Everything was done with great speed but also with care for my well-being and feelings. I marveled at the combination of haste and calm. They are used to facing these problems every day but it was impressive to watch. They assured me that they would get a cardiac surgeon for me. My reaction was to think that they were kidding. Are they going to find a cardiac surgeon on a Sunday morning who is just waiting for me to show up? But to my surprise as soon as they finished administering something to stabilize me they put me on a stretcher and we snaked our way through the sea of human bodies to an elevator. When we arrived at the operating theater a surgeon and two assistants were already there and prepared to act. For the previous surgeries I have had, the preparation time has been at least six hours, more often a day or more. In this case, I had arrived unannounced in the emergency room at 10:30 AM and was ready to be operated on before Noon.
The surgeon explained that he would first be doing an angiogram to decide if I had a blocked artery. If that was so, which seemed likely, he would do an angioplasty to insert a stent that would unblock the artery. I was given a very mild sedative but I was fully aware of everything he was doing. The procedure for the patient is similar to the cardiac ablation I had last year. The surgeon works on the heart from an incision in the groin. This kind of surgery is completely beyond my imagination. How could anyone think up such a procedure? How did they experiment to find out if it worked? Millions of us owe our lives to the brilliance of researchers on the heart and the steady hand of cardiac surgeons.
After about an hour the surgeon said he was finished. I thought he meant that the first procedure to find if there was blockage of an artery was complete. I expected that the implanting of a stent would be a much more complicated procedure. Instead, he said he had successfully completed both procedures. The right artery had been completely blocked and the others had problems too. Some future work will likely be needed. For now, I would be ready to resume my daily life after a brief stay in the coronary care unit of the hospital. The length of stay, I was told, was usually three or four days.
The coronary care unit provided a good amount of privacy, as much privacy as a hospital can manage. A room of one’s own in a hospital is not usually what one can expect. The most distinctive feature of the CCU was the machinery. I was hooked up for most of the time to five machines. Together with regular injections of something and withdrawals of blood one can feel like an extension of a machine. The nursing staff as usual were what kept the place human. How nurses put up with all these sick and complaining bodies during twelve-hour shifts is a mystery to me. There were also a surprising number of physicians who were on the scene (the white ones showed up on Monday). I was not entirely sure why there were so many physicians involved although they were dedicated to team work and these days cardiology has many sub-specialties
The main production of the day was “rounds.” The chief of the unit who was clearly in charge showed up in the room with a dozen other physicians who I presume were starting out as interns or assistants. I had never seen this kind of performance except in hospital dramas on television. I could hear the chief posing questions to the underlings out in the corridor. When the crowd entered the room, they moved swiftly. I was impressed that the chief knew everything about me and my present condition. His questions, I realized, were partly for the benefit of the staff he was with.
On the second day, the chief physician was aware that the four medicines I had been put on had caused a big drop in blood pressure. My blood pressure has always been on the low end of normal. Most people who have heart attacks have high blood pressure so that a resulting decrease in blood pressure is an indirect benefit of the medicine. In my case, a very low blood pressure caused dizziness when I tried to walk. Since I have seldom taken any medicines my body reacted strongly to this sudden influx of strange chemicals. I was assured that the cardiac team would adjust the prescriptions to my individual needs. They halved the dose of one of the medicines which worked to cure any dizziness. The low blood pressure continued but I was confident that it would get back to near normal. Fortunately, that was my one adverse effect and it did not delay my release from the hospital.
A good friend came a long way to accompany me on my being discharged from the hospital. It was late afternoon and a taxi on the Upper East Side was nowhere to be found. So I suggested we take the subway. I was at first somewhat concerned that the Lexington Avenue subway is the most crowded line in the city. I was not sure about suddenly experiencing a train jammed with human bodies when I was only a few minutes out of a hospital bed. But then I realized that the heavy rush hour traffic on that line is downtown in the morning and uptown in the evening. This being the late afternoon, I actually got a seat for the ride downtown. Life had returned to its ordinariness.
I have read of many people who after their first heart attack drastically change their diet and other behavior. My father had his heart attack at age sixty-six. It got him to stop smoking and to change his diet, which probably added years to his life until lung cancer from the smoking took its toll. Tobacco, alcohol, red meat, sugar, salt, fat, caffeine are cited as culprits; a lack of exercise and an excess of mental stress are clearly not a help to the heart. I would be willing to change anything in my behavior but I cannot identify any of those factors in my diet or behavior. I asked several physicians what they thought had caused the failure of my heart and they shrugged. They might have quoted another line from Samuel Beckett: “You’re on earth and there’s no cure for that.”
