A leading broadsheet marked Good Friday this year with an article about the need to overcome the “taboo” surrounding physician-assisted dying. It seemed a rather odd way not only of celebrating the day, but of referring to a topic that has had its fair share of uninhibited public discussion in the past two to three decades; but the writer was, I suppose, trying to distance the issue from the stigma that still hangs around the word “suicide”. Edith Hall, in this remarkable, brave and compassionate book, evidently shares something of this concern, seeking to disentangle the idea of “euthanasia for someone facing an inevitable and agonising death” and “temporary and intermittent urges” to end one’s life. The great moral weight of the book’s argument is the conviction that suicide as we normally think about it is an act that inflicts drastic damage on survivors. Anyone contemplating deliberately ending their life needs to be alert to that damage – a damage that can have transgenerational consequences impossible to quantify.
Transgenerational trauma is at the heart of the book. Hall presents us with a tragic family history, both her great-grandfather and her grandmother having taken their own lives, leaving her mother with a crushing burden of guilt and bewilderment, expressed in years of emotional repression or confusion and self-harming habits. As Hall writes, no one was paying much attention in the mid-20th century to the needs of suicide’s “survivors” – children, siblings, friends, carers. People were largely left to work out their own strategies, and these strategies, often involving some level of denial, had their own lethal effects: Hall’s last but one chapter, “The Author’s Tale”, describes her own harrowing struggle over many years with suicidal depression, and the crucial role that consideration of the violence her suicide might inflict played for her.
This is where her classical studies prove significant. Hall is one of the most prolific and insightful commentators in English on Greek tragedy, and in Facing Down the Furies she draws out an aspect of this literature that not many have highlighted. In her view, what is strikingly distinct in the tragedies of Aeschylus, Sophocles and Euripides when they deal with suicide (and with other forms of untimely and violent death) is their readiness to imagine the reactions of survivors – parents, spouses, children, whole households – so that the unnaturalness of the act is not blunted or romanticised. “You’ve destroyed more than just yourself,” says Theseus, lamenting his dead wife Phaedra in Euripides’s Hippolytus. And, with perhaps even more poignancy, the same author’s Suppliant Women depicts a father resolving on suicide after his daughter has killed herself.
In a way, this unsparing recognition of suffering is the other side of what is laid out so poignantly in a very different drama, the Philoctetes of Sophocles, where extreme physical anguish is compounded by the lack of any observer: “He [Philoctetes] desperately needs to have his suffering acknowledged,” as Hall writes. Part of the function of tragic writing is the securing of witness: the telling or showing of suffering does not ease pain but at least breaks down the terrible isolation of the sufferer. Perhaps – so tragic literature suggests – the fact of witness preserves the glimmer of hope that unmitigatedly terrible experience can be “meaningful”, at least to the extent that it is accompanied by compassionate acknowledgement.
So for Hall, the tragedians were her “witnesses”; they offered words and images to let her know that the crushing inheritance of family catastrophe and the blinding loneliness of suicidal depression had been seen, thought, spoken. Her book is written to pass on that perception and to tell us, when we face the pressure of unrelieved unhappiness or meaninglessness, that our lives are always bound with those of others, and so are not simply a property for us as individuals to dispose of.
Digesting all this, we may come to understand more clearly the reactions that help to perpetuate the stigma surrounding the issue. There is sheer anger: how could they do this to me, to us? There is condemnation, religious or otherwise: this is a sinful rejection of the gift of life. There is passivity, collusive passivity: it’s their decision, it’s a matter of freedom. The anger has to be dealt with by the sort of patient narration that Hall undertakes so sensitively in her extended memoirs of her family (providing, incidentally, a vivid snapshot of Scottish civic and cultural life from the mid-19th to the mid-20th century). Condemnation abandons this patient quarrying for understanding and will get us nowhere. Collusive passivity simply fails to register the depth of destructive impact; at worst it spills over into the cheapened existentialist dramatising of suicide as the ultimate expression of sovereign autonomy (Dostoevsky has some things to say about that).
There is a textbook oversimplification that associates ancient Stoicism with a view resembling this, and it has found avatars in more modern discussions. Hall reminds us that in its most familiar form (in Pliny, or Marcus Aurelius’s Meditations, say) it is bound up with a distinctive culture of “noble” liberty, independence, honour and reputation, which is not quite what the earlier and more pragmatic Stoics actually suggest. She also notes that in later writers (David Hume is a good example) it is typically favoured by wealthy, male, single thinkers, people who are not that interested in the effects of their actions on others because they do not live in a particularly interdependent framework of relations.
She notes that religious attitudes to suicide have played a large part in establishing the stigma around it. Biblical prohibitions against the taking of human life were read as implicitly forbidding taking one’s own. Just as the killing of a family member is in some sense a worse offence than killing a professed enemy, so suicide deserves special opprobrium because it is the violent ending of the life that is closest to you – your own.
Hall does not go into the full detail of St Augustine’s treatment of the question in his City of God, but it has some resonance with her summary of the Roman cult of “noble” suicide. Augustine is discussing the fact that some women (especially nuns) raped during the Sack of Rome in 410 took their own lives, and he compares it with the well-known Roman legend of the suicide of Lucretia after being raped by Tarquin. He gives very short shrift to the idea of suicide for the sake of honour, and says firmly that the victim of sexual violence is not to think of herself as guilty, nor is anyone else to treat them as culpable. Lucretia is for him an example of what he analyses at length in City of God, the Roman obsession with status and reputation at the expense of internal moral clarity. He recognises the depth of shame that is felt by survivors of rape, but warns against assimilating it to guilt. By contemporary standards, he pays no real attention to the abiding trauma of physical violation, the burden of self-disgust and so on; his treatment of the question is one that does not give much space to the subject’s point of view. But he does at least counter the idea that internalising the blame that a patriarchal society projects is a good thing.
Hall, I suspect, is not a great aficionado of Augustine, but there is some common ground here. Dealing with suicidal thought or temptation involves restoring a sense of being positively involved with the lives of others – the feeling that people are “invested” in your life, and that killing yourself is an injury to them. But for that to happen, the culture you live in also needs to demonstrate that investment. For the survivor of rape or any other form of abuse, for the demonised sexual minority, for those left behind in
the bloodthirsty competitiveness of some academic hothouses or online networks, what makes a difference is not only an individually positive attitude but the assurance of – once again – being witnessed, being taken seriously, being treated as though your well-being were intrinsic to that of others. Policies around – for example – student mental health (something that Hall, a professor at Durham University, and this reviewer both have some experience with) are not only about survival tactics for individuals but about creating cultures that challenge shaming and affirm what I’ve called investment. And this book is triumphant proof that teaching and writing about the humanities is a vitally necessary dimension of such culture creation. Anyone who has ears to hear, let them hear.
