Graceful Exits: When, Why, and How to Die #4

This post is one of a series of posts wherein Dr. Bossypants explores that final task we all face: Dying.Consider yourselves warned: Being mortal is challenging, and death is a stressful topic. No doubt you will read these posts with some degree of sadness, despair, and denial. However, Dr. Bossypants sincerely hopes readers will consider such matters thoughtfully, and when the time comes to face our own death or that of a loved one, Dr. Bossypants hopes we can act with wisdom, compassion, acceptance, and bravery.

The adjustments required to age without whining and to die without a sense of failure are difficult in and of themselves, but they are made far worse when cultural values run heavily to overvaluing youth and “saving” lives at all costs. Dr. Bossypants tried to lift the veil of shame promoted by big business in our last blog. Now she turns her wrinkled brow and piercing gaze to the vast enterprise we call modern medicine.

Even before the Covid crisis, healthcare was one of the most fraught issues on the global radar. Is basic healthcare a privilege or a right? How are our medical dollars spent? Should providing such care make people rich? Should pharmaceuticals make people even richer? How many lobbyists are enough? Who deserves the more intensive and expensive treatments? Is basic nutrition a legitimate component of healthcare? These are fascinating and divisive quandaries, but they are only tangentially related to the main focus of these blogs: the right to die on our own individual terms.

 In future blogs, Dr. Bossypants will consider psychology, biology, and religion as they interact with our widely shared fear of death, but in some ways, the source(s) of human avoidance of death is a chicken and egg question. There’s little doubt that as a general rule, people don’t want to die, and they don’t want the people they love to die. This has paved the way for not only overactive commercial efforts, but also for medical research and practices that may actually contribute to human suffering nearly as much as they do to human wellbeing.

The Medical Mandate: Hippocratic Oath Run Amok?

Healthcare professionals of all sorts have ethics codes, personal and religious values, and legal constraints that guide their practices. These are highlighted and augmented as people are enculturated into their professional identities. Most people have heard of the Hippocratic oath and likely assume that healthcare professionals (other than dentists) are required to “Do no harm.” Just kidding. Dentists are included. Dr. Bossypants has an uncle who is a dentist. That was a private joke.

So, back to the topic. The original Hippocratic oath has been tinkered with repeatedly over time. Translations vary, and certain politically loaded phrases have been inserted or omitted. This reflects the fact that human morality and professional ethics have an evolutionary fluidity that responds to scientific discoveries and political pressures. The real Hippocratic oath is much more nuanced than the simplistic “do no harm.”

Most of us know a fair number of physicians and other healthcare workers personally and/or professionally, but it is unlikely you’ve had “the talk” with any of them. Do you know their views on suffering and death? We assume they favor neither and have devoted themselves to fighting both. This can be a problem because the frame then dictates that death is the enemy—something to be fought, feared, and avoided.

Even though Dr. Bossypants understands that frame, it is out of touch with reality, and it is wrong. Yes, suffering sucks, but death is not the enemy. It is a natural outcome of being human. When people are near death and medical interventions pull them back, their lives should be considered prolonged, not saved. The possibility of a good, humane death versus prolonging the pain or struggles for a short extension of life should always be openly examined.

As we noted in earlier blogs, physicians are slowly coming around to favoring the legal right to be of assistance in dying, but it’s a struggle for many. Healthcare professionals are dedicated to making lives better, healthier, and longer. For many, healing is a calling. They strive to do no unnecessary harm, and most people think of death as harm. There’s some irony in all this. Neurologist and author, Oliver Sacks wrote, “It is the fate — the genetic and neural fate — of every human being to be a unique individual, to find his own path, to live his own life, to die his own death.” Part of responsible health care should involve providing painfree and dignified ways to die when the time comes. And with dogged determination, Dr. Bossypants will continue to bravely point out: The time will come.

Philosophy, Morality, and Medicine

            In the fascinating domain of bioethics, a concept called “the technological imperative” is often discussed. In one version, this means if we can do it, we should do it. Applied to medical interventions, this could mean that because we can keep a person in a coma alive indefinitely, we should. Because we can use chemo to control the tumor for two more weeks, we should. Because we can revive a person with extensive brain damage, we should. Given human ingenuity, it is assured that we will continue to develop ways and means to keep severely injured, massively disabled, and/or terminally ill people alive longer than they would have been without these interventions. In many contexts, this is a wonderful testament to the human spirit. But it is not a mandate. It is an option. The real moral mandate is respect for human autonomy.

            People have the right to request life-extending medical procedures, and they have the right to refuse these interventions. They should also have the right to request assistance to die (though in many states, this last request will be denied). There are significant physical and economic costs to consider, and everyone has the right to engage in thoughtful conversations with professionals and loved ones to weigh the options. Just because a liver transplant or life on a ventilator is possible, it is not a moral obligation to undergo the procedures that could extend life. Loved ones occupy a certain space in these considerations and most of us value and are influenced by their input, urgings, and permissions. Professionals should provide whatever information anyone wants or needs. It is not morally correct for them to urge anyone to stay alive; it is not morally correct for them to urge anyone to die; and it is not morally correct for them to withhold information or lie about anyone’s condition.

On the other hand, should physicians be required to be of assistance if someone has chosen to die and asks for their help? Of course not. They should neither be required to help nor restrained from helping. Some physicians believe that the short version of the Hippocratic oath, do no harm, disallows them from helping someone die. But how do we define harm? Is it harmful to cause prolonged pain? Is it harmful to force someone who wishes to die to instead lay in a bed, unable to move, sometimes for years? Death is the natural outcome of life. Ernest Hemmingway observed that every human life ends the same way. It is only the details of how the person lived and how the person died that distinguishes one from another. Some people will choose to live for as long as they possibly can, using every method available. But some will choose otherwise. Within their worldview and life experiences, prolonged life is not their highest value.