Did I learn anything from this experience? I can’t say that I did although it confirmed the attitude I have had for at least the last four years when the game went into extra innings. As I lie in the emergency room surrounded by a whirlwind I was completely calm. I reflected on the fact that this could well be the last inning. When I considered that I might be about to die I had no emotional reaction at all. Every day offers that possibility and I find myself very peaceful about the prospect. I would not call the attitude wisdom but nevertheless a detachment from the minor irritations in daily life helps to provide a wide perspective about what is important.
After my stay in the hospital my body continued to react to the surgical intervention and the medicines. Contemporary surgery is deceptively simple in appearance and almost devoid of pain. But the body still needs time for adjustment until every cell of the body has been informed of what has happened. The cardiologist checked me on Friday and scheduled a stress test for July. On Monday I had a persistent pain where I had not had pain before and considered going to the ER. Monday night I did not sleep at all and was jolted upright every time I started to fall asleep. This seemed serious. It is generally a bad idea to decide anything at 5 AM but I figured if I was going to the ER I should beat the morning rush hour.
I dialed 911 at 5:30 AM and asked for help. As I was putting down the phone I could hear a siren. I thought that could not be for me. Then I heard a second siren and thought that might be for me. Actually, both sirens were for me. Within three minutes I had a fire truck, a police car, and an ambulance at my front door. Beth Israel Hospital is two blocks from me, a fire station is a block and a half. The firemen went on their way, the two cops and two EMS workers assisted me. We did beat the rush hour traffic. A week after having been released from the hospital I found myself back in the ER. For the next five hours they gave me numerous tests and watched over me carefully but found nothing wrong. I was slightly embarrassed at my over-reaction but it is comforting to know how fast help can arrive if I really need it.
The tremendous advance in the treatment of heart disease can paradoxically be seen in cancer statistics. It is often said that “we are not winning the war on cancer.” Actually, there have been great advances in the treatment of cancer, most dramatically with childhood cancers (a drop of half since 1975). People live longer because cancer can be postponed until later in life. Heart disease and cancer are primarily diseases of aging. Fewer people dying of one means more people living long enough to die from the other. The Centers for Disease Control has a diagram that starts in 1958. Heart disease is far above cancer at the beginning of the chart. Over the years, deaths from heart disease have fallen 68 percent. Cancer rates fell 20 percent which is impressive but compared to the advance in fixing the heart the progress in cancer treatment may seem like a lack of success.
When heart difficulties arise, they can be treated as mechanical problems – clogged piping, worn-out valves – for which there are fixes. People between 55 and 84 are increasingly more likely to die from cancer than from heart disease. After that age, there is a reverse in deaths from the two but advances in heart treatment mean that deaths by cancer will soon surpass heart deaths. Improvements will no doubt continue to be made in both areas but there will never be a “victory” over cancer.
Cancer is not so much a disease as a phenomenon. As the body grows, its cells are constantly dividing, copying their DNA and bequeathing it to daughter cells. They in turn pass it on to their own progeny: copies of copies of copies. Along the way, errors inevitably occur. Some are caused by carcinogens but most are random misprints. Mutations are the engines of evolution; the trade-off is that every so often a combination will give an individual cell too much power. It begins to evolve independently. Other cells are left at a competitive disadvantage and the “successful” cell becomes a cancerous tumor.
Cancer is just a matter of statistical probability. Live long enough and you will finally be unable to beat the odds. But until that time comes, one can be grateful for the advances in care of the heart which have made such a long life possible. I know that the health care system is a mess, especially its racial and economic disparities, but I have no personal complaints. I am especially grateful for the people in the ER who energetically assisted me even before they knew my name, social security number, and insurance carrier.
CHAPTER THREE: DEATH EDUCATION: DOES ANYONE NEED IT?
Since the 1960s in the United States there has been a death and dying movement. Central to this movement has been the claim that everyone needs “death education.” Many universities began offering courses on death. The movement has tried, with limited success, to have courses offered in secondary and elementary schools.
The reflections in this book have emerged out of the struggle to teach the young. For twenty-five years I taught a course called “The Meaning of Death” to undergraduate students in a large urban university. The course was limited to fifty students who signed up in the first few days of registration. At the beginning I feared that the course might attract the suicidal, the morbid. or students looking for an easy course. Almost never was that the case. The students were among the best and the brightest, and as psychologically balanced as any group of college students can be these days.
