I. Death as an anthropological condition. - II. The ontological question regarding death and dying. - III. Death and biology. - IV. Thanatology: the science of death and clinical criteria for determination of death. - V. Death and cultures. - VI. Death Ethics: ethical questions regarding death. - VII. Conclusions.
While animals and plants simply cease to exist, men die. Death is a very particular kind of object which arises together with the dawn of humanity. This is why it is correct to read it as an anthropological condition. Anthropology itself as a discipline studies rituals connected with death and dying. But it should be noted that the earliest expressions of human arts are mostly related to funerary rites. The way humans take care of the bodies of their parents, brothers, and friends has always been different from the way they deal with other corpses.
Not only is death somehow essentially connected with the human experience as such, it is also among the first speculative objects of human intellective endeavor. Plato in his Phaedo put it this way: «Those who apply themselves correctly to the pursuit of philosophy are in fact practicing nothing more nor less than dying and death». Philosophy developed from the quest for becoming. All the ancient ontology could be said to be an attempt to explain why there is being instead of nothing, where ‘nothing’ means death.
Even when philosophy becomes more formalized and applies itself to biology and more broadly to scientific reasoning, death remain among its objects of reflection. Biology itself, though devoted to the study of life rather than death, cannot avoid recognizing that every living being must necessarily die according to its very nature. Studying life means considering even such phenomena as apoptosis and decay.
There is a specific discipline devoted to the study of death as a process, rather than an object: thanatology. Born out of legal medicine, it is a forensic science that studies the measurable aspects of the process of decaying, such as time, conditions, probable causes. It also deals with the social implications of death and dying, thus delving into rituals and habits connected with death and body disposal.
Measuring death is not only a scientific problem. It has also become of paramount importance for medicine and bioethic which must evaluate the appropriateness of the ascertaining criteria of death. In cases such as organ donations it is crucial to understand when someone can be legally considered dead, to proceed with the organ explant. These criteria have evolved in recent years due to the scientific and technological advancements of medicine. Consequently, the need has arisen to better understand the value of such measurements in order to answer the question: When is someone really dead?
To be dead carries different values in different cultures, for each and every culture has elaborated specific answers to the questions posed by death. According to the answers different cultures give, we have different rituals, habits, and attitudes toward death, dying and all the issues connected with them. Usually these different approaches are rooted in specific stands on the afterlife answer.
The above quotation from Plato makes clear the link between death and philosophy. This connection is even stronger in a specific branch of philosophy: Ethics. The Ethics of death deals with themes like happiness and death and articulates such questions as: is there a way to die well?; should we fear dying?; is there a duty regarding the dead?
These questions bring about legal questions which are closely tied with the ethical dimension. Besides the more familiar topics related to this area such as euthanasia, therapeutic obstinacy and therapeutic abandonment, the central question in this field is: is there a right to die? And if so, what are the duties for those who should make this right work?
Ultimately, death is clearly a reality which cannot be exhausted in a few disciplines. It is at the core of many human sciences. It constitutes fields like anthropology, both at the philosophical and ethnological levels, biology, and medicine, not to mention theology and the whole religious area. Being aware of death and dying seems to be at the same time a human privilege and burden. It is surely one of the marks of distinction among living beings. It is simply impossible to talk about humans and their specificity without considering death.
I. Death as an anthropological condition
The opening statement of the study pointed out the difference between the event of ceasing to exist, occurring to every living being, and that of dying, occurring to humans and maybe at a certain degree to superior animals.
At a first glance, the difference between these two ways of ceasing to exist could be understood as the difference between being aware of ceasing to exist and not. Those who know they are going to leave this world can be said to die, while those who do not, will not.
Of course, the analogical use of language allows us to say that plants die too, like every other being, but properly speaking one thing is the natural course of life, which entails death, and another is the understanding human beings give to this process. These are two distinct kinds of reality which explain the use of these different verbs.
To die means not only that we are aware of what is going to happen to us or to those around us, but it relates to a whole set of feelings, emotions, cultural forms, rites, thoughts, and habits which must not be underestimated. It has been noted that the earliest human traces are always somehow connected with funerary rituals. Besides this factual recognition, it can be added that death emerges as an anthropological question which challenges the very fundaments of human life itself.
In this sense, we do not see animals struggling against the death sentence hanging over their lives; no human being at a first sight is happy to ponder the necessary end of his journey, nor is he happy to see his fellow humans dying, although this is an unavoidable truth everyone understands quite early. This truth led fundamental thinkers like Plato to say that death was the real engine not only of every philosophical enterprise, but also of every endeavor on the part of humans to make sense of their own lives.
Even ancient Greek authors such as Homer or Plato defined men as mortals, rather than “Anthropos”, deeming therefore mortality as the real mark of distinction of humanity.
Thus, dying and have knowledge about dying are two different things. Ancient philosophy was somehow born out of the need to explanation the mystery of death. These expressed two fundamentally different positions. One position denied that after death there is something more (i.e., Democritus). The other explained death as a passage toward an eternal life not tampered by death (i.e., Plato).
Despite the different naturalistic and metaphysical positions, they both saw death as a problem to be dealt with. These different approaches tried to make sense of a phenomenon not easy to explain through normal ways of inquiring. Since no one has ever come back from the realm of death to tell us how things are in the afterworld, there is no empirical evidence that can be used for or against either position. This does not mean the topic cannot be discussed on subtler grounds (i.e. the metaphysical one), but it should be recognized that if one accepts a sort of fundamental empiricism, it is not possible to give a meaningful account of this phenomenon.
