An important issue that arises from reading a recent editorial published in this periodical (Wein, Reference Wein2010) about dying with dignity – bearing in mind the semantic root of the word hospice and the significant foundation of unconditional hospitality (Saunders, Reference Saunders and Feifel1977; Floriani & Schramm, Reference Floriani and Schramm2010a) – is related to the delicate question of to what extent the modern hospice movement will be able to fully serve those patients who deviate from the norm (Parsons, Reference Parsons1951); in other words, those who do not simply go along with what they are told will happen. In this case, those who would like – legitimately, one should consider here – to fight to the end, with the use of continuous and persistent interventionist practices. In my opinion, this is one of the major internal challenges faced by the hospice movement at this historic moment, in which it is becoming increasingly visible and widespread around the world, resulting in an intense interface with the biomedical paradigm, grounded in the know-how of its routinized and medicalized practices. This interface has brought undeniable consequences, both positive and negative, one should say (McNamara et al., Reference McNamara, Waddell and Colvin1995; Menezes, Reference Menezes2004), but we are still unable to ascertain the real impact of those consequences on the hospice movement.
However, despite this provocative question proposed in the editorial, my attention was drawn to another aspect, about which I would like to present some considerations.
As regards the conceptual difficulties surrounding dignity (Bayertz, Reference Bayertz1996), and in relation to the contradictions that may result from its use as a battle flag by the hospice movement (Sandman, Reference Sandman2002; Billings, Reference Billings2008), I would like to add a third possibility to the polarized themes often observed when discussing the so-called “dignified death,” “dying with dignity” or “dignity in death.”
In this context of the “journey of death,” as well as the supposed “passive acceptance” of death and “fighting to the end” — the two possibilities described in Wein's text — a third way of facing death could be presented: death as an enemy to be faced in a battlefield displaced from its physical sphere. In this case, it would be neither a matter of fighting for one's life, of wanting to survive at any cost, nor of a passive acceptance of death (if indeed accepting death passively is actually possible), but rather of a specific kind of struggle to not be defeated by death, although the patient knows that he or she is going to die: a fight taken on in the deepest fathoms of human nature, a fight that gives sense and will to those who face it, a fight to not succumb to death, a will to transcend it. In other words, for this type of struggle, the fight will not be against death, but rather with death.
This is one of the meanings of kalothanasia, a disposition that can be seen in certain patients who, so to speak, “escape” the said dichotomy often seen in patients on death's threshold. This virtuous mode of handling death (kalós thanaein) by the battling patient removes the whole external and misleading look of resignation and endows that patient with an inner will of extreme courage.
It is relevant to point out that kalothanasia can also be seen as an important set of behaviors and trends on which the modern hospice movement is grounded (Kellehear, Reference Kellehear1990; Floriani & Schramm, Reference Floriani and Schramm2010b). It constitutes an underlying layer that disseminates a set of compassionate and transformative care actions for the dying person, within a context that does not depend upon the way in which each patient faces death and dying. This typical will of kalothanasia can be found, for example, in the words of Twycross, when he says that “terminal illness should not be regarded as an intrusion into life; it is part of life and can be a time of increasing maturity and deepening spiritual experience for all concerned. It is our job as doctors to help it be so” (Twycross, Reference Twycross1975, p. 21).
Therefore, regarding the discussion about the dignity with which a patient faces the “journey of death,” notably when the verge of death, this third mode of facing death should be considered: as well as a “fight to the end” and an “end to the fight,” one can visualize a “fight to beyond death.”