Hall writes with lucidity and directness, and her treatment of the classical texts is consistently insightful. There are one or two forgivable bumps in the road here and there. The reference to an intriguing apocryphal story of St Peter confronted by a suicidal woman is a bit garbled in the notes, assimilating two ancient works attributed to the same author that happen to be printed together in the same volume. Also, the citation of two texts from Hebrew Scripture as a “Jewish proscription of suicide” is rather misleading: one of these texts is an instance of the general prohibition against murder which the rabbinical commentators took as including the prohibition of suicide; the other bears no obvious relation to the topic and may be a faulty transcription. Jewish scholars have generally allowed that there is no direct condemnation of suicide in the Torah, and certain dramatic acts of individual and collective suicide when faced with persecution or massacre (from the death of King Saul or the mass suicide of the defenders of Masada against the Romans) have been regarded by the commentators as pardonable, even sometimes as admirable. We might see here an implied argument (whether we accept it or not) that in a way complements Hall’s main concern: in these instances, a survivor of mass violence would be left exposed to the worst fate imaginable, so that collective suicide could appear a more merciful and moral possibility.
But that is not Hall’s main focus. What we have is a moving reflection on how the sense of anchorage in the lives and needs of others is central to keeping us alive, especially when not much else appears to be doing so. In one way, the phrase quoted above about “intermittent and temporary urges” does less than justice to the intensity of suicidal ideation grounded in traumatic loss, obsessive guilt, or extreme and unbroken depression. Some would say that it is more like the steady presence of a death sentence, with only the timing being uncertain: not a matter of unbearable physical agony but a mental hopelessness that makes a liveable future just as unimaginable. Indeed, the case for physician-assisted dying often appeals to just that sense of an unimaginable future, whether or not accompanied by excruciating physical pain. This is not a book about temporary bouts of darkness, but about the long and winding road of internal terror or emptiness that leads to the final decision for death; about the deep roots in family history as well as individual suffering that push in that direction.
Which is why I hope we hear more from Edith Hall about how her reflections bear on the question of “assisted” suicide – reservations about which are not all rooted in some variety of irrational dogmatism (religious believers in fact disagree on this as on a good many other ethical questions). As the pressure for legal change mounts – a petition led by Esther Rantzen recently triggered a debate in parliament – there is also a heightened awareness that how and by whom decisions are to be made if there is new legal provision are not straightforward, precisely because of the complex mutual “investments” involved where a dying person and their families and friends are concerned. There are reassuring and not-so-reassuring stories; there is a nagging uncertainty in some minds about how a new policy would work in terms of resourcing for palliative care, the use of funds, the pressures on an overloaded healthcare system and so on.
Hall is right to want to resist assimilating all forms of “willed” death to the desperate, isolated, heartbreaking and hurtful instances at the centre of her narrative. But as we go on grappling with these questions we need not the breaking of an imaginary taboo, perhaps not even just the disappearance of a tradition of stigma, but more of the granular, sensitive, honest recording that this book offers, and more of the deep resource of the imagination represented by the great tragedians she so eloquently brings alive for us.
Facing Down the Furies: Suicide, the Ancient Greeks, and Me Edith Hall Yale, 256pp, £18.99
Dying alone usually has a negative connotation attached to it. This is probably why movies portray it as sad and heartbreaking. On the flip side, dying while being surrounded by friends and family is often thought of as a good death. The person was loved and made to feel secure as they passed on. They didn’t have to endure the pain of dying alone.
But what happens in the final moments of death is a subject that’s largely still being discovered. No one really knows for sure definite answers to the big questions like “Does your consciousness continue after you stop breathing?” or “Will you have a better death if you have loved ones surrounding your bed?”
Social researcher and death studies scholar Glenys Caswell from Nottingham University noted that, for some people, dying alone is something that they choose of their own accord (via The Conversation). One of Caswell’s studies, which was published in the journal Mortality in 2017, involved interviewing 11 elderly persons who lived by themselves and seven hospice nurses about their thoughts surrounding dying alone. While there was some belief among the hospice nurses that dying alone is not something they’d endorse, Caswell found that for the older people, “dying alone was not seen as something that is automatically bad, and for some of the older people it was to be preferred.” They preferred it to having their freedom curtailed or being confined to a care home.
They Might Die Alone To Spare Their Loved Ones Pain
“We have those patients who die in the middle of the night. We hear stories about the loved one who just stepped out for five minutes and the patient died. We may have even witnessed a quick death ourselves. I believe this happens by the patient’s choice,” wrote Miles. She added that this happens mostly in instances when the dying person is a parent. “I believe it is a protective factor,” she explained.
Henry Fersko-Weiss, a licensed clinical social worker and executive director of the International End-of-Life Doula Association, feels slightly differently about the topic. While he doesn’t discount the fact that some people might die alone, he shared in a YouTube video that people like feeling connected and safe before they pass away. Fersko-Weiss said that “because of the way we think about death, [we] feel that we’ll be a burden to loved ones” if we let them see us die. Sparing loved ones the pain of it all might be at the heart of the decision but this is something friends and family should have an open conversation about, he added.
Having An Open Dialogue With Your Loved One Can Help
No matter how painful those final moments might be, it can be a good idea to equip yourself with the right tools to have open conversations that foster understanding on both sides, say the experts. You might want to lean into what dying people want you to know about how they’d ideally want to go, and also assess your own emotions, cultural biases, and ideas around it. If you’re unable to broach the topic yourselves, enlist the help of hospice care workers or even a therapist.
It is possible that the person who is dying is concerned that the loved ones whom they are leaving behind will carry with them for the rest of their lives the burden of seeing them pass, shared Fersko-Weiss in the video. You could reassure them by saying something like, “Of course, we want to be there. It doesn’t matter how it looks or how it sounds or how emotionally difficult it may be to be present. It is part of our love for you that we would want to be there,” said the death doula.
How you choose to be present when someone you love is dying is a decision both the dying and those being left behind can arrive at together, per the experts. And, in the instance when your loved one chooses to wait and die alone, “openness created through discussion might also help to remove some of the guilt that family members feel when they miss the moment of their relative’s death,” added Caswell (via The Conversation).
As Medicare Advantage grows bigger and bigger, there’s one area the industry and regulators haven’t figured out how to make work yet: hospice.
Why it matters: The end-of-life care option is the only Medicare service that can’t be offered in the private-run alternative, which now covers over half of enrollees.
Medicare is winding down an experiment — years earlier than expected — that let some Medicare Advantage plans offer a hospice benefit, citing operational challenges and limited interest from insurers and hospices.
