The fundamental premise of Stewards of the Flame is that the the logical culmination of this trend would be to deny death entirely, assuming that the machines were "improved" to the point of keeping mindless bodies functioning indefinitely -- and that this would be a very bad thing. Natural death, in my opinion, is death resulting from the normal shutting down of the body when the unconscious mind is ready to die. It happens to everyone, if no accident or acute disease strikes prematurely, as long as the process is not thwarted by interference with the body in the way all too common today. I am aware that this view is termed "deathism" by the proponents of technological life extension, some of whom fervently believe that physical immortality is just around the corner. I should make plain here that I don't oppose research aimed at achieving this. If such research eventually leads to it, then my whole conception of human life is mistaken, and I am not unwilling to be proven wrong; if humans are destined to become immortal, then that's the reality honesty would require me to accept. But I don't think it's going to turn out that way. I think people will go on dying in old age (older than the present maximum) no matter what technology does to repair their bodies. We don't know what death brings, but it surely brings something, or else everyone who has ever struggled through life has done so to no purpose. The purpose of life is a mystery in the first place, but I cannot conceive of living indefinitely without conviction that the effort leads somewhere; I am sure I would grow weary and long for something our present existence cannot provide.

The life-extension enthusiasts admit that people might get bored in time and say that in that case, they could kill themselves. I have personally known people who say this. And of course, the issue of assisted suicide for the terminally ill is a major controversy today. I live in Oregon, where assisted suicide is legal, so I hear a good deal about that. I am opposed to it. Originally, though I was personally opposed, I believed the law should allow individuals to make their own choice. Now I realize that if this choice is legitimatized and becomes common, some people will choose to hasten death merely to spare their families the physical and financial burden of caring for them, and eventually those of us without families may be subtly discouraged from continuing to receive care at the expense of the taxpayers. This situation would not exist if high-tech intervention were not automatically employed early in the course of illness which, in the case of an elderly person, is inevitably going to be fatal. The choice to live or die should never have to be conscious; it is matter properly left to the unconscious mind or, metaphorically speaking, to God. Suicide is wrong because it is a violation of one's own deepest inner determination, just as the artificial maintenance of the aged body is a violation. As Richard Bach has written, "Here is the test to find whether your mission on Earth is finished: if you're alive, it isn't." When, and only when, the unconscious mind is ready to die, natural death occurs -- provided that medical treatment isn't getting in the way of nature.

There has been a lot of discussion in the past few decades about the pointless and often cruel way in which people are routinely treated in their last months of life, and many calls for reform. But though the solution -- hospice care -- is now available, comparatively few people take advantage of it. Many are simply unaware that it exists. Others, or their families, are so conditioned by our culture's denial of death that they believe rejecting futile treatment is tantamount to suicide, or at best an abandonment of "hope." In my novel, the forced prolongation of pseudo-life is not arbitrarily imposed by the medical authorities that run the planet; it is a law supported by the people, who do not want to admit that they are mortal. I suspect this is a realistic assumption about what would happen. The vast majority of Americans polled say that they want to die at home, not in a hospital; yet they end up in hospitals all the same. Continuation of treatment is not compulsory, yet most don't contest the medical establishment's imposition of it, perhaps because don't know that they can -- that there are better alternatives -- or perhaps because society as a whole offers no support for the idea that the natural ending of life need not involve suffering. Unfortunately, the only thing likely to bring about widespread change is the financial impossibility of providing high-tech terminal care to an aging population. Individuals, however, can improve their own future prospects by familiarizing themselves with some of the material listed below.

Links to Sites About Better Care of the Dying

Growth House The Internet's leading online community for end of life care -- award-winning international gateway to resources for life-threatening illness and end of life care; also offers RSS feeds and streaming audio. "Our primary mission is to improve the quality of compassionate care for people who are dying."

