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Dead HeadsWhy doctors are bad at mortality.

By Kent Sepkowitz Posted Thursday, March 1, 2007, at 3:14 PM ET

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Ron Rosenbaum explored Elisabeth Kübler-Ross's lesser-known views on death. Doctors have taken less diffident approaches toward dying patients: Mickey Kaus took on the issue of seeking "good deaths" in hospitals in 2000, and Michael McConnell and Ronald Dworkin chatted about assisted suicide three years earlier. Daniel Engber explained the Oregon "Death With Dignity" law.

In fact, doctors aren't bad at handling the details of dying. We know how to ease pain, promote comfort, and arrange the medical particulars. But we are disasters when it comes to death itself, just like the rest of the human species. (Morticians often have the same problem.) I admire Chen's and Stein's pep-club optimism, but they might have integrated Ernest Becker's seminal Denial of Death into their discussions. Becker's basic point is that all of human behavior can be traced to our inability to accept our own mortality. Cowards that we are, we not only refuse to consider our own inevitable death, but our patients', too: We duck the tough discussions, flinch and flutter and order another test, and finally leave it to a (usually much younger) colleague to sit down with the family. We don't slink away because we are bad people; we slink away because we are people.

Becker also is curiously absent from How We Die, Sherwin Nuland's examination of death—a work that has made him the godfather of death books. Yet despite the omission, Nuland succeeds where Chen and Stein fall short. Here's my explanation: Nuland was not young when he wrote How We Die, and unlike Chen and Stein, he was not trying to reform American health care. Rather, he wrote with the panic and urgency of someone who sensed his own upcoming deadline, giving us a kind of What To Expect When You're Expecting To Die. He admits to doctors' yellow streak, pointing out that medicine is "more likely to attract people with high personal anxieties about dying." We are the ones seduced by the irrational belief that knowing about a disease will prevent it. Instead of a quick fix for our weaknesses, Nuland envisions patients making the big decisions with their loved ones, informed and advised—not directed—by their doctors. In other words, he reduces doctors to their proper supporting role. (Nuland also has a new book out about aging.)

I agree with Nuland that doctors' failure to deal well with their patients' deaths is not a bad habit that can be corrected by medical-school remediation. Doctors and patients would be better served if we stopped sophomorically pursuing the "good death" reassuringly reducing the end of life to another commodity subject to adjustment and negotiation. Instead, we should do what we can to make the dying and those who survive a tiny bit more comfortable when the time comes. As doctors, we should ease pain; as humans interacting with other humans, we should console those who are anguished as best we can because it is the right thing to do, not the professionally optimal approach. This modest goal is all we can hope to accomplish—but still seldom do.