Qualities of Life

            As mentioned in previous blogs, my years as a rehabilitation counselor taught me a great deal about the value of life—even life with significant restrictions and chronic pain. I respected and admired the hard-fought daily battles my clients faced to live as naturally and comfortably in their limited bodies as possible. Over the time I served them, a few chose to end their lives, presumably because the difficulties were too daunting, or they were simply tired of life. They did not inform me ahead of time. If they had, or if I had even suspected they were planning to end their lives, by law I would have had to intervene. They knew this. Thus, they had to enact their deaths alone and in ways that seemed risky, painful, and traumatic.

This quandary has been dramatized by Hollywood many times. For instance, consider the attempt to die by Hilary Swank in the movie Million Dollar Baby. Paralyzed from the neck down, Swank’s character tried to bite her tongue so deeply that she would bleed to death. In the movie, no medical professionals would listen to Swank’s requests to end her life. In fact, legally, they probably could not have helped even if they had been willing.

In the last blog, Dr. Bossypants pointed out that humans are terrible self-forecasters. Many of us like to make fun of weather predictions, but meterologists are a lot more accurate about the next day’s highs and lows than people are when they try to forecast what they might be worse than death for them.

In one study, psychologists Dan Gilbert (of Harvard University) and Tim Wilson (of the University of Virginia) observe that most (healthy) people say that if their quality of life is low, they would rather not have medical interventions designed to give them more time. “However,” as the American Psychological Association’s website notes, “when medical researchers interviewed people who were slowly dying and experiencing a very low quality of life, such people almost unanimously reported that they would go to great lengths to add even a few days to their lives.”  

This worries Dr. Bossypants. Why? Because we are all susceptible to the forces at work on us. First, we want to believe we will live forever—other people die; not us. So when we are near death, we’re shocked and have no game plan. Second, big business has invested heavily in making us ashamed and afraid of dying. Third, the medical world is over-identified with prolonging life and less equipped to provide aid and comfort in the dying process. These are huge factors, but of course, there’s more. We have yet to tackle religion, government, psychology, and biology. We are, indeed, complex beings. Stay tuned.

Graceful Exits: When, why, and how to die #3

This post is one of a series of posts wherein Dr. Bossypants explores that final task we all face: Dying.Consider yourselves warned: Being mortal is challenging, and death is a stressful topic. No doubt you will read these posts with some degree of sadness, despair, and denial. However, Dr. Bossypants sincerely hopes readers will consider such matters thoughtfully, and when the time comes to face our own death or that of a loved one, Dr. Bossypants hopes we can act with wisdom, compassion, acceptance, and bravery.

At his request, Linda helped her stepfather die. Some would say she murdered him. Walter was 87; his hands weren’t steady enough to give himself the injection, so on a rare visit to her childhood home, Linda agreed to help him end his life. Typical of this successful retired engineer, Walter had everything ready.

He’d decided not to burden Linda with his request ahead of time. When Linda arrived, they reminisced a bit. Since they lived thousands of miles apart, they’d not seen each other for years. Linda later told me she was shocked at how old and disabled Walter had become, but equally surprised at the clarity of his thinking. As Walter explained what he needed from her, Linda admitted she freaked out a little inside, but Walter had picked the right stepdaughter. He knew Linda was both gutsy and compassionate, and he hoped these attributes would predispose her to agree to help. They did. He had a bottle of Shiraz, Linda’s favorite wine, a few sleeping pills, and a syringe of phenobarbital. He knew that some people who tried to swallow enough barbituates to die sometimes threw up instead, and he didn’t want to die alone anyway.

Almost immediately after Linda calmed herself and agreed to help, Walter took the sleeping pills with the wine they were sharing. As Walter grew drowsy, he told Linda how much he had loved her mother, what a great life he’d had, and how grateful he was for her help. Then he drifted to off sleep.

Linda steeled herself, pulled on the latex gloves Walter had thoughtfully provided, gave him the injection, held his limp hand, and waited as his breathing slowed and stopped. His eyelids twitched some, but it was a peaceful death. She put the gloves in her purse, closed the door, got in her car, and drove away. Far, far away. Walter did not live in a state that would look kindly on what Linda did. As she told me the story two years later, she admitted she still has fears of being tried for murder. “But I’d do it again,” she said. “He was so grateful. So ready.” Walter had outlived his wife and had no close relatives. He’d endured chronic pain for years because he didn’t like what the painkillers did to his mind. “He was tired of hurting, tired of being lonely, tired of life. He’d thought things through, and he was ready to die,” Linda added. “I’m so glad he didn’t have to use a gun or die alone.”

Fear of death: Where does it come from?

Death is the final human experience; every last one of us will die. But for something so common, death remains a frightening mystery many would prefer to ignore. Being afraid of the unknown is natural and understandable, but there are forces in modern culture that exacerbate our fear of death and add a monster-sized dose of shame to the aging and dying process. Big business and medicine are significant external forces, but of course, we have to consider religion, biology, and psychology as well.

In this and future blogs, Dr. Bossypants will mull these forces over with you. It won’t be easy, but we need to turn some things around, open up the topic, and get as comfortable as we can with every aspect of our mortality. There are certainly extremely private people among us who would prefer to die alone, but most people express a hope to have loved ones nearby as they die. And when faced with the imminent death of a loved one, most of us want a chance to say goodbye, and many want to be present for the departure.