Sick to Death and Not Going to Take It Anymore! Online edition of the book. "People would expect a headline that shouts 'New Drug Prevents Heart Disease in Elderly' to herald a story about something thoroughly laudable. The headline could be equally correct and say instead 'New Drug Promises Major Increases in Dementia.' Saving the lives of children who otherwise faced polio was reasonably understood to be a very good thing. Saving the lives of elderly persons by eliminating one among a group of competing causes of death is more complicated. Eliminating one illness might well change the nature of the death and delay its timing, but the language of saving lives is misleading."

Personal site of Dr. Ira Byock, author of Dying Well. Many articles and links. "The medical profession most commonly approaches dying as if it were solely a problematic medical event. From the first day in medical school, doctors are taught to approach patients by defining a set of medical problems to be solved."

Pallimed. An excellent blog containing information and commentary about hospice and palliative medicine. It has a companion blog, Pallimed: Arts & Humanities, which explores how the arts and humanities influence and are influenced by topics in palliative care.

Americans for Better Care of the Dying. Excerpts from the book Handbook for Mortals are online at this site.

Before I Die. PBS Online, April 1997. Many good articles, but some advocate assisted suicide.

On Our Own Terms: Bill Moyers on Dying. PBS, 2000. Accompaniment to the TV series; includes video excerpts.

CPR: It's Not Quite Like 'ER'. Robert Wood Johnson Foundation, from its former website Last Acts. The reality of cardiopulmonary resuscitation, and its uses and limitations at the end of life.

Natural Death Handbook. Natural Death Centre (a British organization), 1993.

Final Passages. Home care of the dead and home-directed funerals.

The Truth About Dying. Deseret Morning News, April 25, 2003. "A truthful prognosis ... 'means then they won't be beat up by tests and surgeries, they won't spend what time they have left recovering from useless tests and painful invasive procedures that will simply result in more time in the hospital rather than with the people they want to be with.'"

What Is Hospice Care? American Cancer Society, January 2007. "Hospice is a philosophy of care. The hospice philosophy recognizes death as the final stage of life and seeks to enable patients to continue an alert, pain-free life and to manage other symptoms so that their last days may be spent with dignity and quality, surrounded by their loved ones. Hospice affirms life and does not hasten or postpone death."

Video: HospiceAdvantage operates many hospices

Hospice Net. An independent, nonprofit organization working exclusively through the Internet; provides information and support to patients and families facing life-threatening illnesses. Hospice Foundation of America. Aims to help those who cope personally or professionally with terminal illness, death and the process of grief and bereavement. American Hospice Foundation. Mission is to improve access to quality hospice care through public education, professional training, and advocacy on behalf of consumers.

International Association for Hospice and Palliative Care. Mission is to increase the availability and access to high quality hospice and palliative care for patients and families throughout the world.

Family Hospice and Palliative Care. Exists to enhance the quality of life for terminally ill patients, their families, and caregivers by providing quality palliative and supportive care, primarily in the home.

Caring Connections, a program of the National Hospice and Palliative Care Organization (NHPCO). Advance directive forms for all states are available here for download.

Hospice Patients Alliance (HPA). Formed by experienced hospice staff and other health care professionals who saw that hospices were not always complying with the standards of care, and in fact, were in some cases, violating the rights of patients and families and exploiting them for financial gain. HPA Family Guide to Hospice Care is available here for download.


Some Books on Reforming Care of the Dying

Good End: End-of-Life Concerns and Conversations about Hospice and Palliative Care, Michael Appleton, Hats Off Books, 2005, 1587364816.

Dying Well, Ira Byock, Riverhead, 1998, 573226572.

When Autumn Comes: Creating Compassionate Care for the Dying, Mary Jo Bennett, iUniverse, 2004, 059531662X.

The Hospice Handbook: A Complete Guide, Larry Beresford, Little, Brown, 1993, 0316091383.

The Troubled Dream of Life: In Search of a Peaceful Death, Daniel Callahan, Georgetown University Press, 2000, 0878408150.

Final Journeys: A Practical Guide for Bringing Care and Comfort at the End of Life, Maggie Callanan, Bantam, 2009, 0553382748.