This consideration helps us understand why since the beginning of the speculation on death we find basically two different sets of thoughts, each rooted in a different speculative attitude: one – the metaphysicists' argued in favor of a broader idea of reason, able to tackle even phenomena beyond empirical inquiry. The other – the empiricists’ – deemed it not possible to overcome the boundaries of empirical evidence, stating therefore that every speculation not firmly grounded on empirical experience could not be carried on.
To summarize, anthropology can be said to be defined by the question of death, more precisely by man questioning his own death. Even before the possible answers he can provide, the fact itself of elaborating such a question gives rise to the inquiry on what kind of creature is the one who is going to die sooner or later.
Among the metaphysicists Plato’s stand on the question has become exemplary. According to Pierre Hadot’s reading of Plato, «if it is true that philosophy subjugates the body’s will to live to the higher demands of thought, it can rightly be said that philosophy is the training and apprenticeship for death» (Hadot, 1992: 94). Here we can see how death constitutes not only the object of philosophical and anthropological speculation, but also the end which determines how the philosopher lives. The answer to the question on death determines the way to live.
On the other side, we find the empiricists’ stand which, in the words of Epicurus says: «Grow accustomed to the belief that death is nothing to us, since every good and evil lie in sensation. However, death is the deprivation of sensation. Therefore, correct understanding that death is nothing to us makes a mortal life enjoyable, not by adding an endless span of time but by taking away the longing for immortality» (Epicurus, 1993: 63).
For these thinkers, wisdom means not to strive for impossible desires such as immortality, but to accept natural laws like death and decay with impassible serenity.
Whereas faith and hope characterize those who believe in another world after death. Materialists get rid of the whole problem by saying that when we are, death is not there, and when death comes, we are not.
Aristotle was of another mind on this topic. He did not share his teacher’s view about man’s composition, though he shared with Plato the idea that man is a complex entity made of body and soul. At the same time, however, he did not think that these two and co-essential components could stand alone, one capable of surviving the other. He held that the soul somehow has a hierarchical priority in the composite (sinolon), as much as form has a priority on matter, but he did not go so far as to declare a full independence of the soul from the body. For this reason, it is debated whether he might have conceded that the soul could survive the body’s death.
Nevertheless, in his biological works “De generatione animalium” we can find interesting remarks regarding organs and organisms, where it is possible to see his conception of living beings as a whole. Therefore, it is cautiously possible to argue that from his perspective to die means a loss of integrity, that the loss of the soul must be understood as the loss of the unifying principle of the organism and that should be seen as the death. This conception will be useful further on in this study where issues such as timing death will be crucial for medical reasons. Obviously, this course of thinking leads to the question ‘what does it mean to be a whole?’, which is in turn a more complex issue than it might seem.
While it is clear that Aristotle denies the Platonic dualism and the consequent views on immortality—he seems to suggest that a desire for immortality is a wish for the impossible—it is not certain that he believes that death is the final end of the soul entirely. The highest part of the soul, the purely intellectual part, is akin to the divine, he argues, and may survive death.
To summarize ancient philosophy’s attitude toward death we can say that, whatever the metaphysical horizon these philosophers shared, whether idealistic (like Plato’s and his school’s) or materialistic (like Epicurus’s and his epigones’), the wise man thought death was not something to be worried about, either because it would have led to a better place, the hyper-uranium, or because when death comes we are not here anymore. The two positions shared the opinion that death is not a practical problem, but a fascinating question.
II. The ontological question regarding death and dying
The Aristotelian position though, the one we have seen to be more nuanced and which in many respects is a sort of synthesis of the previous theses (with a clear tendency toward Platonic transcendence), became the principle upon which the late Christian middle age built its own perspective on the topic. As we said, the topic of death reflects the principal ontological tenets of the philosophers who dealt with it. We need to better understand these ontological implications before moving further.
Whereas Plato conceived a dualistic ontology, with a clear ontological distinction between entities in this world and those in the metaphysical realm, the former being less true than the latter, Epicurus, together with Democritus, Lucretius, Parmenides and many others shared the view that being was to be conceived only in one way. This was later to be called the univocal thesis, or monism. There were different kinds of monism: that of those who thought all being was made of thought, like Parmenides, and that of those who thought all being was made of matter, or atoms, like Democritus. But whatever it was these thinkers thought of the nature of being, they all shared the view that it should be of one and only one nature. Nothing like dualism o pluralism (Empedocles for example thought of four seminal causes) was to be admitted in this kind of ontology. The difference could not be more radical. Here comes the Aristotelian idea that being needs to be described in many ways, but not in every way. Aristotle came up with an idea that mediated between those two apparently irreconcilable views: He proposed that the very nature of being is somehow analogical, not univocal (like Parmenides), nor equivocal (like Heraclitus), preserving therefore the unity of being, as rightly requested by the advocates of the univocal thesis, but setting this unity not within the being itself but rather in its complexity. He was the first to talk about substantial unity, the unity of the substance.
This rather complex ontology was later to be adopted by Christian philosophers and theologians such as Saint Thomas, who further developed this intuition, giving a reasonable explanation for one of the most profound mysteries of the Christian religion, which was the resurrection of the body. In Christian faith it is held that soul and body, separated because of death, will reunite when the Resurrection takes place. The human body gains a brand-new role in Christian thought. It is not a prison of the soul anymore, as it was in Greek philosophy, nor it is the only true being that constitutes us, so that when it has gone, we are not there anymore.