Catch up quick: Usually, when a Medicare Advantage beneficiary decides to enter hospice after receiving a terminal diagnosis, traditional Medicare pays for this care while they remain enrolled in their private plan.
That could make navigating insurance “very, very clunky” for hospice patients, especially when they have health care needs unrelated to their terminal illness, said Lynne Sexten, CEO of Agrace Hospice.
And this affects a lot of people. Nearly half of the 1.7 million Medicare Advantage beneficiaries who died in 2022 used hospice services, according to the Medicare Payment Advisory Commission (MedPAC).
Experts say the roots of this awkward arrangement likely goes back about 40 years, when private Medicare first became a permanent offering. At the time, traditional Medicare had just started covering hospice, so officials had limited data on how much it cost.
What they did: Medicare’s Innovation Center began an experiment in 2021 that allowed Medicare plans to contract directly with hospice providers.
It aimed to test whether that could make end-of-life care transitions more seamless for Medicare Advantage patients while reducing costs and improving care quality.
Participating health plans also covered palliative care and transitional care, where patients continued curative treatments like dialysis or chemotherapy temporarily during their hospice stay.
The Innovation Center announced abruptly in March that it would end the program in December, a year after officials said it would run through 2030.
The news came after two major insurers — UnitedHealth Group and Elevance — pulled out of the model. Only 13 insurers participated this year.
Hospices largely cheered the decision. Lower reimbursement rates, delayed payment from insurers and burdensome quality reporting made the experiment difficult for hospices that chose to contract with insurers, an independent evaluation of the program found.
The Centers for Medicare and Medicaid Services stressed that its decision to end the experiment doesn’t mean it failed, and the agency in a statement to Axios said it will continue to evaluate results.
Many insurers also faced a learning curve on how to work with hospice for their Medicare enrollees. Hospice is delivered and paid for differently than other Medicare benefits.
The experiment tried to do too much too fast, said Kevin Kappel, vice president at SCAN Health Plan, a nonprofit insurer that joined Medicare’s hospice experiment last year.
“I think people underestimated how complex it was to do. … We’ve learned a lot,” Kappel said.
Yes, but: Hospices and insurers said they still need to figure out how to make care more seamless for Medicare Advantage beneficiaries.
“This is by no means the end of the story for end-of-life care providers and MA plans,” said Ethan McChesney, policy director at the National Partnership for Healthcare and Hospice Innovation.
It’s been a full decade since MedPAC, the congressional advisory committee, recommended including hospice in Medicare Advantage, warning that excluding it “fragments care accountability and financial responsibility for MA enrollees who elect hospice.”
What we’re watching: Industry leaders say hospice doesn’t necessarily have to become part of Medicare Advantage to improve care integration, or at least not right away.
Ohio’s Hospice, a nonprofit provider that participated in the Medicare experiment, said it will continue working with Medicare plans to extend palliative care and symptom management to more patients, CEO Kent Anderson said.
While Anderson said some peers worry about the growth of Medicare Advantage, “the longer we sit outside the managed care world, the less relevant we’ll become.”
When Amy Pickard’s mother died suddenly in 2012, she was understandably grief-stricken. But she also felt frustrated and overwhelmed, since her mother didn’t plan ahead for her death.
“I would have given anything to talk to my mom just one more time, but it wasn’t to hear her tell me she loved me; I needed her to tell me the friggin’ Wi-Fi password!” Pickard says.
Since her mother lived far away, Pickard didn’t know what bills needed to be paid or what to do with her mother’s now-deceased body.
“I just said, can you put her [body] on ice? Because I have no idea what is going on,” Pickard recalls. In an effort to normalize death and create a death-positive movement, Pickard teaches people how to throw a death party and add some humor to the inevitable and often daunting end-of-life duties.
Dealing with uncomfortable death duties
Pickard refers to all of the different decisions that need to be made and tasks that need to be completed after someone dies as “death duties.” She says these duties are “the hellscape of details forced upon a grieving loved one after their person dies.” This includes responsibilities such as cleaning their house and sorting their belongings, making funeral arrangements, settling their finances and closing their estate.
After her horrible experience with her mother’s death duties, Pickard wanted to help others avoid the same issues. “I was preaching the gospel of advanced planning to my friends,” she says. Surprised at how her friends took to the lessons, Pickard thought, “I have a message here. And it’s landing.”
In 2014, she created a long list of questions related to when someone dies. The list was a booklet called Departure File, which she still sells today. She included, “all the minute, everyday things that came up that I had no answer to, like ‘Do you have a storage space?’”
“Good To Go!” death parties are changing the narrative
Pickard realized most people think of death and dying as morbid and creepy, so they don’t like to talk about it. She also knew most people would probably not want to answer the questions in the Departure File, so she decided to create a party where everyone filled out the answers.
“I thought, ‘I’m a good communicator, I’m an extrovert and I have a sense of humor, so why not have a party?’” she says.
During the parties, Pickard tapped into her sense of humor by creating death-themed soundtracks with songs like “Another One Bites the Dust” and “Stairway to Heaven.” She also had everyone bring a potluck dish based on the recipe of a loved one.
She didn’t have a business plan when she started; instead, she learned as she went along and as her business evolved. Her parties are now referred to as “Good To Go!” parties, though guests have also described them as “Death Tupperware Parties” or “Fete du Mort” shindigs.
People who attended the initial parties “were blown away by it—all of us felt a beautiful kind of electricity in the room,” Pickard recalls, noting that no one else was hosting these types of events. “It is unbelievable how important this is, and how in denial our entire society is over the one absolute positive thing that we know with 100% certainty is going to happen,” she says.
Normalizing the death-positive movement
In a bid to overturn this cultural thinking, Pickard considers herself to be part of the death-positive movement—a way of thinking that encourages people to have end-of-life celebrations and speak openly about death, dying and corpses.
The modern-day concept of the death-positive movement dates back to the 1970s, but the death-positive movement was further popularized in 2011 by Caitlin Doughty, a mortician who believes people should change their perceptions about death. On her website, The Order of the Good Death, Doughty says death should be a part of your life. “Accepting that death itself is natural, but the death anxiety and terror of modern culture are not,” Doughty states on her website.
When Pickard’s father died, the experience was opposite that of her mother’s death. Pickard attributes that to the fact that he filled out the Departure File and talked openly with her about advanced planning. When she first created the Departure File, she wanted to help others and didn’t consider how it could one day help her. Like her mother, her father died suddenly. When he was intubated in the hospital, she gave a copy of his Departure File that included his advanced care directive to the staff. Their response was, “No one ever does this. This is amazing.”