And finally, it is unlikely many people want to suffer unnecessarily. So what makes this so crazy hard? First, let’s consider the huge monetary gain from making us embarrassed about aging and fearful of death. We’re talking some big-ticket items!

Industrial strength resistance to death

Francis Bacon said, “It is as natural to die as it is to be born.” It may be natural. It may be inevitable. But not many of us are willing to accept or seek death, and as we’ll discover in our explorations, those who do are often labeled criminal, insane, or heroic. In Walter’s case, all labels might apply. Was Walter criminal? Yes, weirdly, he was an accomplice to his own “murder.”  Was Walter insane? Some would argue he was diagnosably depressed just because he was ready to end his life. Was Walter heroic? Yes, he acted to save himself and loved ones much pain, trauma, and expense.

Like sex and love, the fear of death and the longing to stay vital and alive provides endless plotlines for literature and theater, and a golden opportunity for businesses to promote merchandise. Sex sells, but so does the fear of dying. Increase the fear: sell more products.

Both health enhancing and life prolonging products are advertised endlessly. As my mother’s body began its steep decline, she surreptitiously ordered a few miracle cures from shady companies. She was then completely inundated with brochures, phone calls, and special offers, all promising to cure her neuropathy, her dizziness, her lack of appetite (or whatever distressing symptoms she was experiencing) and restore her to perfect health. It was a cruel waste of her money and energy, and her loved ones did their best to discourage this misplaced hope, but of course, we are all susceptible to believing the lies we wish were true.

Any effective marketing stirs up primal human longings and fears and then embellishes and exaggerates. Even if we may not initially believe we need a product, the ads convince us that we are missing out. The underlying message is that we should desire the outcome being promised. If we don’t desire it, there is something wrong with us. We should want to live for as long as possible, and we should strive to keep our loved ones alive for as long as possible, no matter what.

These shoulds weigh heavily on families. My beloved mother-in-law, Paula, developed Alzeimer’s disease and suffered slow decline into complete dependency and cognitive nothingness. But her heart continued to beat. Until an infection provided the final push, she lived unknowingly in a rocking chair and a bed. Her family members supported each other and cried a lot as we let the infection run its course. We loved her fiercely and knew her well enough to know it was time to let go. But the shoulds still hovered nearby. Somehow, the idea that taking extreme measures demonstrates love has infiltrated our cultural thinking. The shoulds are merciless.

The word should often signals a moral mandate. Staying alive at all costs or trying to keep one’s loved ones alive as long as possible are not, I repeat, not moral mandates. But insinuating that they are is good business. Regardless of emotional, physical, and financial costs, everyone should strive to keep themselves and their loved ones alive. Failing to do so is “shameful.” When Linda helped her stepfather die, she not only stepped over a legal line, she stepped over this faux moral mandate. “Sometimes, I think I should feel guilty,” she admitted. “But Walter did the heavy lifting. I hope, if the time comes, someone will do that for me.”

The lure of eternal youth

Products and procedures that promise youthful appearances are big business (far upwards of 16 billion a year in the United States). Wrinkle removing creams, hair implants, and face lifts do not enhance health or prolong life. They simply disguise the aging process and drain our savings accounts. They promote the notion that signs of aging are ugly and shameful; we should be embarrassed when we don’t try to hide them.

Not only does this shaming lead to purchasing, it leads to denial and inhibits healthy conversations about aging and dying. According to the ads, aging is something to disguise, and death is a failure.

Caroline and Pam are pseudonyms for some old friends of mine. We all bemoan aging, but my friends handle things differently. Caroline buys the latest fashions, claims she has single-handedly kept stocks in Botox high, dyes her hair, wears a lot of make-up, and has endured a number of cosmetic surgeries. Pam has gone gray, refuses to pluck her chin hairs, clip her nose hairs, or manage her increasingly wild eyebrows. She owns an impressive collection of hiking boots and handguns. You might assume Caroline is the one more afraid of aging and death, but they’re both somewhere in the middle.

“None of that stuff Caroline does makes one damn bit of difference,” Pam often says. “She can hide her age in her nips and tucks, but she’ll die when she dies. Just like the rest of us.” Caroline counters with, “I don’t want to look old. But you won’t catch me packing a gun. If someone decides to shoot me, at least I’ll look my best.”

Pam hikes with her pistol and trusty dog and finds solace in nature. She believes the success of the advertising industry in Caroline’s life is due in part to the fact that most of us are increasingly disconnected from nature. The lives and deaths portrayed in the entertainment industry and in video games are far from the natural truths and realities of life and death. John Muir, the famous naturalist, said, “Let children walk with Nature, let them see the beautiful blendings and communions of death and life, their joyous inseparable unity, as taught in woods and meadows, plains and mountains and streams of our blessed stars, and they will learn that death is stingless indeed, and as beautiful as life.”

Nice sentiment, but most of us can’t go quite that far. It is natural to age, decline, and die. But most of us don’t think of death as stingless or beautiful. Dr. Bossypants bows in admiration to the actor, Frances McDormand, who without make-up or Botox, ages frankly and honestly in front of us all. She recently said, “My position has always been that the way people age and the signs that we show of aging is nature’s way of tattooing. It’s natural scarification, and the life you lead gives you the symbols and the emblems of your life, the road map you followed.”

Aging is stressful, disappointing, and challenging, but it isn’t your fault. It just is. Don’t let the advertising industry convince you otherwise. There is nothing inherently wrong with trying to look and act younger (Dr. Bossypants is especially fond of purple hair), but don’t let it feed your fantasies of eternal youth, rob you of the pride of aging openly, or stifle the conversations we all need to have with ourselves and our loved ones.

