The "End of Life" Question

In a cool room, gently away...

Of course this is an ancient question, but in our age we are forced to appraise it with new eyes. That is due to at least three factors:

• we now have drugs and techniques to keep someone alive in an unhealthy state for much longer than was previously possible

• as a relevant effect of the above, we have far more people living long enough to develop dementia, and to suffer it for many years

• we live in a deeply litigious state. I’m fairly sure that, up until about the year 2000, it was “the done thing”, an unacknowledged open secret, that hospital doctors would agree to “hurry someone along” when there was no hope of recovery. It was understood what the concerned relatives meant when they asked for “a dignified end” for old Uncle Harry, and the doctor would increase the painkiller accordingly. But today, the fear of surprise litigation prevents this. Everything has to be recorded, examined and accounted for, every legal pitfall skilfully avoided.

All of this means that old Uncle Harry is going to get a tube stuck in him and he will be kept bubbling away for years, comatose or paralysed or vegetative, and it means his relatives will have to see him in that state, for years, until the “blessing in disguise” finally deigns to strike.

This is a ridiculous and cruel situation. We need to discuss it, and in discussing it we need to be brave, not squeamish, and serious, not childish.

I will come clean. I think we need some legal means to accelerate death when this is desired by the patient and his relatives.

To be clear, I don’t think an otherwise healthy twenty-something who is depressed - even as severely clinically depressed as I was in my twenties - should be helped to die. I find that absolutely egregious. I despise the Canadian and Dutch states for making the option legally available for such people. The Canadian state openly advertising this as some kind of “deathstyle choice” surely ranks alongside Drag Queen Story Hour as one of the worst manifestations of a godless clown-world.

But if someone has a terminal or degenerative condition that no medical care can alleviate, it is a very different matter. Yet here we, as a society, tend to become very squeamish.

Just as Millennials want to preserve our childhoods for as long as inhumanly possible, and GenX want to likewise extend their adolescence and Boomers their twenties, we all seem to be obsessed with extending life itself for as long as possible, regardless of the costs. And the costs are real: dignity, happiness, family finances, family emotional health…

On the Right, there are at least two justifications for this. One is our (correct) mistrust of the state. The afore-mentioned Canadian adverts for assisted dying, as if such a choice is of no more weight than one’s choice of sofa to buy for the living room, suggests the Canadian state desires to rid itself of its “legacy” population. In a time when the same desire is apparent in every White (or formerly White) country, people are right to mistrust the state. However, that doesn’t solve the problem.

Another right-wing justification is Christian morality regarding suicide and euthanasia. I find this rather ironic, considering that people were much more relaxed about “helping someone out the door” when we were much more Christian than we are now. It’s almost as if, the less Christian we become, the more desperate we are for the reassurance of Christian morals - and the more shrill the better. Is it a case of “the boy doth protest too much”? More charitably, perhaps we feel that, as a society, we are incapable of devising a new moral system to deal with this situation, so in panic, we default to the most rigid form of a previous moral system.

But that moral puritanism on the Right is complemented on the Left with the most disgusting, ghoulish attitude. They seem to make a fetish out of trivialising any serious matter to the maximum extent possible. If it’s serious, then they’ll shock us and impress themselves by cheapening it, by approaching it with the most childish attitude they can muster. But we have known for years that childishness is all we can expect from the Left. It is now up to us to be the adults, for there are no others in the room.

But, while the task of being an adult should be enlivened by romance and some idealism, it must be restrained by a lot of realism.

It is not “a good way to go” to spend five years in a vegetative state, stuck in a bland room surrounded by a few uprooted remnants from a life you do not remember, alone but for the nurses who never knew the real you and visits from those relatives and friends who, after years of this nightmare, can still bring themselves to visit, even though you don’t recognise them and often don’t even realise they are in the room with you. You don’t even know “you”, or that there is such a thing or ever could be such a thing. You know nothing, except for the immediate sensations your body is experiencing, but you don’t understand those either.