Before Pickard’s father passed away, she said to him, “You know that everything is taken care of.” She says the look of peace on his face in response brought her comfort. It was at that moment she understood that advanced planning also brings peace to a person before they die.
“It was such a weird, ironic moment that the company that I created for others actually helped me and helped my grief,” she says. “With [my dad’s] instruction, I felt empowered. I felt I was honoring him.” The directions he provided also eliminated any uncertainty she may have faced making decisions about duties related to his death.
Planning for death is planning your life
Even though “Good To Go!” parties are humorous and lighthearted, there are still times, understandably, when people are grieving. Pickard handles these situations by offering a tissue and trying to help them understand that, “when you plan for your death, it’s actually planning your life.”
She explains that people prepare for natural disasters by stocking up on candles and getting a generator, but they don’t plan for their death. “We spend more time building a burrito than we do thinking about what we want to happen when we die,” she says. Advanced planning is a way of letting people know how you want to be remembered, she adds.
Pickard recently expanded her business to help people declutter their homes while simultaneously creating advanced planning regarding their material things. She refers to this task as legacy organizing.
“I am helping people organize their homes for their death,” she says. She explains that her services are similar to that of a “death concierge.” She says, “I encourage people to clean out their places with their families. And that way, you make new memories. It’s actually fun.”
This lighthearted approach to death and advanced planning underscores Pickard’s mission with “Good To Go!” parties. “I’m not a doctor; I’m not a lawyer. I am just literally a girl that’s lived through grief and wants to help other people get through it too.”
Studies show that when cancer returns, patients are often quite willing to receive toxic treatments that offer minimal potential benefit.
By by Mikkael A. Sekeres, MD
My patient was in his early 30s and his leukemia had returned again following yet another round of treatment.
He was a poster child for the recently reported rise in cancer rates in the young, and had just asked me what chemotherapy cocktail I could devise for him next, to try to rid him of his cancer.
I hesitated before answering. Oncologists are notorious for always being willing to recommend to our patients one more course of treatment, even when the chances of success are negligible.
One grim joke even poses the question, “Why are coffins nailed shut?” The answer: “To keep oncologists from giving another round of chemotherapy.”
This unflattering stereotype is unfortunately backed by data. In one analysis of patients with a cancer diagnosis treated at one of 280 cancer clinics in the United States between 2011 and 2020, 39 percent received cancer therapy within 30 days of death, and 17 percent within two weeks of dying, with no decrease in those rates from 2015 to 2019.
My patient had received his leukemia diagnosis five years earlier, and initially, following chemotherapy, his cancer had entered a remission. He and his parents were farmers from Latin America and relocated at the time to the United States to focus on his treatment. When the leukemia returned after a year, he underwent a bone-marrow transplant, and that seemed to do the trick, at least for a while.
But then it reared its ugly head a couple of years later, and we worked to slay it with yet more chemotherapy and another transplant.
That victory was short-lived, though, and multiple rounds of unsuccessful treatment later, here we were. The last course had decimated his blood counts, landing him in the hospital with an infection, a bad one that he had barely survived.
Does it help patients live longer or better?
Giving chemotherapy toward the end of life would be justifiable if we benefited our patients by enabling them to live longer, or live better. While that’s our hope, it often isn’t the case.
Recognizing this, the Centers for Medicare & Medicaid Services has identified giving chemotherapy within two weeks of death as a poor-quality indicator that may adversely affect payments to hospitals. As a consequence, cancer doctors are discouraged from offering treatment to patients at the end of life, and can get in trouble with hospital administrators for doing so.
Despite the CMS measure, though, over the past three years the percentage of patients treated at the end of life hasn’t changed much, with one recent study actually showing an increase in patients treated.
Why do we do it? Perhaps optimism is part of our nature, and what draws us to a career in oncology. I focus on the positive, and that may actually help my patients. Other studies have shown that optimism in people with cancer is associated with better quality of life, and even longer survival.
And perhaps the data on giving chemotherapy close to a person’s last days on Earth, and the CMS quality metric, are unfair, and insensitive to the realities of how doctors and patients make decisions.
I stared back into the eyes of my young patient and then into those of his father, who was about my age. He looked kindly, with a thick, bushy white mustache, a red tattersall shirt, and work jeans. This man adored his son, accompanying him to every appointment, and always warmly clasped my right hand with both of his in thanks for our medical care — a gesture I felt unworthy to receive, given my inability to eradicate his son’s leukemia.
If our roles were reversed, how would I react if my son’s cancer doctor told me that the option for more chemotherapy was off the table, as CMS recommends, given the less than 10 percent chance that it would work, and the much higher likelihood that it could harm?
Wouldn’t I demand that the doctor pursue any and all means necessary to save my son’s life? Patients often do, and studies have shown that patients with cancer that has returned are quite willing to receive toxic cancer treatments that promise minimal potential benefit.
We discussed giving another round of chemotherapy, though I told my patient and his family that I was reluctant to administer it given the vanishingly slim chance that it would help. We also talked about my patient enrolling in a clinical trial of an experimental drug. And finally, we talked about palliative care and hospice, my preferred path forward.
“You’ve given us a lot to think about,” my patient told me as he and his family got up to leave, even smiling a bit at the understatement. His father came over to me and clasped my hand warmly, as usual.
But a couple of days later, despite how well he looked in clinic, my patient developed an infection that landed him in the intensive care unit. If I had given him chemotherapy, we would have blamed the treatment for the hospitalization.
But the cause actually lay with his underlying cancer, which had compromised his immune system, making him more vulnerable to infections. This time, my patient became sick enough that he decided enough was enough, and he accepted palliative care.
For many of my patients at the end of life who doggedly pursue that “one more round” of chemotherapy, a hospitalization becomes the sentinel event convincing them that the side effects of treatment just aren’t worth it anymore. It’s then no wonder people die so soon after their final treatment and time in the hospital.
It isn’t justifiable to give people with cancer chemotherapy when it is futile, just to be able to say “we tried something.” That’s what the CMS quality metric is trying to prevent. But in doing so, it shouldn’t interfere with a patient’s opportunity to come to that decision themselves.
He has an easy smile, blue eyes and a life-threatening bone infection in one arm. Grateful for treatment, he jokes with the medical intern each morning. A friend, a fellow doctor, is supervising the man’s care. We both work as internists at a public hospital in the medical safety net, a loose term for institutions that disproportionately serve patients on Medicaid or without insurance. You could describe the safety net in another way, too, as a place that holds up a mirror to our nation.