Graceful Exits: When, Why and How to Die, #2

This post is one of a series of posts wherein Dr. Bossypants explores that final task we all face: Dying.Consider yourselves warned: Being mortal is challenging, and death is a stressful topic. No doubt you will read these posts with some degree of sadness, despair, and denial. However, Dr. Bossypants sincerely hopes readers will consider such matters thoughtfully, and when the time comes to face our own death or that of a loved one, Dr. Bossypants hopes we can act with wisdom, compassion, acceptance, and bravery.

Grappling with Autonomy, cont.

Cyborgs and superheroes aside, to be human is to live in a time-limited and vulnerable body. It involves a lifelong negotiation between dependence, independence, and what Dr. Bossypants likes to call interdependence. We need each other, but we don’t want those needs to overcome our right to live our lives as we see fit. In a previous era, Dr. Bossypants was a rehabilitation counselor. It was humbling to witness the courage of people with severe injuries and disabilities as they struggled to graciously accept the assistance they needed while preserving both autonomy and dignity.

Some of these amazing people became my friends. They often lived lives shortened by their health challenges. Some assessed their situations and chose to die rather than endure the pain and limits. For instance, after years of dealing with unhealable and painful tumors caused by skin breakdowns, Michael (a pseudonym, of course) rolled himself into his front yard on a sunny day in June and shot the back of his head off. Dr. Bossypants firmly believes Michael had the right to make that choice, but she is deeply grieved that this was the method he was forced to use. But he had few options. Had he revealed his desire to die, he would have been reported and hospitalized, and perhaps even medicated against his will. Had he asked a physician for a prescription or injection, or other forms of assistance in dying, he would have been requesting something that is illegal. Perhaps if Michael had been able to talk over his options openly, including the option to end his life, he would have chosen a different option, or an easier, gentler way to die.

As a culture, we are obviously ambivalent about bodily autonomy. Autonomy is defined as the right of self-governance. Bodily autonomy includes the right to limit who touches you and how you are touched, the right to offer or deny the use of your body for science, profit, or experimentation, and the right to be protected from bodily exploitation. Ironically, it also includes the right to abuse our own bodies; we are allowed to eat things that are terrible for our health, sleep too little, or repeatedly expose ourselves to toxins, such as too much sunlight, smoke, or alcohol. (Small amounts of dark beer should not be included in this list.)

For the sake of fashion, we can adorn our bodies with piercings and tattoos or seek corrective or cosmetic surgeries to hide, remove, or add distinguishing features. Of course, many of us do not have the money necessary for facelifts, nose jobs, liposuction, breast enhancements, or hair plugs, but if a person does have the means, most cultures allow for these expressions of bodily autonomy.

As science advances, people increasingly have options to use their bodies, or parts of their bodies, for the common good. They can volunteer for drug trials. Kidneys, portions of livers, bone marrow, blood—all can be offered to save lives. Except in rare situations, we do not cross the line and force someone to use her body for the sake of someone else. Your sister or child may die if you choose not to donate a kidney, but there are no laws requiring you to make that donation.

We can also exercise bodily autonomy when we consider life-extending surgeries or treatments. Some, like chemo for advanced cancer, might provide an extra few weeks or months of life. Others, such as heart surgeries, might extend life by decades. The principle of bodily autonomy allows people to request or refuse these treatments. Dr. Bossypants believes such requests or refusals should be informed by frank discussions with family, loved ones, and well-informed medical professionals. Sadly, for many reasons, this is often not the case. These conversations are among the hardest humans will ever have. How do you even approach such things? It isn’t easy, so we often shy away and leave it up to fate, God, or the doctors.

Rational adults have the right to make informed choices about their bodies, including their deaths

Medical professionals have historically been accused of violating autonomy by trying to save lives at all costs without full disclosure or discussion. Even though it’s the inevitable outcome for all living beings, death is framed as a failure for medical professionals. Many recent authors have bemoaned this implicit bias in medical training and the continuing paternalistic attitudes that go with it. Letting someone die runs deeply against the grain.

In 1973, 25-year-old Dax Cowart was in an accident that burned him so severely he lost his fact, vision, ears, fingers, and much of his skin. Over the course of his extremely painful treatment, he begged to be allowed to die, but his right to refuse treatment was ignored, his attempts to kill himself, thwarted.

It was a huge fight. A psychiatrist called in to examine Dax ruled that he was sane and competent to make such a decision, but Dax’s requests were still denied. He lived through years of excruciating treatment, and eventually went to law school where he became a patient’s rights attorney. Throughout his life, he remained adamant that he should have been allowed to die.

Medical ethics courses often use Dax’s story to alert physicians to the quandaries they will face. In some circumstances, the right to refuse treatment is well-established, and since the 70s, in fits and starts, our culture has begun allowing terminally ill people access to medical assistance to end their lives, though even the most progressive laws are still quite restrictive.

Physicians’ views on their role in providing this assistance has slowly shifted, with a recent survey indicating a slim majority approving of such help–but only in these carefully circumscribed circumstances. In a recent Medscape article, Dr. John Bakos wrote, “The ability to rationally choose to end your life should be a protected right of every human.”

As we noted above, end of life conversations are often filled with dread. Nurses, doctors, social workers, counselors, pastors, loved ones—no one is exempt. We’re so afraid of saying the wrong thing that many important topics remain unexplored. In some situations, this leads to extended suffering and tragic outcomes. In the forum in the Journal of the American Medical Association Dr. Ashish K. Jha wrote, “We need to refocus our efforts toward end-of-life care so that we can better identify the needs of patients with advanced illness, and then offer intensive treatment when patients want it, help enable a more peaceful death when they don’t, and learn how to manage that transition.” 