Christian thought somehow managed to keep together by means of faith two otherwise opposite views on this matter: this topic is explored at length in two other entries devoted to the topics of Soul and Resurrection.
The Christian view can no longer be a dualistic ontology, since this would have lost the created body. It could not be a monistic one either, since this would have bound God too much with His creation, somehow divinizing the world or humanizing God. In both cases we would have what has been called Immanentism. The solution came from Aristotle and his analogical theory of being. He managed, following the thinking of Plato, to keep being and not-being together in the unity of things that are. This is what is technically called the analogy of being, that is, seeing that the aspects according to which something changes are simply aspects of that change, and that not everything changes when a mutation occurs. Something changes, and something does not. Thus, there is a kind of not being, not being this aspect anymore, which is compatible with the original being, and somehow the otherwise deadly contraposition between being and not-being has been reconciled. There is a possible sense of not being, which is not self-contradictory, and this was the ground for the idea of analogy. Being was not to be conceived monolithically. It rather had to be thought of as the composition of being and the relative not being.
On this renewed ontological ground, it became possible to think of death not as something inconceivable, but rather as something relative. Christian philosophy, built on Aristotelian ontology, achieved the goal of making death a possible topic of human inquiry.
A different stance will be taken by modern thinkers such as Heidegger and Sartre, authors who did not share the perspective of classic metaphysics or of empiricism, and who described the anguish death brings about when we start to think about it. The emotive tonality of death these authors pointed out comes from the lack of meaning they attribute to death. Death ceases to be a transitional stage or the end of everything to become an irrational absence of logical life, a sort of pure nonsense. Modern authors as such, rejecting Christian ontology, also rejected the logical coordinates which allowed to make sense of death, and coherently devoted their energies to the description of the human condition in such an irrational situation. But what made this condition not rational and not bearable was the underlying nihilistic ontology.
Heidegger’s stance on death has been of great importance in the last century. He agreed with Plato that “to philosophize is to learn how to die”, but he went on and thought death was somehow the real marking point of human nature, therefore the attitude men have toward their own death is what makes the difference between authentic life and “fake-one”. Being-toward-death is the definition he gave to this attitude to describe the authentic relation of men with their own nature. The ontological status of this thought is deeply rooted in Heidegger’s thesis according to which “Higher than actuality stands possibility”. This reverse of classic Aristoteles’s metaphysical tenet leads Heidegger to look at death not as something to be worried about, but as the horizon that makes possibilities come true, he expresses this point through the famous paradox: “the possibility of impossibility”. The preeminence accorded by Heidegger to potency rather than actuality is not undisputed on the ontological ground, as a matter of fact most of Heidegger ontology is framed as an objection to Aristotle ontology, that he thought to be an ontology of the simple presence. It was not, many scholars have shown Heidegger’s critique on classic ontology fails its target, since it would be incorrect to label ancient reasoning on being under the category of “simple presence”, nevertheless Heidegger's thought about it gained a quick fortune in the last decades. Actually his thought on this topic has lost part of its appeal, since the whole ontological debate on the subject has changed object.
Thus, to be able to speak about the being of death, what kind of an object death is, the philosophical solution was to adopt an analogical ontology, because neither the univocal nor the equivocal would have been fit to deal with a reality which has such an ambiguous status, while the analogical allows to see it in different respects as something that is initially and is not anymore in a later time. Analogy, so to speak, provides the means to overcome the otherwise impossible boundary of the absolute not-being, nothingness, making it a nothing-about-something, that is a relative negation of something.
To put it in less philosophical terms, death is a means of change. It is the end of something and the beginning of something else. Some unity fails to persist and divides itself in a multiplicity of parts on another scale of magnitude. Think of an organism that ceases to be a living organism, but whose parts (organs) keep on living to a lesser degree of unity, until the decomposition process has terminated.
III. Death and biology
It may seem curious, to say the least, to reflect on the biology of death, since biology should be the science of life rather than death, but it is not. The apparent paradox fades away once we consider that biology addresses the issue of life conceived as life of a given species and for a species to live it is necessary that the individuals who constitutes it die, making room for new ones.
This consideration allows us to understand even why death has been so often bound to reproduction. Generation is somehow the biological goal of every species and to make this possible, death has to be programmed. The specific biological concept to describe this event is apoptosis (ἀπόπτωσις falling off/down) which means on the cellular level a form of programmed cell death that occurs in multicellular organisms.
What happens if this “mechanism” of programmed death fails and cells do not die, like in cancer, is that the whole organism dies. Therefore, in a way we can trace quite a clear analogy between the death of individuals among the species and the programmed death of cells within the organism for both deaths are somehow connected with the survival of a broader level of life: species and organism are more than individuals and cells. This line of biological reasoning helps explaining the important difference between a natural, biologically programmed death, and a violent one, the former being a necessary step in the logic of the biology, while the latter is not.
Of course, it can be argued that more often than not animals die for violent causes such as being eaten by other animals, and that is undoubtedly true. Nevertheless, these are “violent” and yet perfectly natural deaths, since to be eaten by other animals serves both the purpose to keep alive different species and to maintain the ecosystem balanced. Even in this case, similar to the case of cells and organism, we see death as means to a greater end. Death by human violence, that is the specific violence connected with human nature, that is a completely different topic.
In this respect death in biology is a necessary mechanism useful to keep life going on, a necessary means to the superior end of living.