The young think of death as far away and, for the most part, they are right. I was always surprised, therefore, that at least some young people do wish to reflect on dying and the meaning of death. I was always uneasy about the academic integrity of the course, starting with the presumptuous title that was not of my choosing: “The Meaning of Death.” I had to admit in the first class of the course that I don’t know the meaning. Perhaps meanings would have been a better word in the title but the problem goes deeper, namely, whether death is the proper subject matter for a college course. It was cross listed in two schools and had four departmental listings, which is indicative of its maverick nature. Because it was listed as a religion course, some students were religious studies majors who might have come expecting the study of ancient sacred texts on death. Many other students who signed up for the course were indifferent or hostile to religion.
In the first years of the course I realized that the most common reason for a student choosing the course was that someone close to the student had recently died or was dying. The student might have been looking for therapy more than for an academic course. A classroom is not a place designed for therapy but people take comfort wherever they can find it. I explained in the first class meeting that the course was not aimed at therapy. If a student wished to speak about a personal experience of death – as many did – that was their choice, but I would not play at being a therapist.
The course delved into any place and any medium that might help in the understanding of death. The casual transgression of academic disciplines did not seem to bother students but it did concern me. I do not think this approach is a good model for other courses. I used this grab bag approach because I did not know how else to get hold of death.
From this experience I can see the value of a college course on death offered as an elective. As for requiring high school and elementary school students to study death and dying, I am skeptical. Advocates of death education say that the traditional college age is too late for beginning one’s education in this area. That is true and I return below to the need to begin “death education” in early childhood. Before describing how to answer the need, however, are we certain about the need itself?
A New Need?
Is there a need for death education and, if so, is that something new? Has the world always needed it but failed to recognize the need until recently? I noted above that the movement seems to have emerged in the late 1960s. Is there any special significance to that date? Was this movement part of a package deal that saw all aspects of the culture and its education shaken up? Like other fads of that time it may have peaked long ago and now is the preserve of a few faithful followers. Or like other aspects of the 1960s, it might be a movement that is still gathering momentum. As it was in 1968 (or 1468) the fundamental issue of death is not going away. The death rate on earth is one hundred percent; one out of one dies.
The question is whether this time and this place are in need of a particular change in education. Are there factors that have reshaped the fundamental idea of mortality, forcing us to face new questions about the universal experience of dying? Anyone can list both positive and horrific factors of the past century that have affected the human experience of dying. Whether or not that list essentially changes the experience of dying cannot be confidently asserted by anyone.
A common claim is that we need death education because the issue of death is hidden in contemporary culture. Is it true that individually and collectively people avoid the subject of death? At first glance, the claim seems wildly off the mark. Popular culture seems saturated with violence and killing, war and terrorism. Whether one watches the news or a drama on television, death is usually the lead story. The blockbuster movies that Hollywood sends around the world are most often technically brilliant but powerfully violent exercises concerned with death.
The person who claims that death is a taboo topic must either be oblivious of the surrounding cacophony or else is speaking paradoxically. I think that someone who says that the culture is silent on death is referring to the absence of reflection on one’s personal mortality. That is, the reality of one’s own death is seldom engaged or discussed. The culture does its best to hide from general view the sick and the dying. The constant portrayal of death on the movie or television screen could be part of the evasion of real dying. Watching characters on a screen be blown away can lead to a belief that one is facing death while in fact the experience is a distancing of oneself from one’s own mortality. The idea conveyed is that death is what happens to other people.
The claim is also made that the absence of reflection on dying is a recent development. Any clear comparison with the past on this point is hampered by the limitation of material from previous eras and our inability to know the experience of ordinary people from 5000 or even 500 years ago. We can try to construct a picture from materials such as funeral markings, religious rituals, popular poetry, and diaries. We have the pronouncements of a few philosophers and religious leaders but the relation between their words and society at large is not clear.
Plato, as the first great philosopher in the West, is often cited as expressing the attitude of ancient thought concerning death. Plato put the case simply and starkly that philosophy is a “meditation upon death.” He argues that “those who philosophize aright study nothing but dying and being dead.”i The trial and death of Socrates comes to us from Plato’s writings. The attitude of Socrates to his own dying undoubtedly shaped the outlook of his young disciple, Plato. The death of Socrates, along with the death of Jesus of Nazareth, became in the West the preeminent examples of how one’s dying should be approached, namely, with clarity, courage and hope in a better life. Dying was what human life moved toward and therefore dying was what a human being constantly prepared for.