As Dumbledor said to Voldemort in the Harry Potter series, “Indeed, your failure to understand that there are things much worse than death has always been your greatest weakness.” Yes, there are things far worse than a timely, humane death. Some studies asked severely ill people about factors that would trigger a wish for death. They named things like incontinence, inability to move, being fed through a feeding tube, or being kept alive with a ventilator or other machines. However, subsequent interviews revealed that while a subset of the respondents changed their answers as they adjusted to the deficits they dreaded, many did not. Writer Melissa Dahl noted, “Our future selves are frustratingly unknowable.”

If our future selves are frustrating, then the future selves and attitudes of our loved ones are likely to be full-on maddening. But this should not stop the conversations. It should stimulate and enliven them. If my daughters asked me what suffering I would or would not want to endure to stay alive a bit longer, my answers might change over time. The language in most Advanced Directives provides a starting point, but as Dr. Bossypants will repeatedly stress throughout these blogs: These are not one-off conversations. Many people fear being a burden, losing the ability to contribute meaningfully to their family or community, or losing the ability to feed, bathe, and/or dress themselves. The loss of dignity that goes with loss of bodily functions is also frequently named. And dementia is probably one of the most dreaded losses associated with aging.

To have these compassionate, sensible, and difficult conversations, we have to grapple with the notion of bodily autonomy as a human right and a moral obligation. We have the right to make choices about the ways we live our lives, the ways we treat our bodies, and the ways we age and die. We also have the obligation to make sure these are informed choices that take into account the needs and wishes of those around us.

In her famous poem, The Summer Day, Mary Oliver wrote, “Tell me, what is it you plan to do with your one wild and precious life?” and we just eat that up. We love mulling our wild and precious lives. But many of us resist the truth and implications of the line that comes just before: “Doesn’t everything die at last, and too soon?”

Yes, everything dies at last, and for most of us, it seems too soon. We are interconnected, autonomous beings, able to engage in conscious, thoughtful conversations and decision-making, but equally able to ignore our autonomy, deny autonomous choices to others, and engage in denial. Denial is an attractive but costly option. Battling death to the bitter end is also an option. There are many forces at work around and within us that make these appear to be only acceptable options. But they are not. Dr. Bossypants will bravely explore both forces and options in coming posts.

Graceful Exits: When, Why, and How to Die, #1

INTRODUCTION

This post is one of a series of posts wherein Dr. Bossypants explores that final task we all face: Dying.Consider yourselves warned: Being mortal is challenging, and death is a stressful topic. No doubt you will read these posts with some degree of sadness, despair, and denial. However, Dr. Bossypants sincerely hopes readers will consider such matters thoughtfully, and when the time comes to face our own death or that of a loved one, Dr. Bossypants hopes we can act with wisdom, compassion, acceptance, and bravery.

Grappling with Autonomy

They found my grandfather draped over the corral gate at 4:00 AM on a cold March morning in Montana. The little drifts of snow on his slumped shoulders signaled he’d been dead for a while. Calving season was in full swing. Granddad Ray had gone to check the cows and had not returned. He was 65 and had survived one heart attack ten years before. It had been serious enough that my father had to give up his dream of a college degree and come home to help run the ranch.

I was seven when my grandfather died. He was a loving presence in my life: a carpenter, mechanic, cowboy, electrician, plumber, painter, putterer—all skills required to keep a ranch going—which he did, with Dad’s help, until the day of his death. The funeral was huge. I don’t remember many of the details of the gathering afterward, but one thing stood out because it puzzled me for so long. The grieving grown-ups consoled each other by saying things like, “That’s the way I’d want to go.” And “He died on his own terms.” All I knew was that my granddad was gone, and he’d died by himself in the cold. This did not seem like something anyone would wish for. It has taken me 60 years of life and decades of professional training and clinical work to fully understand why the way he died was comforting to some of his mourning friends and family.

In rural western states, we tend to value our own version of independence and with some irrational exceptions, we amplify the value of autonomy. We’ll explore one of those exceptions from various lenses throughout this series: the right to choosing when and how to die. Not everyone wants this autonomy. In fact, there are those among us who would deny others this autonomy. Quite a few people don’t even want to give this issue a passing glance, and those who do want the right to die on their own terms face some serious challenges legally and psychologically.

Fast-forward fifty-seven years from my grandfather’s death. At an agonizing snail’s pace, the end of my mother’s life was drawing near. Her decline was painful to watch and impossible to discuss. Like many hard-driving high achievers, she found the loss of functioning and the betrayals of her body to be shameful obstacles she tried to overcome by force of will and denial. Her bladder gave out. Her bowels formed obstructions. Her neuropathy advanced and she fell so many times, we begged her to use a walker. By the time she conceded, she was too weak to make use of it. She hated the catheter, the immobility, and the need for help–all were experienced as humiliating indignities. She also hated looking in the mirror.

My mother’s resistance to aging and death robbed her of honest conversations. “I can’t believe I’m this old,” she’d say once in a while, but anything deeper than that was forbidden terrain. She clung to the notion that she could recover from the various ailments that come with age if she tried hard enough or found the right medicine. She was an easy target for the sellers of snake oil and magic cures.

Mom had lived much of her life with this same dogged defiance and it had served her well. She overcame childhood abuse and poverty, tackled the hardships of ranch life, survived early widowhood, became a successful realtor, put her children through college, and held things together. She was a force to contend with. She brought this attitude and energy to the aging process—aging was an obstacle to overcome. She was no quitter. To give up or given in to aging or dying was to fail.

