownst to us. Cardiac cells are also actively dying, and the lining of our gut is in a dynamic state of regeneration. Cells that are injured or not working properly are programmed to commit suicide in a controlled fashion, a process known as apoptosis that was first described over 50 years ago. Necrosis, another cellular death process, has traditionally been regarded as a passive and unregulated process — but in the past few years we’ve learned that even this process is more complex than we thought with the advent of ‘new’ cellular death subtypes such as necroptosis. Whatever the ultimate reason, our cells at least, have perfected the art of dying well.
As medicine and science continue to redefine death, technology is also blurring the line between life and death.
Death, at the systemic level
Oxygen is our ultimate life source. Within minutes of losing oxygen, the heart of a healthy person ceases to function. As the heart stops, fresh blood stops circulating oxygen to our organs and brain, and we eventually die. But the dying process is still not well understood. Because we often lose ‘consciousness’ while the heart is trying to pump, the brain has always been assumed to be under-active during cardiac arrest. But in 2013, University of Michigan researchers found that the brain emits gamma waves (the waves associated with waking consciousness) even after the heart stops beating. Moreover, in 2015, they found that during cardiac arrest, the brain synchronizes with the heart and the brain-to-heart connectivity intensifies. However, this brainstorm, likely in an effort to jolt the heart into beating, sends the heart into an accelerated demise. The researchers theorize that in controlling the brain’s electrical output during death, we may be able to rescue heart function in emergency settings someday. And that’s good news for the more than 400,000 Americans affected by sudden cardiac arrest annually.
While science continues to uncover the mysterious processes underlying death, medicine is blurring the line between life and death. Until the 1950s, once any one of the vital functions like heartbeat, electrical brain activity or respiration ceased and shut down the remaining bodily systems, you were considered dead, plain and simple. With the advent of the mechanical ventilator, which forces oxygen in and out of the lungs, a new category of death called brain death arose. In 1968, Harvard medical school reported “a new criterion for death” in their landmark paper, A Definition of Irreversible Coma. Clinicians still use the apnea test to determine clinical brain death, where a patient is briefly disconnected from a respirator to see if they can breathe on their own, and thus determine if the brain stem is functioning. If they cannot breathe, they are pronounced brain dead. Brain dead patients retain several attributes associated with life, such as skin color, warm skin, heartbeat, kidney function, etc. Organ harvesting, and even baby delivery, can take place after brain death is established. Since the body in this condition appears relatively alive, the philosophical question of someone’s ‘aliveness’ arises for many. (To clarify, brain death refers to cases of no obvious brain function, not a coma or vegetative state.). That a person is dead when all brain functions cease is a commonly accepted medical view, but there are still other viewpoints, such as defining a person dead only after their heart stops beating.
As medicine and science continue to redefine death, technology is also blurring the line between life and death. A former colleague of mine and co-founder of the Brain Preservation Foundation has recently awarded a team of researchers for successfully cryopreserving (memories and all) an entire rabbit brain, marking the first time a whole mammalian brain has been kept in near-perfect condition for future use. This ‘future use’ is still up to the imagination, but futurists like Ray Kurzweil predict that uploading our brain to either a machine or a new body is no longer beyond the realm of possibility. Of course, the science here is very new, but we’ve clearly moved beyond a black and white definition of death.
There is no doubt that research and medicine have redefined the science of dying. How are culture and technology redefining the art of dying?
While I thought that I was learning how to live, I have been learning how to die. ~ Leonardo Da Vinci
In the wake of the Black Death, priests — the cultural guarantors of salvation through the administration of last rites — became a scarce commodity. Without enough priests to attend to the dying, the newly minted printing press offered a contemporary solution for salvation, allowing pamphlets containing prayers and penances to be easily producible and distributable. It was during this time of 15th century innovation and scarcity that the Latin texts known as Ars Moriandi began circulating European households. Ars Moriandi — literally “The Art of Dying,” offered advice on how to die well according to the Christian ideals of the time. Most cultures have in some way, shape or form crafted their own ‘guide’ to dying well. With the advent of social media and palliative care, perhaps our own Western culture is redefining what it means to die well.
Traditionally, Western culture keeps death at a nice, safe distance. A process left to hospitals and funeral parlors and not for everyday conversation. Perhaps, we do ourselves a disservice in keeping death so distant. In his book Being Mortal, surgeon Atul Gawande writes, “Our reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and denied them the basic comforts they most need.” Our language, in particular when speaking about the “C-word,” illustrates our discomfort with death and dying. People “battle cancer,” “lose their fight” with cancer (as if it was a proper match to begin with), and are dubbed “survivors” if they achieve remission. So death and dying are seen as failings of our bodies and technology. But what if we could change this narrative to show that acknowledging the inevitable end is just as heroic, and giving us permission to say “If I can live well, then I can die well.” Indeed, more and more high-profile people have chosen to artfully display what it meant to them to be dying, an effort that is opening up a new conversation about death and may just change our narrative altogether.
Oliver Sacks, renowned neurologist, enveloped his end with literature. His essays written over the last two years of his life culminated in one volume simply titled, Gratitude. In it, he explores the paradox of finding presence through detachment:
“This is not indifference but detachment — I still care deeply about the Middle East, about global warming, about growing inequality, but these are no longer my business; they belong to the future… I cannot pretend I am without fear. But my predominant feeling is one of gratitude.”
Although David Bowie did not disclose his cancer to the public, he must have also felt enough gratitude to leave his fans a parting gift. In fact, his producer Tony Visconti wrote of his last album, Blackstar, “His death was no different from his life — a work of Art.” So maybe this is why open and honest conversations about dying and death are important — in a way, they teach us how to live.
There is a theory in psychology called the terror-management theory. In a nutshell, it means that when we’re faced with the idea of death, people defensively turn to things they believe will shield them from death, literal or otherwise. Thinking about death also motivates people to indiscriminately uphold and defend their cultural worldviews, whatever those may be. An interesting 2010 study found that people who were naturally more mindful were less defensive of their worldviews after being reminded of death, suggesting that “mindfulness reduces defensive responses to existential threat.” Basically, the more mindful we are of our own death, the less fear and anxiety it will give us. Mindfulness doesn’t have to be enacted when we’re sick or elderly; it is a skill that can be cultivated when we are young and healthy. In 1969, Elizabeth Kübler-Ross (you may remember her from the stages of grief) wrote: “If all of us would make an all-out effort to contemplate our own death, to deal with our anxieties surrounding the concept of our death… perhaps there could be less destructiveness around us.”
The science of dying is being redefined. The art of dying may also be changing in our culture, where we can learn to live well not in spite of death but because of it. With a new narrative that demystifies death, we see that the end-of-life dignity sought out in hospices and hospitals may in fact lie in a life well-lived. As Sherwin Nuland expertly wrote,
“Ars moriendi as ars vivendi: The art of dying is the art of living. The honesty and grace of the years of life that are ending is the real measure of how we die. It is not in the last weeks or days that we compose the message that will be remembered, but in all the decades that preceded them.”