Aristotle himself in his foundational work on biology, De generatione et corruptione, struggled a great deal with the notions of coming-into-being and passing-away. His reasoning made clear that ceasing to be cannot be an absolute turning into nothing, because, if that were the case, it would not be possible to have a living world at hand: everything would have turned into nothing long before. Experience bears witness to a different conclusion. Therefore, he had to postulate the existence of a prime matter, a substratum which persists while a substance gives rise to a totally new form.
Leaving aside the complex and debated issue of prime matter, we can see the topic of death in its original place and the theoretical problems it gives rise to. It is difficult to deal with death properly because of its commingling with not-being. But then again, the solution comes from the distinction between different kinds of not being: relative and absolute, the former linked to accidents, the later to substance, and substance to prime matter.
What “matters” in the Aristotle’s discussion is the idea that either generation and corruption, which is another name for death, need to be grounded on some higher metaphysical principle, since if they were not, we would have nothing to look at right now. Thus, in some way, death is another word to indicate a form of change, a kind of mutation of something that persists through the whole chain of becoming. This is what the otherwise a bit bizarre idea of prime matter accounts for. And it is also the meaning of the famous preface to a Christian funerary rite that says: vita mutatur, non tollitur (life is changed, not taken away).
The profound problem examined by biology is how it happens that something that was live and real until a given time, later is not anymore. It tries to answer the question ‘where did it go?’ The answer it gives is: ‘it became something else, not totally disconnected from what it previously was, but another thing’. This change could only be addressed from an ontology which could speak about change without losing its grip on being: this was what the Aristotle’s idea of analogy accounted for.
IV. Thanatology: the science of death and clinical criteria for determination of death
Closely connected with the previous paragraph is thanatology or the science of death. What kind of science is this? We can see from its suffix “logy” that it is a descriptive science indicating that it is a thorough description of the signs commonly occurring while death is happening.
Since dying is a process, the problem of the thanatologist is to ascertain when exactly death happened, and this precision is needed for many reasons, most of them coming from the forensic domain. It may be important for legal reasons to know when and how someone died, but even for medical reasons, for example transplants, it is important to understand when we can consider someone truly dead and when we cannot.
The usually neglected point in this kind of study is the nature of the “time of death”. Looking for the exact time of death means to give a sort of chronological flag to the event of death, while death and dying, as a biological process, cannot be interpreted in that way. Biology teaches us that every living being has its own life rhythm and therefore its own death rhythm. The need to give a chronological time in hours, minutes and seconds serves legal purposes and pragmatic necessities, but it fails to recognize the nature of the phenomenon under scrutiny here.
Nevertheless, it is useful and at times dutiful to inquire in detail about how the dying process proceeds out to better understand the causes that lead to the end. This is much more important when death occurs not for natural causes, but for violent ones, in such cases to determine the exact chain of events that lead to death can help the investigator cast light on the causes of death.
As we know, the history of criteria for ascertaining death reflects progress regarding knowledge about life and its mechanisms. As long as breath was held to be the primary cause of life, according to the ancient Aristotle’s biology, breathing was looked upon as the marker for ascertaining death. Ancient physicians used to put a little mirror in front of the mouth or under the nose of the supposedly dead person to check his breathing activity. If none was revealed, then the person was declared/recognized dead.
The more medicine learnt about the functioning of primary bodily functions, the more the ascertaining criteria changed, so that once the circulatory system was well understood the standard for determining death became the lack of a pulse beat.
Regarding the neuro-psychic functions that determine the so-called facies hippocratica, that is, the facial expression once all vitality has deserted the body it also began to be studied
It was in the 1960s that medicine changed its view on death as a result in part of new knowledge about the nervous system and, more so, of new technology both for diagnosis, like EEG (electric encephalon gramma) and treatment, like machines for extra corporeal circulation. According to the new guidelines generated by these developments, death was ascertained in a patient by unreceptivity and unresponsiveness, no movement (observed for one hour), apnea (three minutes without breathing), no reflexes (both brain stem and spinal) and flat electroencephalogram which was an important confirmatory tool. In addition, it was compulsory to rule out hypothermia (body temperature ≥32o C) and the use of CNS (central nervous system) depressants. All tests had to be repeated after 24 hours. These were the famous Harvard criteria.
When organ transplants entered into medical practice, it was established by the American Medical Association (AMA) that those in charge of the organ explant could not be part of the team ascertaining the death of the donor, to avoid a conflict of interest among members of that team.
The fact that technology provides the tools both for diagnosing the cessation of life functions and for keeping people alive who otherwise would be dead raised a heated bioethical debate in which prolonging life artificially and organ explant to save other lives seemed irreconcilable. This situation made it more compelling to define death in a clear-cut way. Although a precise definition of death is not possible since the nature of death defies such a treatment, practical reasons urged an agreement at least on the criteria for ascertaining death.
In 2012 in Montreal the World Health Organization released the International Guidelines for the Determination of Death. The document made an effort to produce an operational definition of death:
“Death occurs when there is permanent loss of capacity for consciousness and loss of all brainstem functions. This may result from permanent cessation of circulation and/or after catastrophic brain injury. In the context of death determination, ‘permanent’ refers to loss of function that cannot resume spontaneously and will not be restored through intervention”.
The struggle among different schools about which organs should be considered more relevant for detecting death, whether the cardiopulmonary system or the brain’s, somehow reflects the kind of anthropology we are adopting. The whole brain criteria, that is the idea that someone is recognized as dead when all the brain functions can no longer be detected, shows an organismic approach whereby death is the irreversible loss of functioning of the organism as a whole.