The bad news for most of us, and especially for people like my mom is this: the decline associated with aging can sometimes be forestalled but ignoring the signals will not make them go away. As her decline continued, her physical pain and needs grew so intense that she reluctantly agreed to try hospice because of the services they could help us with. We didn’t use the term hospice, though; it was to be called comfort care at all times. We all knew Mom was dying, but it was not a topic she would talk about. After her last fall in the assisted living facility, she laid helpless for who knows how long? She was incoherent when they found her.

Over the next few days, she lost consciousness, but still her body fought on. She lingered another two long days and nights, completely unconscious, snoring an awful raspy snore through open dry lips. The family held vigil, reading to her, combing her hair, holding her hands, being present as we assumed she would want. But she died alone. Mom was a very private person. Mid-evening on the third day, those of us gathered wondered if she might might need some space to let go, so we all stepped into the next room, with the door slightly ajar. In the span of that five minutes, she took her last breath and let go. Her spirit brushed my shoulder as it departed. I slipped in to check on her and found she had died. “She’s gone,” I told my beloved family. We filed in to said goodbye to the thin, distorted shell she’d left behind.

Avoiding the tough conversations

In his book, Being Mortal, physician Atul Gwande helps readers understand the disconnect between medicine and mortality. He gently probes the encrusted layers of denial humans use to avoid thinking or talking about dying and death. This denial runs deep in the human psyche and is aided and abetted by advances in medical science that insinuate there’s a chance we can beat back or fully defeat most diseases and heal from most injuries. Denial is a widespread and time-honored way to cope, but like Gwande, I’m not convinced it serves us well in the end.

My childhood on the ranch gave me plenty of exposure to the life cycle of living beings. Everyone had a part to play. The cats were mousers, the dogs helped with herding, the chickens laid eggs until they aged out, and they were then stewed for Sunday dinner. Birth and death were constant companions. I was part of a culture that prides itself on being neighborly, honest, and generous, but also tough and self-sufficient. I sobbed myself to sleep when my 4-H lambs were sold to slaughter. I wanted my parents to let me keep the lambs, or at least pretend someone bought them for pets. My parents didn’t sugar-coat the truth. I’d played my role, raised the lambs, and won my blue ribbons. But they were nice fat lambs that would provide nourishment for others and money for my college fund. And that was that.

We were frank about the life cycle of the animals, but not about our own. My father died at age 44 during open-heart surgery. I was 19. Even as he was prepped for surgery, no one seriously thought that he might die. He didn’t have an up-to-date will or advanced directives. The closest our family ever got to end of life discussion included vague instructions that began with “If something ever happens to me…” and whatever followed was not specific guidance, but vague expressions of trust and love.

And what does this have to do with autonomy?

To a significant degree individual autonomy is defended in our country, but the notion that individuals could or should choose their own death is not widely accepted. Instead, like the mourners at my grandfather’s funeral, people dare to hope for a quick, timely, pain-free death, but most of us don’t claim or fight for the right to one. Many, like my mother, consider it shameful to be mortal or weak in any way. Death is an enemy to fight off, and battling to the bitter end is not only admirable, it’s sometimes framed as a moral duty. There are problems with this reasoning. Perhaps, in some situations, fighting to stay alive at all costs is morally praiseworthy, but in many cases, it’s neither praiseworthy nor required. Instead, clinging to life can cause unnecessary suffering. And framing death as a failure simply insures failure. We are all going to die.

But we cling to life. We cling for many reasons, some obvious, some less obvious. And not only do we cling individually, we force others to cling. We deny them medical assistance, honest conversations, and easier, more loving ways to die. Instead, we pile on denial and guilt, urging everyone to fight on, even in the face of the obvious eventual outcome. Dr. Bossypants has decided to dive in, write about mortality, denial, autonomy, suicide, and medical assistance in dying. In doing so, she hopes be of help in thinking such important matters through, or at least stir up a bit of commentary. For the coming weeks and months, there will be a series of posts addressing these related and sometimes difficult issues. Stay tuned, share, think, and stay in touch. This is an important conversation.

Toxic Femininity

Too much vitamin B6 can cause nerve damage. Too little vitamin B6 can cause nerve damage. Pretty much anything can be toxic in extreme expression or dosage. Life is always about balance. It’s regrettable that humans are such stereotypers. We want to organize our worlds into categories of things that seem alike and then keep everything boxed in, labeled, and inert. But life doesn’t work that way. Depending on endless factors and influences, we are more or less of any of our attributes in any given moment.

So let’s talk about one concept that can get very dangerous in extreme expressions: We’ll call it femininity (expressed as childbearing). In our present situation, only a woman’s body can take an egg and sperm, or an implanted embryo, and nurture it along until it becomes a fetus, and then, if all the other factors in play cooperate, the process moves along until a human baby is produced. Someday, this baby-making function will have a fully mechanized option, from test-tube fertilization to incubator fruition, and at that point, one might assume (and fervently hope) that every baby thus produced will be a deliberate, careful, conception and an eagerly anticipated addition to a loving parent (or parents)-in-waiting.

Presently, for the vast majority of us, conscious, deliberate baby-making is and should be an exciting undertaking, fraught with danger, but worth the risks. It is usually a voluntary undertaking. Yes, I know that sometimes, the production of babies, especially male babies, has been forced, or framed as patriotic. Fodder for Hitler’s war. An offspring to carry the family’s name and fortune forward…

But I digress. Back to our theme. Just because for now, a woman’s body is necessary to make a baby, it does not follow that baby-making is the definition of woman-ness or femininity. To squeeze the definition of femininity into that box is a form of cruel insanity. Toxic extremism. But that’s what we’re doing when we take away volition, deliberation, planning, and enactment of baby-making as an optional use of one’s body. Baby-production should always be a choice.

