All of us, at some point, have been preoccupied by death – though few more so than Woody Allen. “I’m not afraid of death; I just don’t want to be there when it happens,” he wrote. “I don’t want to achieve immortality through my works, I want to achieve it by not dying.” Such quips invoke a wry smile, but they also cut to the heart of our troubled relationship with death, and our inability to think about it clearly. Over the past year, however, we have all, in some way, been forced “to be there when it happens”.
Almost as soon as the pandemic struck, we developed a morbid fascination with the new coronavirus. Death became a part of daily life: as restrictions were introduced and the rules of society were rewritten, our only constant seemed to be the daily announcements detailing how many more lives had been taken by the new disease.
We have, of course, always been aware that death will come for us all. Yet for most of us, most of the time, we don’t know where, when or how. We don’t know whether it will be sudden or slow, peaceful or painful, surrounded by family or alone while connected to impersonal bleeping machines. The fact that we are aware, from an early age, of being stalked by unknown threats is naturally very frightening. Every fibre of our being drives us to do what we can to avoid it. But it is precisely because of the great influence death has on our lives that is vitally important we think about it more clearly. For as we are now discovering, how we regard our final chapter has important consequences for how we live beforehand.
As a pathologist, I’ve spent more time staring death in the face than most. I have personally performed thousands of autopsies – and if they’ve taught me anything, it’s that while death is inevitable, it needn’t be terrifying. In one sense, that’s because I have never conceived of Pathology, the study of disease, as being focused solely on death; contrary to the popular stereotype, it is all about helping the living.
Every time you have a blood test or a swab, or a doctor takes some tissue for analysis, these samples come to the “path lab”, where pathologists are responsible for making or refining a diagnosis that then informs your doctors which treatments are necessary. Even autopsies are mainly about the living, providing explanations to both the bereaved and clinical teams.
After all, medicine, in all its specialties, is always about caring for the living. Every decent doctor always does their best for every patient, bearing in mind two central tenets of medicine. The first is ancient: first, do no harm. You should never start a treatment unless you are as sure as you can be that it will cause less harm than the disease. The second – prevent harm where you can – is more modern, arising over the last couple of centuries following the spectacular successes of health interventions such as clean water supplies, vaccinations and antibiotics.
But as we are discovering, in unique moments of crisis such as this pandemic, these two principles can come into conflict. The first applies to individuals, while the second often implies society-wide measures that can help some individuals, but at the same time may harm others. Thinking about how to balance these principles is not easy. That became clear last week, when I appeared alongside Jonathan Sumption on the BBC’s Big Questions. During a segment on whether Britain’s lockdown was “punishing too many for the greater good”, his claim that not “all lives are of equal value” caused quite a stir. But it also raised an important question: surely there is more to life than just living and dying?
Death is a brutal endpoint, but no reasonable doctor (or court of law for that matter) makes treatment decisions based simply on whether or not a patient will die. It is also vital to take into account “quality of life”, which is not just some sort of luxury add-on that can be dispensed with in a crisis. It is literally all the things that make life worth living for different people. For an elderly person this may be having a cup of tea with family or friends; for a young sportsperson it may be competitive matches. Take these things away and the old person may die of loneliness, or the young person may tragically end their own life.
But are these life-endings equivalent? Perhaps, on a philosophical level, they are. On a practical level, however, the death of an 85-year-old person from a preventable cause has cost them a few years at the end of life, while a 25-year-old has, on the same calculation, lost over 60 years of life, including their most active and event-filled years. However much people may object philosophically to such discussions, avoiding them in practice can have serious unintended consequences for public policies.
It is uncomfortable to think about, but it seems quite clear to me that when you examine the “quality of life years” lost as a direct result of lockdowns, and compare them to those which would have been lost to the virus had we done nothing at all (which, for clarity, I am not advocating), the former is far greater. This is because you don’t have to die to lose quality of life. Being unable to function properly because of depression, for example, or untreated cancer, or a postponed operation, still results in loss of quality of life – as does merely being confined to your house. Surely no reasonable person can disagree that this loss must be considered when evaluating the appropriateness of society-wide measures that affect all individuals?
I suspect part of the reason we struggle to think about death rationally is that so many of us are reluctant to acknowledge that the human lifespan is limited. There’s something reassuring about clinging to the idea that we can all live forever – or perhaps to 150, which is sufficiently far away that it might as well be forever. But such hopes are misleading.
Yes, the average age at death has increased over the last century or so. But that is because more people are living to nearer our maximum age, not because that maximum age has increased. Medical advances mean that fewer of us die as children, in childbirth, of injuries and infections than used to be the case, meaning that most of us live into our 70s and 80s. The average age has increased in tandem with these advances. But the maximum age possible has not changed: the vast majority of us will still die in our 70s and 80s.
In fact, increases in average age at death have actually slowed down and even reversed slightly in recent years – and there is every biological reason to expect that we are near a plateau for the average human lifespan. Interestingly, that limit is already unusually high. There is a clear relation between lean body mass and maximum lifespan for mammals: shrews live a year, while elephants live for 80. On this basis, humans should live for about 30 years.
The fact that we can live up to three times longer than expected is a remarkable evolutionary feat. It is most likely due to the development of language, which has meant that human parents can pass along a lot of useful information to their children while still learning from their own elderly parents. But after we get too old, our “usefulness” (from an evolutionary, not a philosophical standpoint) runs out. So the expected age at death in the UK – currently just over 81 (which incidentally is a year younger than the average Covid death) is getting close to as good as it will get.
And that isn’t necessarily a bad thing. After all, death is an essential part of the human condition. It may be a frightening prospect, but it can motivate us to get the most out of every single day. You simply can’t put a value on that, which is why putting everyone’s life on hold in the face of a new pathogenic threat would only make sense if that threat were so overwhelming that the very fabric of society was at risk.
Does Covid meet that criterion? Looking at cold, hard data, I am not convinced. Take just one straightforward statistic as an example: healthy under-50s made up less than 1% of apparent Covid-related deaths in 2020 — fewer than 700 of the 72,178 deaths recorded by Public Health England. For comparison, there are around 1,700 deaths a year from road accidents in Britain. When that context is understood, and when we start to accept death as a natural endpoint and quality of life as a vital consideration, today’s morbid climate of fear seems far from justified.
A far more intuitively wise outlook was offered by Jeanne Calment, the world’s oldest ever person. She lived to the exceptional age of 122 years and 164 days. On her 120th birthday she was asked by an over-enthusiastic young reporter “How do you see your future?” Her response: “Short.” If only we could all be so frank. Perhaps then we will be better able to enjoy everything that comes before.