It is important to stress the whole as the criterion for the ascertaining of death, because it is the more debated philosophical point at stake. For we cannot possibly have a clear definition of this whole. We can argue the signs that can show its unity analogically, but they cannot be considered more than signs.
V. Death and cultures
Whether we look at death as a biological concept or consider the criteria for ascertaining death, death needs at least a logical definition. Considering that definitions and criteria are cultural phenomena, in order to move closer to a definition of death, we need to explore it from a cultural perspective.
If we agree that death and dying carry a further meaning beyond the physical one, then there cannot be anything like a ‘natural death’ where ‘natural’ stands for a not artificial way of dying. More broadly, the distinction between natural and artificial when applied to the human sphere fails to account for specifically human phenomena, which are always somehow not merely natural, but a comingling of nature and culture.
Every culture is born from the establishment of a funeral cult. The need to take care of one’s dead led to the institution of cultural practices, rites, and funerary arts that eventually became the roots of culture. One example is the thorough description Homer gave us of the burial of Ector. Further back in time, Plato describes death as the only real ‘concern’ of the philosopher, and more deeply philosophy itself as the primary effect of the reflection on death.
Cultures arise from the meditation of death and from the answers man gives himself to this unsolvable mystery. Saying that death is not just the occasion for cultures to display their own funerary rituals, but that it is the core, or the engine, of culture itself is historically founded. According to Eliade’s studies on traditional archaic societies, where the myth of eternal return was first elaborated and took root, we see that this figure was devised as an exorcism in the face of the terror of annihilation. Ancient man attached himself to myths and ancestral traditions to face his fear of death.
It was the Christian tradition that allowed a whole different approach to the theme, setting death as a step into the real life, a life never to be lost. Before Christianism, Greek culture had other approaches to the theme of death such the Orphic Pythagorean tradition which clearly divided the fate of the soul from that of the body, the latter truly subdued by death, while the former survived it. This strong tradition was later rethought by Plato and his scholars in a dualist anthropology, where the soul is seen as imprisoned in the body and therefore dying is nothing more than the liberation from this corporeal jail.
Christian religion, while accepting many aspects of Platonic philosophy, did not accept its devaluation of body. For Christian doctrine is very clear about the fate of body which will resurrect at the given time. This doctrine opposes all speculations that somehow underestimate the material world. In fact, the thesis devaluating the material world was once considered explicitly heretical. It was the well-known Manichean heresy, according to which matter was created by an evil god, and death was part of this bad part of the creation, while the soul and the immaterial world were part of the good one.
The strong connection between culture and death is quite clear from anthropological studies understood today mostly as the sociological study of death/mourning rituals occurring in different cultures, reminds us of the unavoidable link between these two domains.
In Evangelium Vitae, written in 1995 by S. John Paul II, we find defined the concept of culture of death: “This reality is characterized by the emergence of a culture which denies solidarity and, in many cases, takes the form of a veritable "culture of death". This culture is actively fostered by powerful cultural, economic and political currents which encourage an idea of society excessively concerned with efficiency. Looking at the situation from this point of view, it is possible to speak in a certain sense of a war of the powerful against the weak: a life which would require greater acceptance, love and care is considered useless, or held to be an intolerable burden, and is therefore rejected in one way or another”.
The expression “culture of death” occurs twelve times in the document and indicates a precise model of society where death has become the solution to certain ethical problematic issues rather than a mystery to be accepted and contemplated. We have moved somehow from the idea of death as the engine of culture to that of death as the goal of culture, reaching a sort of metaphysical perversion of meaning which needs to be understood.
Christian culture elaborated an approach to the good way of dying, but then again death in such a perspective has to be seen as the entrance to the never-ending life, so life is again at the center of the scene in this framework. This is the reason Christian teaching on matters regarding death traditionally shows what technically is named favor vitae, ‘in favor of life’. The fact that the idea of life is not a merely biological one allows Christian doctrine even to evaluate and avoid extremities such as therapeutic obstinacy, as we will see here below.
It is worth considering Philippe Aries’ classic work on this theme “Western Attitudes toward Death, from the Middle Ages to the Present” (1974) that addresses the role death played in the last centuries. Aries shows the paradigm shift western culture underwent from the idea of “familiarity of death, with neither fear nor despair, halfway between passive resignation and mystical trust”, to that of being somehow unnamable. This movement between a sort of confidence with death to that of dramatic distance with it is explained by Aries in terms of a change in the anthropological understanding of the self. The modern self was no longer a public subject, it started to be thought as something more intimate, whose actions mattered more, whose being was yet to be fulfilled by means of his actions, and consequently death started to be seen as a sort of deprivation, a cruel limitation to the human potential “the possibility of impossibility”.
In the previous paragraphs, it has been noted how the question of death criteria arose within the technological boost Western society has been through. This technological framework is much more than a simple amplification of technical faculties, it brings with it a whole new way of thinking where efficiency and utility come first. This new mindset is rapidly changing the way life, and therefore death, are understood, and this new understanding sees death as a practicable way out when suffering, or even just the “quality of life”, is considered to be unacceptable. These new questions are entering into disciplines like bio-politics, bioethics, and medical ethics.
VI. Death Ethics: ethical questions regarding death
Abortion, capital punishment, assisted suicide, euthanasia, organ transplants, just to mention a few, are the issues at stake when we talk about the ethics of dying.