What is reflected can be difficult to face. It’s this: After learning that antibiotics aren’t eradicating his infection and amputation is the only chance for cure, the man withdraws, says barely a word to the intern. When she asks what he’s thinking, his reply is so tentative that she has to prompt him to repeat himself. Now with a clear voice, he tells her that if his arm must be amputated, he doesn’t want to live. She doesn’t understand what it’s like to survive on the streets, he continues. With a disability, he’ll be a target — robbed, assaulted. He’d rather die, unless, he says later, someone can find him a permanent apartment. In that case, he’ll proceed with the amputation.
The psychiatrists evaluate him. He’s not suicidal. His reasoning is logical. The social workers search for rooms, but in San Francisco far more people need long-term rehousing than the available units can accommodate. That the medical care the patient is receiving exceeds the cost of a year’s rent makes no practical difference. Eventually, the palliative care doctors see him. He transitions to hospice and dies.
A death certificate would say he died of sepsis from a bone infection, but my friend and I have a term for the illness that killed him: end-stage poverty. We needed to coin a phrase because so many of our patients die of the same thing.
Safety-net hospitals and clinics care for a population heavilyskewed toward the poor, recent immigrants and people of color. The budgets of these places are forevertight. And anyone who works in them could tell you that illness in our patients isn’t just a biological phenomenon. It’s the manifestation of social inequality in people’s bodies.
Neglecting this fact can make otherwise meticulous care fail. That’s why, on one busy night, a medical student on my team is scouring websites and LinkedIn. She’s not shirking her duties. In fact, she’s one of the best students I’ve ever taught.
This week she’s caring for a retired low-wage worker with strokes and likely early dementia who was found sleeping in the street. He abandoned his rent-controlled apartment when electrolyte and kidney problems triggered a period of severe confusion that has since been resolved. Now, with little savings, he has nowhere to go. A respite center can receive patients like him when it has vacancies. The alternative is a shelter bed. He’s nearly 90 years old.
Medical textbooks usually don’t discuss fixing your patient’s housing. They seldom include making sure your patient has enough food and some way to get to a clinic. But textbooks miss what my med students don’t: that people die for lack of these basics.
People struggle to keep wounds clean. Their medications get stolen. They sicken from poor diet, undervaccination and repeated psychological trauma. Forced to focus on short-term survival and often lacking cellphones, they miss appointments for everything from Pap smears to chemotherapy. They fall ill in myriad ways — and fall through the cracks in just as many.
Early in his hospitalization, our retired patient mentions a daughter, from whom he’s been estranged for years. He doesn’t know any contact details, just her name. It’s a long shot, but we wonder if she can take him in.
The med student has one mission: find her.
I love reading about medical advances. I’m blown away that with a brain implant, a person who’s paralyzed can move a robotic arm and that surgeons recently transplanted a genetically modified pig kidney into a man on dialysis. This is the best of American innovation and cause for celebration. But breakthroughs like these won’t fix the fact that despite spending the highest percentage of its G.D.P. on health care among O.E.C.D. nations, the United States has a life expectancy years lower than comparable nations—the U.K. and Canada— and a rate of preventable death far higher.
The solution to that problem is messy, incremental, protean and inglorious. It requires massive investment in housing, addiction treatment, free and low-barrier health care and social services. It calls for just as much innovation in the social realm as in the biomedical, for acknowledgment that inequities — based on race, class, primary language and other categories — mediate how disease becomes embodied. If health care is interpreted in the truest sense of caring for people’s health, it must be a practice that extends well beyond the boundaries of hospitals and clinics.
Meanwhile, on the ground, we make do. Though the social workers are excellent and try valiantly, there are too few of them, both in my hospital and throughout a country that devalues and underfunds their profession. And so the medical student spends hours helping the family of a newly arrived Filipino immigrant navigate the health insurance system. Without her efforts, he wouldn’t get treatment for acute hepatitis C. Another patient, who is in her 20s, can’t afford rent after losing her job because of repeated hospitalizations for pancreatitis — but she can’t get the pancreatic operation she needs without a home in which to recuperate. I phone an eviction defense lawyer friend; the young woman eventually gets surgery.
Sorting out housing and insurance isn’t the best use of my skill set or that of the medical students and residents, but our efforts can be rewarding. The internet turned up the work email of the daughter of the retired man. Her house was a little cramped with his grandchildren, she said, but she would make room. The medical student came in beaming.
In these cases we succeeded; in many others we don’t. Safety-net hospitals can feel like the rapids foreshadowing a waterfall, the final common destination to which people facing inequities are swept by forces beyond their control. We try our hardest to fish them out, but sometimes we can’t do much more than toss them a life jacket or maybe a barrel and hope for the best.
I used to teach residents about the principles of internal medicine — sodium disturbances, delirium management, antibiotics. I still do, but these days I also teach about other topics — tapping community resources, thinking creatively about barriers and troubleshooting how our patients can continue to get better after leaving the supports of the hospital.
When we debrief, residents tell me how much they struggle with the moral dissonance of working in a system in which the best medicine they can provide often falls short. They’re right about how much it hurts, so I don’t know exactly what to say to them. Perhaps I never will.
Patient One was 24 years old and pregnant with her third child when she was taken off life support. It was 2014. A couple of years earlier, she had been diagnosed with a disorder that caused an irregular heartbeat, and during her two previous pregnancies she had suffered seizures and faintings. Four weeks into her third pregnancy, she collapsed on the floor of her home. Her mother, who was with her, called 911. By the time an ambulance arrived, Patient One had been unconscious for more than 10 minutes. Paramedics found that her heart had stopped.
After being driven to a hospital where she couldn’t be treated, Patient One was taken to the emergency department at the University of Michigan. There, medical staff had to shock her chest three times with a defibrillator before they could restart her heart. She was placed on an external ventilator and pacemaker, and transferred to the neurointensive care unit, where doctors monitored her brain activity. She was unresponsive to external stimuli, and had a massive swelling in her brain. After she lay in a deep coma for three days, her family decided it was best to take her off life support. It was at that point – after her oxygen was turned off and nurses pulled the breathing tube from her throat – that Patient One became one of the most intriguing scientific subjects in recent history.
For several years, Jimo Borjigin, a professor of neurology at the University of Michigan, had been troubled by the question of what happens to us when we die. She had read about the near-death experiences of certain cardiac-arrest survivors who had undergone extraordinary psychic journeys before being resuscitated. Sometimes, these people reported travelling outside of their bodies towards overwhelming sources of light where they were greeted by dead relatives. Others spoke of coming to a new understanding of their lives, or encountering beings of profound goodness. Borjigin didn’t believe the content of those stories was true – she didn’t think the souls of dying people actually travelled to an afterworld – but she suspected something very real was happening in those patients’ brains. In her own laboratory, she had discovered that rats undergo a dramatic storm of many neurotransmitters, including serotonin and dopamine, after their hearts stop and their brains lose oxygen. She wondered if humans’ near-death experiences might spring from a similar phenomenon, and if it was occurring even in people who couldn’t be revived.