Abortion is not murder. It ends a process that began accidentally, or brutally, or without awareness. Pregnancy is a process. There are mechanized options at the beginning of the process. Fertilized embryos exist outside the realm of the female body. But a willing body is needed for this much-wanted baby. Of course, many people hope to use other people’s bodies for different reasons. They want a new kidney. A new heart. Eyes. Bone marrow. Liver. These life-saving desires require the use of another person’s body, but we do not legally require organ donations to save lives. We do not consider the death of someone who needed a kidney a “murder” because someone else failed to donate a kidney. Why should a woman’s body be singled out?

In an interview aired nationally, a woman who has decided that all pregnancies should come to fruition also declared that any woman who stopped the process for whatever reason, who said “no, I do not want to use my body to make a baby right now” should be killed. Dr. Bossypants has experienced low-grade nausea since that thoughtless and unnecessary broadcast–a horrific expression of woman-hating—perhaps the most virulent form of toxic femininity one can image. A hole is to dig. A woman is to make babies. A man is to war. A cloud is to rain. A mind is to judge. A heart is to kill: For such rigid insanities, Dr. Bossypants has no explanation–only great fear that hateful humans are going to continue down these destructive paths until they usher in extinction. The fight is to be whole, multi-dimensional members of the human continuum, tempering our extreme toxicities with maturity, respect, acceptance, courage, and compassion. The middle way is the only way.

Preventing Abortion

Dear Readers,

Dr. Bossypants realizes there is little to no chance of changing anyone’s stance on much of anything these days. But she forges on, hope against hope, that humans will evolve to the point of rational respect for autonomy, compassionate assistance for those in difficult places; more humility, less hubris. To that end, here is a little POP QUIZ, designed to startle and to reveal the false simplicities and tricky complexities associated with the abortion issue.

Q. 1 An embryo or fetus that has genetic abnormalities or defects such that it will be born dead, or die shortly after birth, should be brought to term because:

  1. We learn more and more about such occurrences by forcing them to happen. Thus, science is advanced.
  2. It gives the woman and potentially her partner and family a chance to suffer longer and learn humility.
  3. The body of the dead baby may have organs that could be donated.
  4. Such tragedies pull whole communities together.

Q. 2 An unplanned and unwanted pregnancy is a gift from God, Allah, or the universe intended to:

  1. Punish the woman for having unprotected sex or having sex at all, and show the woman her real calling on earth.
  2. Make sure humans reproduce enough to keep the workforce strong.
  3. Force a temporary romantic relationship to become a lifelong connection through the birth of an unwanted child, should the pregnancy make it to term.
  4. All of the above.

Q. 3 A fetus is:

  1. A human baby.
  2. A dependent human entity that, if given the use of another human’s body, will often develop into a human baby.

Q. 4 True or False: Even though we do not legally require people to use their bodies or body parts to save the lives of other humans (even their own children) we should legally require women to use their bodies to allow an unwanted fetus to develop into a baby and be born.

Q. 5 True or False: The life, health, and well-being of a pregnant woman are of less concern than an embryo or a fetus.

Q. 6 Birth control should be:

  1. Banned because it violates the laws of nature.
  2. The responsibility of the female, but always in consultation with the male.
  3. Available only to married couples because they are the only ones who should be having sex.
  4. Available only to single people because the purpose of sex in marriage is to reproduce.
  5. Unavailable because it is unnatural.

Q. 7 The government should control:

  1. Women’s bodies.
  2. Men’s sperm.
  3. Guns.
  4. Everyone’s private sexual choices.
  5. Wall Street.

Q. 8 The best way to actually reduce the number of abortions is to:

  1. Make abortions illegal so that those who have them or provide them are criminals.
  2. Make education and birth control methods available and easy to obtain.
  3. Keep males and females segregated until marriage.
  4. Sterilize everyone who might be the type of person who would seek an abortion.

Q. 9 Pain medication should be:

  1. Available to anyone whose pain is not their own fault.
  2. Available to anyone who wants it.
  3. Carefully prescribed because it is addictive.
  4. Unavailable because it is unnatural.

Being female carries with it profound responsibilities regarding when and under what circumstances it is wise to use one’s body to bring another human into the world. It is clearly not a male prerogative—which can have the effect of making males reach for artificial means of control. It can also trigger other females to step over the line, thinking that due to their own beliefs and experiences, they know what is best for all females. There’s no end in sight on this issue, but Dr. Bossypants endorses autonomy and compassion as the best options we have.

Statues as History Lessons

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Being a student of the mind and a fan of the rational, Dr. Bossypants has followed the recent squabbles over whether statues, flags, and such should be taken down or changed because they represent something painful to a group of people. Perhaps they honor an individual who was responsible for the deaths or repression of many innocent human beings. Perhaps they represent a cause that involved defending slavery, stealing property, or murdering human beings.

The argument for leaving these symbols in place is that they represent our history. This is true. We have a checkered history, replete with terrible mistakes and racist, misogynist, hateful leaders. And we should not forget this history. But we should not remember our history by honoring shameful or brutal actors who fought to oppress, own, demean, and/or destroy others. Hopefully, we will never build a statue of Adam Lanza to remember 26 murdered children and teachers at Sandy Hook. Or Stephen Paddock, who opened fire in Las Vegas and killed 58 people, not counting himself. These horrific events will be remembered other ways. Statues of these two men would be deeply offensive and cruel to people still suffering from their actions.