All these subjects inhere the nature of death. Taking organ transplants as an example, the issue is framed within the simultaneous need to have “living organs” and “dead donor”. This need creates the problem of determining the time and place of dying with precision, and yet, as we have seen, this is not possible.
The Aristotelian framework describes death as the separation of the soul form the body, taking the soul as the organizing and unifying principle of the body. From this perspective both dominant criteria of death, brain death and circulatory death, are metaphysically inadequate since they reduce life to one organ, no matter how important this is. From this perspective, the only sure sign of death should be the body’s decomposition, which is useless for the purpose of organ transplantation. The challenge for the future therefore is to find either a way to harvest organs from truly dead bodies that will function in new ones, or to rebuild organs from the patient’s own tissues. This second option avoids both the ethical and the immunological rejection problems of the first.
In the case of abortion, the ethical question regarding the death of the embryo is whether the zygote can be legitimately considered a human being or not. Those in favor of this practice tend not to consider the ontological structure of the question and focus rather on the tension between the rights of the mother and those of the child, according to the former more weight than to the latter. Others in favor of this practice, since they understand that the metaphysical and ontological status of the zygote cannot be undermined, take a different path, arguing that in some case killing should not be considered illegal, and therefore argue that death under specific circumstances should be thought of as a legitimate choice. This course of reasoning, though having a greater internal coherence than the other, is less likely adopted among the pro-choicers, since, no matter how it is justified, the moral quality of the action is that of killing, and this leaves a moral stain on those who take that path.
With capital punishment, the debate on dying focuses on whether there is a right to inflict death upon a guilty person or not. Death here becomes an instrument of justice, while in the previous situation it was an instrument of autonomy. Both these instrumental conceptions of death are highly problematic even though they cannot be equated, since one thing is punishment for one’s misdeeds and another is the death of an innocent being. But the points to be discussed at the ethical level are weather death is a possible moral instrument, and weather is it right to employ it as such. Usually to these questions the answers are of three different kinds: those who see life as an absolute value will answer no; those who share a more naturalistic approach to values in general will most likely say it depends; those who hold a contractualistic view of values would probably say yes in principle, and then argue about which circumstances are acceptable. Thus, the answer to this question depends on which definition of life we hold and what binding value we accord to it.
Euthanasia is a modern word coined from εὖ, eu, (‘well’ or ‘good’) and θάνατος Thanatos (‘death’). The ‘good death’ it refers to is specifically the painless inducement of a quick death. Ethical questions, related to this “induction” are: is the physician who induces a quick, painless death helping the patient or killing him? Is killing part of the job of a physician under particular circumstances? Is killing always wrong? These are just a few of the questions that can arise in relation to euthanasia.
Usually those in favor of this procedure appeal to the controversial “right to die” that, in their opinion, should be specular to the well-recognized right to live. Arguments adopted to defend this position are concerned with the right to refuse care, the caregiver’s burden, and organ transplantations. Arguments against this practice consider the practice a masked way to induce the elimination of the invalid, malafide intentions, a slippery slope toward suicide, the commercialization of health care.
What emerges from this discussion is that death tends no longer to be considered as a fact, but as a right, albeit a disputable one. This semantic shift is important since it changes, or at least attempts to make change, the very nature of a phenomenon which has a proper identity.
At the root of the ethical issues regarding euthanasia is the question: is there a right to die, and therefore a duty to kill? If there is a right to live, there should be, as there is, the duty of someone to keep you alive. According to the same logic, if there is a right to die, there should be a duty of someone to kill. There is however no symmetry to justify this logic. It is true that both life and death are natural processes, but they stand on different biological and metaphysical grounds, so that while there is a whole sphere of values connected to life, there is not a corresponding sphere connected to death. As we have seen, the approach a favor vitae, favors life over death. This situation reflects the metaphysical thesis according to which the being (life) is not at the same level of the not-being (death).
The counterargument to this course of reasoning is the one rooted in the concept of the dignity of dying and concerns itself with alleviating the pain and suffering of devastating injury and illness. The central idea of this reasoning is that dying, and therefore to cause death, is sometimes the right thing to do, since to continue living is a burden too heavy to bear, for the patient and those around them, family, health care system, society. All these arguments are rooted in the ‘quality of life (QoL)’ category. When someone’s life does not fit the QoL indicators, elaborated somewhere else by someone else, then the physician should be entitled to dismiss the patient’s life that is thought to be not so worthy to be lived anymore. Of course, there are also the arguments rooted on the principle of autonomy, which states that the patient will must be respected above all, but this kind of argumentations do not address specifically the moral object of dying per se, they just explicit who, according to the autonomistic perspective, should be in charge of the final decision. If the decision itself is right or wrong, respects the nature of death or not, is left apart, this is why it is not considered in this entry.
As we have seen in the case of abortion, arguments in favor of euthanasia appeal to the ideal of autonomy. These arguments, although emotionally appealing when accompanied by depictions of the suffering of patients in critical conditions, are flawed since as in every other circumstance the simple desire for autonomy of choice is not sufficient to be authorized to exercise that autonomy. The desire to not suffer is unobjectionable, but desiring not to suffer and desiring to die are two different things. The first is the object of palliative cares, the second of euthanasia. In principle, desire and choice are not per se arguments related to dying. It is the object of the desire and wish that morally qualifies the action desired. Death can be the object of desire, but it does not follow automatically that it should be granted. The ever-growing field of palliative care sees euthanasia as medically relevant as a symptom of something gone wrong in the managing of pain that needs to be fixed.