Dying seemed like such an important area of research – we all do it, after all – that Borjigin assumed other scientists had already developed a thorough understanding of what happens to the brain in the process of death. But when she looked at the scientific literature, she found little enlightenment. “To die is such an essential part of life,” she told me recently. “But we knew almost nothing about the dying brain.” So she decided to go back and figure out what had happened inside the brains of people who died at the University of Michigan neurointensive care unit. Among them was Patient One.
At the time Borjigin began her research into Patient One, the scientific understanding of death had reached an impasse. Since the 1960s, advances in resuscitation had helped to revive thousands of people who might otherwise have died. About 10% or 20% of those people brought with them stories of near-death experiences in which they felt their souls or selves departing from their bodies. A handful of those patients even claimed to witness, from above, doctors’ attempts to resuscitate them. According to several international surveys and studies, one in 10 people claims to have had a near-death experience involving cardiac arrest, or a similar experience in circumstances where they may have come close to death. That’s roughly 800 million souls worldwide who may have dipped a toe in the afterlife.
As remarkable as these near-death experiences sounded, they were consistent enough that some scientists began to believe there was truth to them: maybe people really did have minds or souls that existed separately from their living bodies. In the 1970s, a small network of cardiologists, psychiatrists, medical sociologists and social psychologists in North America and Europe began investigating whether near-death experiences proved that dying is not the end of being, and that consciousness can exist independently of the brain. The field of near-death studies was born.
Over the next 30 years, researchers collected thousands of case reports of people who had had near-death experiences. Meanwhile, new technologies and techniques were helping doctors revive more and more people who, in earlier periods of history, would have almost certainly been permanently deceased. “We are now at the point where we have both the tools and the means to scientifically answer the age-old question: What happens when we die?” wrote Sam Parnia, an accomplished resuscitation specialist and one of the world’s leading experts on near-death experiences, in 2006. Parnia himself was devising an international study to test whether patients could have conscious awareness even after they were found clinically dead.
But by 2015, experiments such as Parnia’s had yielded ambiguous results, and the field of near-death studies was not much closer to understanding death than it had been when it was founded four decades earlier. That’s when Borjigin, together with several colleagues, took the first close look at the record of electrical activity in the brain of Patient One after she was taken off life support. What they discovered – in results reported for the first time last year – was almost entirely unexpected, and has the potential to rewrite our understanding of death.
“I believe what we found is only the tip of a vast iceberg,” Borjigin told me. “What’s still beneath the surface is a full account of how dying actually takes place. Because there’s something happening in there, in the brain, that makes no sense.”
For all that science has learned about the workings of life, death remains among the most intractable of mysteries. “At times I have been tempted to believe that the creator has eternally intended this department of nature to remain baffling, to prompt our curiosities and hopes and suspicions all in equal measure,” the philosopher William James wrote in 1909.
The first time that the question Borjigin began asking in 2015 was posed – about what happens to the brain during death – was a quarter of a millennium earlier. Around 1740, a French military physician reviewed the case of a famous apothecary who, after a “malign fever” and several blood-lettings, fell unconscious and thought he had travelled to the Kingdom of the Blessed. The physician speculated that the apothecary’s experience had been caused by a surge of blood to the brain. But between that early report and the mid-20th century, scientific interest in near-death experiences remained sporadic.
In 1892, the Swiss climber and geologist Albert Heim collected the first systematic accounts of near-death experiences from 30 fellow climbers who had suffered near-fatal falls. In many cases, the climbers underwent a sudden review of their entire past, heard beautiful music, and “fell in a superbly blue heaven containing roseate cloudlets”, Heim wrote. “Then consciousness was painlessly extinguished, usually at the moment of impact.” There were a few more attempts to do research in the early 20th century, but little progress was made in understanding near-death experiences scientifically. Then, in 1975, an American medical student named Raymond Moody published a book called Life After Life.
In his book, Moody distilled the reports of 150 people who had had intense, life-altering experiences in the moments surrounding a cardiac arrest. Although the reports varied, he found that they often shared one or more common features or themes. The narrative arc of the most detailed of those reports – departing the body and travelling through a long tunnel, having an out-of-body experience, encountering spirits and a being of light, one’s whole life flashing before one’s eyes, and returning to the body from some outer limit – became so canonical that the art critic Robert Hughes could refer to it years later as “the familiar kitsch of near-death experience”. Moody’s book became an international bestseller.
In 1976, the New York Times reported on the burgeoning scientific interest in “life after death” and the “emerging field of thanatology”. The following year, Moody and several fellow thanatologists founded an organisation that became the International Association for Near-Death Studies. In 1981, they printed the inaugural issue of Vital Signs, a magazine for the general reader that was largely devoted to stories of near-death experiences. The following year they began producing the field’s first peer-reviewed journal, which became the Journal of Near-Death Studies. The field was growing, and taking on the trappings of scientific respectability. Reviewing its rise in 1988, the British Journal of Psychiatry captured the field’s animating spirit: “A grand hope has been expressed that, through NDE research, new insights can be gained into the ageless mystery of human mortality and its ultimate significance, and that, for the first time, empirical perspectives on the nature of death may be achieved.”
But near-death studies was already splitting into several schools of belief, whose tensions continue to this day. One influential camp was made up of spiritualists, some of them evangelical Christians, who were convinced that near-death experiences were genuine sojourns in the land of the dead and divine. As researchers, the spiritualists’ aim was to collect as many reports of near-death experience as possible, and to proselytise society about the reality of life after death. Moody was their most important spokesman; he eventually claimed to have had multiple past lives and built a “psychomanteum” in rural Alabama where people could attempt to summon the spirits of the dead by gazing into a dimly lit mirror.
The second, and largest, faction of near-death researchers were the parapsychologists, those interested in phenomena that seemed to undermine the scientific orthodoxy that the mind could not exist independently of the brain. These researchers, who were by and large trained scientists following well established research methods, tended to believe that near-death experiences offered evidence that consciousness could persist after the death of the individual. Many of them were physicians and psychiatrists who had been deeply affected after hearing the near-death stories of patients they had treated in the ICU. Their aim was to find ways to test their theories of consciousness empirically, and to turn near-death studies into a legitimate scientific endeavour.
