Free Will and Death

One of my primary philosophical interests is free will, which itself is a body of academia. In medicine, I've encountered questions of free will in surprising yet expected contexts relating to death and dying. Free will is the idea that at any junction in which we perceive ourselves making a decision, we have the ability to choose otherwise. It's an extraordinarily powerful drive, enabling us to pursue projects, take pride in our accomplishments, feel shame about our failures, and attribute meaning to our lives. Innately, we all understand this concept of free will as a component of raw human experience. Yet philosophers have found over time that pinning down and explicitly defining this noumenal thing is impossibly difficult.

We can control many things in our life. Against improbable odds - the laws of physics, the actions of our peers, the stock market - we are still able to maintain a set of actions and attributes that we feel are our own; we choose what car we drive, where we live, what we spend our evenings doing. Our free will is liberating, identity-defining. But as patients near the end of their lives, this sphere of self-determination shrinks. They may lose their ability to walk independently, to communicate, to think. Disease, frailty, and the finality of human experience chip away at this practical (rather than philosophical) free will until it edges the person out to the final choice, that of living.

Indeed, this may be what scares us about dying: the loss of choices, the loss of free will, the loss of some fundamental defining aspect of being human. Yet in some ways, this is obvious; what is death but the loss of the self? (Of course, some belief systems incorporate such things as an eternal soul). I found it surprising that my experience with patients and their families at a time of death and dying reflect this idea. Those deaths that are most peaceful are the ones in which the patient has not only accepted a loss of control but also freely given up their free will (if such an idea is possible). Those who have the most trouble have problems resulting from this pesky free will; they regret a decision they made long ago, they refuse comfort care measures, they believe sheer willpower will nourish them, they are anguished by impossible decisions that doctors force them to make.

Alexander Pope ("Essay on Criticism") said, "A little learning is a dang'rous thing; / Drink deep, or taste not the Pierian spring; / There shallow draughts intoxicate the brain, / And drinking largely sobers us again." American medical ethics, over the last few decades, has defined autonomy as an overriding ethical principle. We have moved from paternalistic doctor-defined medicine to a patient-centered model, intending this to be for the better. In the majority of cases, I agree. But I am on the fence regarding the most ethically-wrought cases involving death and dying. The hardest cases are the ones in which there is an overwhelming likelihood someone will die but a possibility they may survive if "everything is done." In the few cases that I've seen, shifting this decision responsibility to the patient (or worse, the patient's family) causes that person more pain than I think is justifiable. First, do no harm. But there is immense harm in perpetuating an illusion of free will at a time when someone is actively losing it.

These are just sketches of ideas I've had. They may not fully reflect what I believe, but I think they are interesting enough to present. I'll end with a quote from French philosopher and 1957 Nobel Prize winner Albert Camus:

"All that remains is a fate whose outcome alone is fatal. Outside of that single fatality of death, everything, joy or happiness, is liberty. A world remains of which man is the sole master. What bound him was the illusion of another world. The outcome of his thought, ceasing to be renunciatory, flowers in images. It frolics - in myths, to be sure, but myths with no other depth than that of human suffering and, like it, inexhaustible. Not the divine fable that amuses and blinds, but the terrestrial face, gesture, and drama in which are summed up a difficult wisdom and an ephemeral passion."