From an ethical point of view, it is not enough for something to be an object of desire, or choice in order to be considered good. The goodness of an action depends on three specific elements: intentions, moral object, and circumstances, so autonomy or desire per se do not have a superior ethical relevance. Of course, they are important conditions to be taken into account, but cannot be considered the final word on the matter.
Death is a very complex topic. It stands at the beginning of human culture. The answers we give ourselves to the mystery death opens up change the way we live. Religions, philosophies, science and every human endeavor try to make sense of it, and yet none of these can give an unquestionable answer. We can measure the compatibility of the answers provided by different disciplines with what reason can tell us about it (that is, very little), but in the end there is no epistemic assurance for whatever sense we make of it.
An honest reasoning about death should recognize the insufficiency of the intellect in this inquire and at the same time it should have the courage not to dismiss such a difficult question. Ancient wise men warned us that death is something to contemplate, to ponder, to get prepared to, something we need to think about, not just something to fully understand or properly define, so that we can deal with it. Today we are influenced by modern science and philosophy that strive to obtain clear cut definitions and precise ideas. But death does not lend itself to typical scientific and objective treatment. This is partly why today it is so difficult to talk about death. We have lost somehow the vocabulary to talk about it. Faith which offers ways of understanding mystery provides language for talking about death that respects the mystery of its nature.
As we have seen in the ontological section, it is only through analogy that we can talk about death. It is neither by means of clear-cut definition, nor by means of mere poetical images, that it can be defined. It cannot be analyzed by means of logic or rational discourse. To talk about it entails necessarily taking a stance we cannot fully justify. We have to make a choice and we lack the proper knowledge to make it. This is the riddle we have to face when we measure ourselves on such a theme.
From the ethical/legal perspective, in order to understand the rapidly changing landscape that death brings about, it is mandatory to put it in relation with the changes science and technology are introducing in society. New disciplines have arisen in recent years brought about by technological advancements, examples being Bioethics, Neuro-ethics, Roboethics. Each one of these new disciplines deals with the new scenarios technology has created and the new moral issues it has brought to light. Death has followed this path too. Questions regarding euthanasia, or therapeutic obstinacy, would not have been conceivable if it were not for the technological advancement that made it possible to keep people alive who otherwise would be dead. Without the heart-lung machine we would never have seen ethical dilemmas typical of these discussions.
As we are well aware, technology has not changed the nature of death but rather the way of dying, and even more the perception of death and dying. Before the advent of life saving machines like the ones previously mentioned the problem itself of prolonging life would have no place to be discussed.
Thus, technology has brought to life new and unpredictable scenarios. It has changed our way of looking at natural phenomena, since now these phenomena have been deprived in some way of their natural end, and what once was just a natural course of events, today can be an object of choice. This consideration works for gene editing as well as euthanasia, organ transplantation and so on.
Technology applied to death brings a sort of narcotization of the very concept of dying. The aim of modern technology is to control the surrounding environment. Death on the contrary is the very essence of what cannot be controlled, so that somehow the only kind of control to be exerted on death is its timing. Part of the appeal that euthanasia plays for those who accept to undergo its treatment is due to the ‘false’ idea of control it offers.
The total loss of control that death brings can generate a very distressing anguish, as thinkers like Kierkegaard and Heidegger well knew, so that to be able to know exactly what is going to happen, when and how, somehow has the power to calm people in pain. The idea of entering into a well-known protocol, into a well-tested system, helps sick people cope with the fear death necessarily involves.
Technology has brought a radical paradigm shift into our lives: the idea that we can exert control even upon things that are by definition out of our control. This illusion is not to be addressed to Technology as such, but rather to the ideology that often goes with it: techno-scientism, that tries to resolve mysteries in problems, giving the false impression that everything can be rationalized, dominated, put under complete control. This set of ideas are neither scientific neither technologically true, since science knows all too well its epistemic limits, and technology has never pretended to be able to control everything.
In the end, we can say that death is a figure of life, a figure of its necessity to change at different levels. Its ontology entails the idea of changing and that of persistence. Despite the many attempts to give detailed and specific accounts of what happens next, it is not scientifically possible to say something about the after-life. In this respect, death remains a mystery, and every attempt to make it happen cannot be scientifically supported, since there is not available evidence in favor of any thesis. From an ethical point of view, this lack of evidence needs to be taken into account by those who aim to practice science or disciplines rooted in science, like medicine.
From a moral stance, every attempt to reduce the mystery to a matter of choice fails to understand the object of choice, which cannot be the denial of the very possibility to choose. Of course, suicide is always a possible action, but this concrete possibility does not speak in favor of its moral legitimacy, for many bad actions can be performed without being morally admissible. Facts cannot be considered rights.
Council of Trent, DH 1511-1512; Pius XII, Answers to some Questions Concerning Reanimation, 24.11.1957, Discorsi e Radiomessaggi XIX, pp. 615-621; Gaudium et spes, 18, 41; CDF, Letter on certain questions regarding Eschatology, 17.5.1979, EV 6, 1528-1549; CDF, Declaration on Euthanasia, 5.5.1980; Pontifical Council “Cor Unum”, Some ethical questions concerning the dying, 27.6.1981, EV 7, 1234-1281; Meeting of the Pontifical Academy of Sciences, 21.10.1985, “Ethical, medical and legal questions on the artificial prolongation of life”; ICT, Contemporary Questions on Eschatology, 16.11.1991, EV 13, 448-572. John Paul II: “Only a true cultural choice can effectively oppose euthanasia”, 6.9.1984, ORWE 24.09.1984, p. 9; Discourse to a Congress on determining the moment of death, 14.12.1989, ORWE 8.1.1990, pp. 10-11; Discourse to the XVIII International Congress of the Transplantation Society, Roma 29.8.2000, Evangelium vitae, 64-67, 105.