Final Gifts: Understanding the Special Awareness, Needs, and Communications of the Dying, Maggie Callanan and Patricia Kelley, Bantam, 1997, 0553378767.

The Nature of Suffering and the Goals of Medicine, Eric J. Cassel, Oxford University Press, 2004, 0195156161.

Sacred Passage: How to Provide Fearless, Compassionate Care for the Dying, Margaret Coberly, Shambhala, 2003, 1590300173.

Unplugged: Reclaiming Our Right to Die in America, William H. Colby, American Management Association, 2007, 0814401600.

The End-of-Life Advisor: Personal, Legal, and Medical Considerations for a Peaceful, Dignified Death, Susan Dolan and Audrey R Vizzard, Kaplan, 2008, 1427798397.

The Dying Time: Practical Wisdom for the Dying and Their Caregivers, Joan Furman, Harmony/Bell Tower, 1997, 0609800035.

Death's Door: Modern Dying and the Ways We Grieve, Sandra M. Gilbert, Norton, 2007, 0393329690.

Hospice, a Labor of Love, Denise Glavan, Cindy Longanacre, and John Spivey, Chalice Press, 1999, 0827214383.

Palliative Care Perspectives, James L. Hallenbeck, Oxford University Press, 2003, 0195165780.

A Good Dying: Shaping Health Care for the Last Months of Life, Joan K. Harrold and Joanne Lynn, eds., Haworth Press, 1998, 0789005026.

All Kinds of Love: Experiencing Hospice, Carolyn Jaffe and Carol H. Ehrlich, Baywood, 1997, 0895031477.

And a Time to Die: How American Hospitals Shape the End of Life, Sharon R. Kaufman, University Of Chicago Press, 2006, 0226426858.

The Needs of the Dying: A Guide for Bringing Hope, Comfort, and Love to Life's Final Chapter, David Kessler, Harper Paperbacks, 2007, 0061137596.

Last Rights: Rescuing the End of Life from the Medical System, Stephen P. Kiernan, St. Martin's, 0312342241,

What Dying People Want: Practical Wisdom for the End of Life, David Kuhl, PublicAffairs, 2003, 586481975.

The Hospice Choice: In Pursuit of a Peaceful Death, Marcia Lattanzi-Licht, Fireside, 1998, 0684822695.

Medicine and Care of the Dying: A Modern History, Milton J. Lewis, Oxford University Press, 2006, 0195175484.

Sick To Death and Not Going to Take It Anymore!: Reforming Health Care for the Last Years of Life, Joanne Lynn, University of California Press, 2004, 0520243005. (Available online.)

Handbook for Mortals: Guidance for People Facing Serious Illness, Joanne Lynn and Joan Harrold, Oxford University Press, 2001, 0195146018. (Excerpts available online.)

The American Way of Death Revisited, Jessica Mitford, Vintage, 2000, 0679771867.

How We Die: Reflections on Life's Final Chapter, Sherwin B. Nuland, Vintage, 1995, 0679742441.

What Happens When We Die?: A Groundbreaking Study into the Nature of Life and Death, Sam Parnia, Hay House, 2007, 1401907113.

Death and Dignity: Making Choices and Taking Charge, Timothy E. Quill, Norton, 1994, 0393311406.

A Midwife through the Dying Process: Stories of Healing and Hard Choices at the End of Life, Timothy E. Quill, Johns Hopkins University Press, 2001, 0801869781.

Hospice Movement: A Better Way of Caring For the Dying, Sandol Stoddar, Vintage, 1992, 0679734678.

Final Choices: Seeking the Good Death, Michael Vitez, Camino Books, 1998, 0940159430.

To Die Well: Your Right to Comfort, Calm, and Choice in the Last Days of Life, Sidney Wanzer and Joseph Glenmullen, Merloyd Lawrence, 2007, 0738210838.

The Good Death: The New American Search to Reshape the End of Life, Marilyn Webb, Bantam, 1999, 0553379879.