Elevating or clinging to symbols of past mistakes does little to light the way forward, but history does matter. We can remember our histories by building memorials that acknowledge the complexities of human motivation, suffering, sacrifice, and leadership. As humans evolve, we grow increasingly aware that to survive on this lonely planet, we need to get along better. We need to curb our appetites, admit our mistakes, and tell the whole truth, as completely as we can. But sometimes, we get it wrong. This is why asking for and granting forgiveness is radically rational and essential. Seeking justice and making amends go hand in hand with progress. Denial and misplaced pride are psychologically easy, but for the planet and the human community, they are very, very costly.

Where Do You Call Home?

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Just as infants attach to their caretakers, humans attach to the places that shelter them. They often call these places home. Voluntary or forced migration has spread humankind across the planet; a process of settling and seeking, exploring and delighting, conquering and retreating. Humans are complex. Some of us are homebodies and stay put for generations. Others uproot and resettle. Historians and geneticists can explain how staying put has allowed evolution to give us the rainbow of skin and eye colors, body types, and specialized attributes of various sorts. But psychologists help us understand this powerful urge to call a place “home.”

Human babies are helpless and vulnerable for a very long time. We need at least one devoted caretaker, but it is far better if we have two or more adults looking out for us—feeding, cuddling, guiding, protecting, and challenging us to become a caring, contributing member of our species. We also need shelter, and we appreciate familiarity and comfort. Familiar shelter is one definition of home. When we feel safe and cared for, we can be generous and trusting—but sometimes, we can also be stingy little rascals; jealous, afraid, and selfish.

Dr. Bossypants finds all this fascinating and when invited to social gatherings, she can blather on with the best of them. But let’s cut to the chase today, shall we? There’s been a rash of light-colored people with blue eyes shouting at darker-skinned people with brown eyes to “Go home.” The absurdity is stunning.

For instance, Dr. Bossypants believes her ancestors arrived on this continent about 160 years ago, give or take. Long before these bedraggled forebears of Bossypants arrived, brown, black, and Asian people had settled here. Some had been here for decades, some for centuries. And some had been here for tens of thousands of years, their arrival obscured by the mists of time. Home? Go home? White people arrived relatively recently to this region of the planet. We’re like toddlers with our arms wrapped around something we like very much yelling, “Mine. Mine. Mine.”

For humans, home is fluid. According to Robert Frost, “Home is the place where, if you have to go there, they have to take you in.” Home is a longed-for place of shelter, acceptance, and security. Home is a jealously guarded abstraction or a generously shared sanctuary. Home is both where we come from and where we are going. As T.S. Elliot wrote, “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.”

Bottom line: Do not shout “Go home” at people. They can legitimately shout the same thing back at you. Work instead at being kind and hospitable. After all, home is where the heart is. Make it a nice place.

 

 

Apples and Progeny

nelle climbing an apple tree 001 (2)Biological parents are often stunned to see themselves reflected in the facial expressions of their children. It is as if they know the child from the inside out. Sometimes, it is a delightful surprise. Other times, it tends toward horrifying, as in “Oh my God, I know that slidey-eyed glance” or “Sheesh, really? Does she have to suffer through that level of anxiety? Can’t I take it away?” But this reflective essence isn’t limited to biology. In fact, some people end up looking just like their dogs.

There are many mysterious forces at work in this passing on of sameness. It isn’t as simple as the rubbing of elbows or fur. It’s not just DNA. Sometimes, the driving force is adoration. Other times, fear. Identification with the lover. Identification with the aggressor. We tend to become more like those we admire, but depending on the level of perceived threat, we may also become more like our enemies.

There’s an old saying: One bad apple spoils the whole barrel. If an apple has molded, the tentacles of mold begin the invisible invasion of apples nearby. Another apple saying is also helpful: The apple doesn’t fall far from the tree. Usually, this is an intergenerational indictment, but it also reflects how proximity can influence growth and development, or inhibit a larger, more expansive worldview.

Dr. Bossypants has the luxury of observing individuals, groups, and societies from a comfortable distance, but this has not mitigated her terror at the general drift of things. Hatred and fear are on the rise. There are many leaders offering people the chance to embrace, parade, and even embellish the worst possible human attributes: Greed, scorn, derision, self-importance, dishonesty, cruelty, revenge, and hypocrisy, to name a few. These are virulent strands of mold, and the whole damn barrel is in grave danger.

People. Do you want a completely weaponized world? Do you want to live your short precious lives in bunkers full of hoarded items, conversing only with similarly frozen-minded, hostile beings? Do you want to devolve, taking your children with you to a dark place of superstition where everyone worships those who lie and hate, who chuckle at their followers through golf games while some of them hustle into crowded spaces to “pray”? While you still can, roll yourselves away from that twisted tree. You’re on the wrong plane. You’re playing for the wrong team.

It will take courage to pull back. To remove the distorting lenses. To turn off the comforting propaganda. Don’t run for the nearest rationalization. Don’t believe the most convenient lies. If compassion and respect aren’t in evidence, it isn’t right. If leading by example isn’t happening, it isn’t authentic leadership. If self-sacrifice and humility are absent, get away. If justice and mercy are in short supply, lean in and supply some, even if the costs are high. The cost of a rotten society will be much, much higher.

Human consciousness allows us to choose our allegiances, which in turn, shape us. Many of us haven’t been making the wisest choices lately. The shape of the future of human life on earth hangs in the balance. Dr. Bossypants has no doubt we can do better. But will we?