The philosophical marker that is often cited as a radical altering of this pattern is a seventeenth-century statement of Baruch Spinoza. Directly contradicting Plato, Spinoza wrote that “the free man thinks of nothing less than of death; his wisdom is a meditation not upon death but upon life.”ii This statement in 1677, the year of Spinoza’s own death, may be emblematic of a change that was in the air in seventeenth-century Europe and whose effects continued into the twentieth century. The focus of the new sciences shifted concern from death to life, a change that might be seen as healthy and hopeful. Some commentators, however, have seen the move as a flight from death, a living in pretense. The modern affirmation of life is seen to be a denial of death.
If modernity is deeply committed to a denial of death, then the belief that the modern era has reached a crisis point could be tested by the resurfacing of death in dramatic ways. The argument can be made that that is just what occurred throughout the twentieth century. Of course, what has been the modern attitude continued to be celebrated in many quarters. For example, Harvey Cox’s world-wide best seller in 1965, The Secular City, acclaimed the arrival of the modern in religion and, predictably, had almost nothing to say about death. The twentieth-century questioning of the modern attitude to death arrived in the United States later than it did in Europe. Many of the most prominent philosophers and theologians of the twentieth century had direct experience of the disillusioning war between 1914 and 1918. The devastating experience of that “great war” shows up in the work of many writers in the first half of the twentieth century.
The philosophical work that is often cited as signaling a turn from the theme of modern progress to one of acknowledging the stark reality of death is Martin Heidegger’s Being and Time, published in 1927. Not only does death return, it becomes the defining element of human life (or what Heidegger calls Dasein). “As soon as a human being is born, he is old enough to die right away.”iii Although Heidegger posits that “man is a being toward death,” this characteristic is not evident, Heidegger contends, because human beings do everything possible to avoid thinking about death.iv
A similar theme emerged in the writing of Sigmund Freud, who like Heidegger, cast a shadow across the twentieth century. Freud, almost in spite of himself, eventually came to posit a “death drive” which struggles with the force of life and finally wins out. “The aim of all life is death,” Freud wrote, “all living creatures strive to die; indeed death appears to be an object of desire.”v Thus for Heidegger, Freud, and their descendants death returned with a vengeance, not as a gentle reminder or a fact of life but as an overwhelming power and an obsessive concern.
The writings of Heidegger or Freud may have brought into the open the modern flight from death. It would be too much to claim that their work was the cause of the shift away from contentment with modern progress. A new prominence of death was no doubt the result of a confluence of scientific, political, aesthetic and cultural causes. I will comment on two of the most obvious and powerful causes of the emergence of death: war in an era of world-wide communication and medical technology in its fight against death.
Warfare has presumably always been a reminder of human mortality. It brings early death to masses of healthy young people. However, the scale of war has changed dramatically, beginning with the United States’ Civil War in which over 600,000 young men were killed. Weapons of offense had outstripped tactics of defense. That war was a prelude both to World War I and to civil wars at the end of the twentieth century. Sandwiched between these later and earlier wars was the horror of World War II, including the Holocaust, and a half century of cold war in which the annihilation of hundreds of millions of people was coolly contemplated.
Large numbers of deaths can obscure rather than heighten awareness of an individual’s dying. In the second half of the twentieth century, however, war came into the living room. Television became increasingly capable of instantaneous transmission of deadly combat. The rise of the death and dying movement coincided with the war in Vietnam, the first televised war. Television was sometimes accused of deadening people’s sensitivity to war and killing. It probably did have that effect but it also had a cumulative effect: disgust and despair at the killing of over two million people in a war whose purpose was never clear. Since that war, the United States has often sent its military when the television cameras have shown great suffering. The United States has also tended to pull out its military when television pictures of dead U.S. soldiers bring pressure on the government.
World-wide communication is a force for spreading the ideals of justice, rights and democracy. The same media can be exploited in the service of killing for what is believed to be a noble cause. Dramatic killings can achieve disproportionate effect through television and the Internet. The bombing of the World Trade Center in 2001 killed fewer than three thousand people. That number would not rank it among the top calamities of the twentieth century, let alone all human history. But people from around the world could view the dramatic unfolding of the event; several million people watched the incineration as it happened. A documentary film, that included footage from 118 amateur photographers, claimed that the bombing was the most documented event in history.vi Did this event change the perception of life and death in New York, the United States or the rest of the world? Some permanent effect is likely in the lives of those who were close to the event. What it has done on any large scale to people’s attitude to death will take decades to become clear.
The second major influence in the contemporary perception of death is modern medicine and its attendant technology. The change here would seem to be for the good; human beings are able to live longer and to live more healthily. Until 1900, fewer than half of the people who entered hospitals returned alive. The physician’s little black bag contained very little help in staving off death. Most deaths occurred in the home so that family members, including children, gained familiarity with death.