Finally, there emerged the smallest contingent of near-death researchers, who could be labelled the physicalists. These were scientists, many of whom studied the brain, who were committed to a strictly biological account of near-death experiences. Like dreams, the physicalists argued, near-death experiences might reveal psychological truths, but they did so through hallucinatory fictions that emerged from the workings of the body and the brain. (Indeed, many of the states reported by near-death experiencers can apparently be achieved by taking a hero’s dose of ketamine.) Their basic premise was: no functioning brain means no consciousness, and certainly no life after death. Their task, which Borjigin took up in 2015, was to discover what was happening during near-death experiences on a fundamentally physical level.
Slowly, the spiritualists left the field of research for the loftier domains of Christian talk radio, and the parapsychologists and physicalists started bringing near-death studies closer to the scientific mainstream. Between 1975, when Moody published Life After Life, and 1984, only 17 articles in the PubMed database of scientific publications mentioned near-death experiences. In the following decade, there were 62. In the most recent 10-year span, there were 221. Those articles have appeared everywhere from the Canadian Urological Association Journal to the esteemed pages of The Lancet.
Today, there is a widespread sense throughout the community of near-death researchers that we are on the verge of great discoveries. Charlotte Martial, a neuroscientist at the University of Liège in Belgium who has done some of the best physicalist work on near-death experiences, hopes we will soon develop a new understanding of the relationship between the internal experience of consciousness and its outward manifestations, for example in coma patients. “We really are in a crucial moment where we have to disentangle consciousness from responsiveness, and maybe question every state that we consider unconscious,” she told me. Parnia, the resuscitation specialist, who studies the physical processes of dying but is also sympathetic to a parapsychological theory of consciousness, has a radically different take on what we are poised to find out. “I think in 50 or 100 years time we will have discovered the entity that is consciousness,” he told me. “It will be taken for granted that it wasn’t produced by the brain, and it doesn’t die when you die.”
If the field of near-death studies is at the threshold of new discoveries about consciousness and death, it is in large part because of a revolution in our ability to resuscitate people who have suffered cardiac arrest. Lance Becker has been a leader in resuscitation science for more than 30 years. As a young doctor attempting to revive people through CPR in the mid-1980s, senior physicians would often step in to declare patients dead. “At a certain point, they would just say, ‘OK, that’s enough. Let’s stop. This is unsuccessful. Time of death: 1.37pm,’” he recalled recently. “And that would be the last thing. And one of the things running through my head as a young doctor was, ‘Well, what really happened at 1.37?’”
In a medical setting, “clinical death” is said to occur at the moment the heart stops pumping blood, and the pulse stops. This is widely known as cardiac arrest. (It is different from a heart attack, in which there is a blockage in a heart that’s still pumping.) Loss of oxygen to the brain and other organs generally follows within seconds or minutes, although the complete cessation of activity in the heart and brain – which is often called “flatlining” or, in the case of the latter, “brain death” – may not occur for many minutes or even hours.
For almost all people at all times in history, cardiac arrest was basically the end of the line. That began to change in 1960, when the combination of mouth-to-mouth ventilation, chest compressions and external defibrillation known as cardiopulmonary resuscitation, or CPR, was formalised. Shortly thereafter, a massive campaign was launched to educate clinicians and the public on CPR’s basic techniques, and soon people were being revived in previously unthinkable, if still modest, numbers.
As more and more people were resuscitated, scientists learned that, even in its acute final stages, death is not a point, but a process. After cardiac arrest, blood and oxygen stop circulating through the body, cells begin to break down, and normal electrical activity in the brain gets disrupted. But the organs don’t fail irreversibly right away, and the brain doesn’t necessarily cease functioning altogether. There is often still the possibility of a return to life. In some cases, cell death can be stopped or significantly slowed, the heart can be restarted, and brain function can be restored. In other words, the process of death can be reversed.
It is no longer unheard of for people to be revived even six hours after being declared clinically dead. In 2011, Japanese doctors reported the case of a young woman who was found in a forest one morning after an overdose stopped her heart the previous night; using advanced technology to circulate blood and oxygen through her body, the doctors were able to revive her more than six hours later, and she was able to walk out of the hospital after three weeks of care. In 2019, a British woman named Audrey Schoeman who was caught in a snowstorm spent six hours in cardiac arrest before doctors brought her back to life with no evident brain damage.
“I don’t think there’s ever been a more exciting time for the field,” Becker told me. “We’re discovering new drugs, we’re discovering new devices, and we’re discovering new things about the brain.”
The brain – that’s the tricky part. In January 2021, as the Covid-19 pandemic was surging toward what would become its deadliest week on record, Netflix released a documentary series called Surviving Death. In the first episode, some of near-death studies’ most prominent parapsychologists presented the core of their arguments for why they believe near-death experiences show that consciousness exists independently of the brain. “When the heart stops, within 20 seconds or so, you get flatlining, which means no brain activity,” Bruce Greyson, an emeritus professor of psychiatry at the University of Virginia and one of the founding members of the International Association for Near-Death Studies, says in the documentary. “And yet,” he goes on to claim, “people have near-death experiences when they’ve been (quote) ‘flatlined’ for longer than that.”
That is a key tenet of the parapsychologists’ arguments: if there is consciousness without brain activity, then consciousness must dwell somewhere beyond the brain. Some of the parapsychologists speculate that it is a “non-local” force that pervades the universe, like electromagnetism. This force is received by the brain, but is not generated by it, the way a television receives a broadcast.
In order for this argument to hold, something else has to be true: near-death experiences have to happen during death, after the brain shuts down. To prove this, parapsychologists point to a number of rare but astounding cases known as “veridical” near-death experiences, in which patients seem to report details from the operating room that they might have known only if they had conscious awareness during the time that they were clinically dead. Dozens of such reports exist. One of the most famous is about a woman who apparently travelled so far outside her body that she was able to spot a shoe on a window ledge in another part of the hospital where she went into cardiac arrest; the shoe was later reportedly found by a nurse.
At the very least, Parnia and his colleagues have written, such phenomena are “inexplicable through current neuroscientific models”. Unfortunately for the parapsychologists, however, none of the reports of post-death awareness holds up to strict scientific scrutiny. “There are many claims of this kind, but in my long decades of research into out-of-body and near-death experiences I never met any convincing evidence that this is true,” Sue Blackmore, a well-known researcher into parapsychology who had her own near-death experience as a young woman in 1970, has written.
The case of the shoe, Blackmore pointed out, relied solely on the report of the nurse who claimed to have found it. That’s far from the standard of proof the scientific community would require to accept a result as radical as that consciousness can travel beyond the body and exist after death. In other cases, there’s not enough evidence to prove that the experiences reported by cardiac arrest survivors happened when their brains were shut down, as opposed to in the period before or after they supposedly “flatlined”. “So far, there is no sufficiently rigorous, convincing empirical evidence that people can observe their surroundings during a near-death experience,” Charlotte Martial, the University of Liège neuroscientist, told me.