I don’t really believe that is “humane”. If someone kept a dog alive for five years in such a state, they would be prosecuted for animal cruelty. Apparently this argument is a cliché in the “end of life” debate, with the common refutation being that it’s entirely different since humans are so different from animals. I don’t think that is a very convincing refutation. If anything, our consciousness and intellect make our suffering, and the fact of our relatives allowing us to suffer, even worse.

There are also more prosaic objections to keeping people in that state, especially in care homes.

The first is that keeping someone in a care home is extremely expensive - about £72,000 per year. Five years of it will easily drain the life savings of an ordinary person along with the value of their assets, so that their relatives will inherit nothing. You might say it is grotesque to talk of such things, to “put a price tag” on someone’s survival. But let’s be honest: the current situation means the total destruction of inter-generational wealth in the working and middle classes. I don’t want that, and neither do you, but averting it will require us to be realistic, not squeamish.

The second objection is very grim indeed. As our Western societies become less White, more culturally bent against White people and more institutionally non-white, old White people in care homes will be extremely vulnerable. I don’t think I need to elaborate. (If you aren’t sure what I’m alluding to, just look at the rest of my work and you will be able to join the dots.) Of course it is possible that remigration will alleviate this problem… but what if it doesn’t?

One solution to all of this, which is often suggested by traditionally-minded people, is that it is wrong to put old people into care homes in the first place. Rather, they say, we should look after our elderly relatives ourselves. That will include every aspect of toileting, as well as administering medication, and will require the constant presence of one relative to deal with the person’s needs and prevent them from hurting themselves or blowing up the house. It needn’t be the same relative all the time, but we mustn’t kid ourselves: a person with advanced dementia needs constant care. Perhaps relatives who have recently retired could do it, but not every family has such members, and it is not how anyone envisages spending their retirement, many will not have the knowledge or emotional resources to handle it, and it will definitely sully their fond memories of the person now exhaustingly under their care.

Another option would be to nationalise the care home industry. I would support this because I loathe the idea (and the reality) of private companies keeping people unpleasantly alive for as long as possible in order to maximise profit. However, I am not sure that nationalising it is a realistic option given the sums involved. A care home with 80 residents must cost £5.8m every year at least. An average town would require several such homes. And this would be in every town in Britain.

For the same reason, the idea that this could be financed by charity is even more hopelessly unrealistic. There simply isn’t anywhere near the charity money for this. (Anyone suggesting that 21st Century healthcare can be financed by charity, like 19th Century healthcare for the poor was financed, is just wasting everyone’s time. Again, we need to be realistic.)

As far as I can see, the bottom line is that we have to stop keeping people alive so long in this condition. There is no way to afford it except by impoverishing ourselves, it is an undignified way to spend one’s last years, it takes a huge emotional toll on relatives and friends, and it destroys inter-generational wealth. For all these reasons, there needs to be some way out. There needs to be a way to foreshorten, against medical capability and against the letter of the Hippocratic Oath, the cruel purgatory that awaits many of us in the last decade of our lives.

I believe that our ancestors, with a tiny fraction of our technological capacity, would be able to come up with something. For example, I can imagine a new tradition, understood by everyone, of the “final night”. It would be spent in a cool room, or perhaps even outdoors, with one’s relatives and closest friends, and there would be much weeping the next morning when they awakened to find that the inevitable had happened, and their loved one had been released from all suffering.

I expect many readers to be angry with me for writing this. I expect some of you will remain angry with me. But I think most of you know, even if I can’t point with confidence at any particular remedy, that the problem I have named here is a real one, and the need for a remedy equally real. If my treatment of it seems callous or shallow, be assured that I do understand the gravity of what we are talking about. It seems disgusting to talk of necessity and pragmatism in connection to such a thing… but then, isn’t that feeling itself an indulgence, a symptom of how idealistic we have become in our Western pamperment, detached from truth and nature?