Brinksmanship

British philosopher Bertrand Russell compared nuclear brinksmanship of the Cold War to a game of chicken. This analogy has been carried over to medicine. In the case of medicine, we want to treat a dying patient as aggressively as possible before crossing that line at which medical intervention does more harm to the patient than good. We aren't particularly good at this. There is no clear demarcation between life and death, as evidenced by the Terri Schiavo case. When should we let nature take its course? When should we put the patient at risk in an attempt to stave off the inevitable? There is great uncertainty in death. In Western Attitudes, Philippe Aries says, "Death has been dissected, cut to bits by a series of little steps, which finally made it impossible to know which step was the real death." Coma, dementia, vegetative state? Where do we draw the line?

And what kind of death do we want? Probably one in which we are embraced by people, not medical machines. In Daniel Callahan's The Troubled Dream of Life, he says, "There is a need to fashion a notion of the self that has, in some sustaining way, come to accept death, a self that understands that control over fate will pass from its hands [...] It should also be a death marked by consciousness, by a self-awareness that one is dying, that the end has come - but, even more pointedly, a death marked by self-possession, by a sense that one is ending one's days awake, alert, and physically independent." The difficulty for doctors is that we, in our combat against death, fail at brinksmanshipping. We overplay our cards for personal, societal, moral, or other reasons. This may contribute to a worse outcome for the dying.