The parapsychologists tend to push back by arguing that even if each of the cases of veridical near-death experiences leaves room for scientific doubt, surely the accumulation of dozens of these reports must count for something. But that argument can be turned on its head: if there are so many genuine instances of consciousness surviving death, then why should it have so far proven impossible to catch one empirically?
Perhaps the story to be written about near-death experiences is not that they prove consciousness is radically different from what we thought it was. Instead, it is that the process of dying is far stranger than scientists ever suspected. The spiritualists and parapsychologists are right to insist that something deeply weird is happening to people when they die, but they are wrong to assume it is happening in the next life rather than this one. At least, that is the implication of what Jimo Borjigin found when she investigated the case of Patient One.
In the moments after Patient One was taken off oxygen, there was a surge of activity in her dying brain. Areas that had been nearly silent while she was on life support suddenly thrummed with high-frequency electrical signals called gamma waves. In particular, the parts of the brain that scientists consider a “hot zone” for consciousness became dramatically alive. In one section, the signals remained detectable for more than six minutes. In another, they were 11 to 12 times higher than they had been before Patient One’s ventilator was removed.
“As she died, Patient One’s brain was functioning in a kind of hyperdrive,” Borjigin told me. For about two minutes after her oxygen was cut off, there was an intense synchronisation of her brain waves, a state associated with many cognitive functions, including heightened attention and memory. The synchronisation dampened for about 18 seconds, then intensified again for more than four minutes. It faded for a minute, then came back for a third time.
In those same periods of dying, different parts of Patient One’s brain were suddenly in close communication with each other. The most intense connections started immediately after her oxygen stopped, and lasted for nearly four minutes. There was another burst of connectivity more than five minutes and 20 seconds after she was taken off life support. In particular, areas of her brain associated with processing conscious experience – areas that are active when we move through the waking world, and when we have vivid dreams – were communicating with those involved in memory formation. So were parts of the brain associated with empathy. Even as she slipped irrevocably deeper into death, something that looked astonishingly like life was taking place over several minutes in Patient One’s brain.
Those glimmers and flashes of something like life contradict the expectations of almost everyone working in the field of resuscitation science and near-death studies. The predominant belief – expressed by Greyson, the psychiatrist and co-founder of the International Association of Near Death Studies, in the Netflix series Surviving Death – was that as soon as oxygen stops going to the brain, neurological activity falls precipitously. Although a few earlier instances of brain waves had been reported in dying human brains, nothing as detailed and complex as what occurred in Patient One had ever been detected.
Given the levels of activity and connectivity in particular regions of her dying brain, Borjigin believes it’s likely that Patient One had a profound near-death experience with many of its major features: out-of-body sensations, visions of light, feelings of joy or serenity, and moral re-evaluations of one’s life. Of course, Patient One did not recover, so no one can prove that the extraordinary happenings in her dying brain had experiential counterparts. Greyson and one of the other grandees of near-death studies, a Dutch cardiologist named Pim van Lommel, have asserted that Patient One’s brain activity can shed no light on near-death experiences because her heart hadn’t fully flatlined, but that is a self-defeating argument: there is no rigorous empirical evidence that near-death experiences occur in people whose hearts have completely stopped.
At the very least, Patient One’s brain activity – and the activity in the dying brain of another patient Borjigin studied, a 77-year-old woman known as Patient Three – seems to close the door on the argument that the brain always and nearly immediately ceases to function in a coherent manner in the moments after clinical death. “The brain, contrary to everybody’s belief, is actually super active during cardiac arrest,” Borjigin said. Death may be far more alive than we ever thought possible.
Borjigin believes that understanding the dying brain is one of the “holy grails” of neuroscience. “The brain is so resilient, the heart is so resilient, that it takes years of abuse to kill them,” she pointed out. “Why then, without oxygen, can a perfectly healthy person die within 30 minutes, irreversibly?” Although most people would take that result for granted, Borjigin thinks that, on a physical level, it actually makes little sense.
Borjigin hopes that understanding the neurophysiology of death can help us to reverse it. She already has brain activity data from dozens of deceased patients that she is waiting to analyse. But because of the paranormal stigma associated with near-death studies, she says, few research agencies want to grant her funding. “Consciousness is almost a dirty word amongst funders,” she added. “Hardcore scientists think research into it should belong to maybe theology, philosophy, but not in hardcore science. Other people ask, ‘What’s the use? The patients are gonna die anyway, so why study that process? There’s nothing you can do about it.’”
Evidence is already emerging that even total brain death may someday be reversible. In 2019, scientists at Yale University harvested the brains of pigs that had been decapitated in a commercial slaughterhouse four hours earlier. Then they perfused the brains for six hours with a special cocktail of drugs and synthetic blood. Astoundingly, some of the cells in the brains began to show metabolic activity again, and some of the synapses even began firing. The pigs’ brain scans didn’t show the widespread electrical activity that we typically associate with sentience or consciousness. But the fact that there was any activity at all suggests the frontiers of life may one day extend much, much farther into the realms of death than most scientists currently imagine.
Other serious avenues of research into near-death experience are ongoing. Martial and her colleagues at the University of Liège are working on many issues relating to near-death experiences. One is whether people with a history of trauma, or with more creative minds, tend to have such experiences at higher rates than the general population. Another is on the evolutionary biology of near-death experiences. Why, evolutionarily speaking, should we have such experiences at all? Martial and her colleagues speculate that it may be a form of the phenomenon known as thanatosis, in which creatures throughout the animal kingdom feign death to escape mortal dangers. Other researchers have proposed that the surge of electrical activity in the moments after cardiac arrest is just the final seizure of a dying brain, or have hypothesised that it’s a last-ditch attempt by the brain to restart itself, like jump-starting the engine on a car.
Meanwhile, in parts of the culture where enthusiasm is reserved not for scientific discovery in this world, but for absolution or benediction in the next, the spiritualists, along with sundry other kooks and grifters, are busily peddling their tales of the afterlife. Forget the proverbial tunnel of light: in America in particular, a pipeline of money has been discovered from death’s door, through Christian media, to the New York Times bestseller list and thence to the fawning, gullible armchairs of the nation’s daytime talk shows. First stop, paradise; next stop, Dr Oz.
But there is something that binds many of these people – the physicalists, the parapsychologists, the spiritualists – together. It is the hope that by transcending the current limits of science and of our bodies, we will achieve not a deeper understanding of death, but a longer and more profound experience of life. That, perhaps, is the real attraction of the near-death experience: it shows us what is possible not in the next world, but in this one.
