Why do humans have to learn how to die?

We are not taught how to crawl, yet we learn how to cut hair. We are not taught how to see, yet we learn how to speak.

Animals also learn. For example: a mother cheetah will catch a live antelope and bring it to her children to practice hunting. And: a parent dog will nip a puppy for discipline.

Nevertheless, the proportions of innate and acquired knowledge between animals and humans are vastly different. Animals are born with most of life’s skills encoded. Humans are born naked.

A natural history item of interest. In the wild, dying, or dead animals are rarely seen lying around. There are at least 2 reasons. When an animal is feeling sick or weak, it will hide out of sight to self-protect – or maybe, with an intuition, to die dignified. The other reason is that scavengers efficiently smell or spy a dying animal and quickly clean up the remains. Humans have a more complicated relationship with corpses.

In the past, our passion to live was no less. The average lifespan was maybe 40 years, though if one survived childhood, the life expectancy was 50 or 60 years. Compared with today, life had to be lived hurriedly. Take Mozart. He died aged 36 but achieved immortality. Beethoven’s penultimate words on his deathbed, aged 57, were: “Applaud friends, the comedy is over.” One senses that there was a greater acceptance of fate and death. People knew how to die. Maybe because there was less of a choice. Medical advances have lengthened life and created hope and expectation (Wein Reference Wein2004), which in turn has created neuroticism. We are anxious because we have something about which we can worry – our prognosis.

I recall a young man who lost his wife. We visited him afterwards and he stated – “I cannot change anything, this is the reality, like a brick wall.” When faced with this wall, as a certainty, we as a species are capable of accepting our fate, even unto death. Life stories, patients, and the elderly teach us this truth. It is unsurprising that we are genetically endowed with this capability, though it may lapse in the face of neuroticism and inadequate societal preparation.

We need psycho-oncologists to teach us how to live while we are dying, recovering, or mourning. Customs, culture, and religions determined and passed on traditional wisdoms, including hope of eternal life, which palliated the misery of death on earth. Where traditional customs have lapsed, people make new ones or turn to the modern priest, the psychologist.

Death is more complicated today, for several reasons: we have lost a belief in the afterlife; modern medicine provides hope against death, and we have been dislocated from natural processes. Take the urbanization of human populations. Seventy-five years ago, 80% of people worldwide lived in rural areas. Today 80% live in cities and towns. This removal from “nature” has likely affected our understanding of birth, life, and death.

The role of the psycho-oncologist is to translate for the patient and family. To convert complex and poorly understood emotions into a language that the patient and family can understand. Tools include words, ideas, paintings, and literature. Words like depression, meaning, dignity, and demoralization have been classified, academicized, professionalized, and monetized. Art therapy is also established.

Though I hope we have not forgotten Irvin Yalom, who taught that “it’s the relationship that heals.” The value of human contact – a thing the priest once practised, as did the local high street butcher and greengrocer, who weekly asked after your family and welfare, and gave advice and comfort. We now have supermarkets with self-serve checkouts, impersonal tele-medicine, robots for companionship, and artificial intelligence that provides psychotherapy.

Thomas Nagel published a paper entitled: “What it is like to be a bat.” He observed that a conscious subjective experience can only exist if there is “something that it is like to be that organism” (Thomas Reference Thomas1974). He chose the bat because it uses echolocation to move about. Humans can imagine from a human perspective how sonar works, but we cannot know what it is like for a bat to live in the world of echolocation. Only the bat can know.

Similarly with humans. One person cannot relocate into the subjective experience of another human being. We can harbor a fair guess and shrewdly empathize, but we must modestly acknowledge our limitations in experiencing the other person’s consciousness. It therefore follows that the therapist cannot do the work for the patient.

As much as we value the prodigious volume of psycho-oncology research over the past 50y years, I think there are 2 relevant human characteristics that have been skirted and minimally investigated: courage and the heroic.

Courage is the cornerstone of facing fear. The next doctor’s appointment will reveal the result of the latest scan and blood tests, which is a terrifying prospect. Courage is needed to visit the doctor and not defer or procrastinate (Wein Reference Wein2005). Heroism, an evanescent aspect of character and soul, confronts the terror of death and goes hand in hand with courage to help us to overcome our fears (Wein Reference Wein2012).

We desperately need psycho-oncology to teach us how to die. Not just the recipe books, but the personal contact to give a fillip to our courage and sense of heroic.