P. ARIES, Western Attitudes toward Death, from the Middle Ages to the Present (London: Marion Boyars, 1974); A. BELTRAMELLO et al., “Updates in the Determination of Brain Death”, The Neuroradiology Journal 23 (2010), pp. 145-150; B. ALBERTS, A. JOHNSON, J. LEWIS, D. MORGAN, M. RAFF, K. ROBERTS, P.WALTER, Molecular Biology of the Cell 6th ed. (New York: Garland Science, 2015); ARISTOTLE, De Generatione et Corruptione, ed. by C.J.F Williams (Oxford: Clarendon Press, 2002); T.L. BEAUCHAMP, A.I. DAVIDSON, "The Definition of Euthanasia", Journal of Medicine and Philosophy 4 (3) (1979) , pp. 294-312; L. BECKER, “Human Being: The Boundaries of the Concept”, Philosophy and Public Affairs 4 (1975), pp. 334-59; J.L. BERNAT, “How the Distinction between ‘Irreversible’ and ‘Permanent’ Illuminates Circulatory-Respiratory Death Determination”, Journal of Medicine and Philosophy 3 (2010), pp. 242-255; A.M. CAPRON, “The Bifurcated Legal Standard for Determining Death,” in S. YOUNGNER, R. ARNOLD, and R. SHAPIRO (eds.), The Definition of Death: Contemporary Controversies (Baltimore, MD: Johns Hopkins University Press, 1999), pp. 117-136; COMMITTEE OF THE HARVARD MEDICAL SCHOOLV to Examine the Definition Brain Death, “A Definition of Irreversible Coma”, Jama 205 (1968), pp. 337-40; D. DE MARCO, Architects of the Culture of Death (San Francisco: Ignatius Press, 2004); M. ELIADE, The Myth of the Eternal Return, or Cosmos and History (Princeton: Princeton University Press, 1971); EPICURUS, “Letter to Menoeceus” in The Essential Epicurus, trans. Eugene O’Connor (Buffalo: Prometheus Books, 1993); E. FESER, J. BESSETTE, By Man Shall His Blood Be Shed: A Catholic Defense of Capital Punishment (San Francisco: Ignatius, 2017); A. GAWANDE, Being Mortal, Illness, Medicine, and What Matters in the End (London: Profile Books, 2014); B. GORDIJN, “The prevention of euthanasia through palliative care: New developments in The Netherlands”, Patient Education and Counseling 41 (1) (2000), pp. 35-46; D. GREEN, Means to an End: Apoptosis and other Cell Death Mechanisms, (Cold Spring Harbor, NY: Cold Spring Harbor Laboratory Press, 2011); P. HADOT, Philosophy as a Way of Life: Spiritual Exercises from Socrates to Foucault (Malden, MA: Wiley-Blackwell, 1995); M. HEIDEGGER, Sein und Zeit, in Heidegger's Gesamtausgabe, vol. 2, ed. by F.W. von Herrmann (1977); H. JONAS, The phenomenon of life: towards a philosophical biology, (Evanston: Northwestern Univesity Press, 2001); S. KIERKEGAARD, The Sickness unto Death (Princeton: The Princeton University Press, 1983); I. MACDONALD, “What is, is more than it is: Adorno and Heidegger on the priority of possibility”, International Journal of Philosophical Studies 19 (1) (2011), pp. 31-57; S.B. MATH, S.K. CHATURVEDI SK, “Euthanasia: Right to life vs right to die”, Indian Journal of Medical Research 136 (6) (2012) pp. 899-902; D.S. ODERBERG, “Death, unity, and the brain”, Theoretical Medicine and Bioethics (2019); M. PERNICK, “Brain Death in a Cultural Context: The Reconstruction of Death, 1967-1981,” in S. YOUNGNER, R. ARNOLD, and R. SHAPIRO (eds.), The Definition of Death: Contemporary Controversies (Baltimore, MD: Johns Hopkins University Press, 1999), pp.3-33; PLATO, Euthyphro, Apology, Crito, Phaedo, Phaedrus, trans. Harold North Fowler, The Loeb Classical Library (Cambridge, MA: Harvard University Press, 1960); H.M. ROBINSON, “Prime Matter in Aristotle”, Phronesis 19, No. 2 (1974), pp. 168-188; J.P. SARTRE, Being and Nothingness: A Phenomenological Essay on Ontology, (London: Routledge, 2003) ; W.J. SMITH, Culture of Death, The Age of “Do Harm” Medicine (London: Encounter Books, 2016); W.J. SMITH, Forced Exit, Euthanasia, Assisted Suicide, and the new Duty to Die (New York: Encounter Books, 20069; A.M. DE LIGUORI, Preparation for Death: Considerations on Eternal Truths (Veritatis Splendor Publications, 2013); V. TAMBONE, G. GHILARDI, “An Ethical Evaluation Methodology for Clinical Cases”, Persona Y Bioetica 20 (1) (2016), pp. 48-61.