Death awaits us all. Not news. Yet most of us are adept at denying its presence. As much as we moan and grumble, when we contemplate the alternative, most of us are relatively content with life. Inconveniently, though, death has a habit of imposing itself, as it did when my father died unexpectedly
Existentialism is a way of thinking about existence as well as its opposite, lack of existence, which is brought on by that infamous passage, death. Dr Irvin Yalom, a much-lauded Stanford professor of psychiatry, is widely regarded as the world’s leading expert on existential thought. Almost a year ago, interviewing Yalom at a conference attended by more than 500 people, I asked whether he, himself, as the great philosopher on end-of life-issues, feared death. He responded by making an interesting distinction between "death anxiety" and "death terror".
Death anxiety, Yalom observed, is an instinctive fear encoded within our DNA—a fear that, ironically, offers a Darwinian advantage to our species. When we are animated by fear of death, we can become willing to take precautions that might extend our survival. Or we may resort to heroic measures that lengthen our lives. Healthy people may respond to death anxiety by complying with sensible guidelines, such as refraining from smoking or refusing to overeat. Someone with serious illness, such as cancer, might react to death anxiety by finding courage to pursue treatment--like chemotherapy or radiation--that, although potentially toxic, can save their life. Almost inevitably, we have some degree of death anxiety which we can never fully vanquish.
But there is also "death terror" which can lurk not only in the shadows of death, itself, but even in death-like moments. Let me share a story that I have never told before.
In the midst of applying to residency training programs to become a cancer specialist, I did a clinical rotation at a prestigious hospital. As I quickly came to understand, the time I spent at that institution would be less about learning the craft than about auditioning for a residency position. Things went well for the first three weeks, but then I discovered that each medical student would be obliged to lead a morning teaching conference in front of the staff, which included the esteemed judges responsible for selecting future residents. I worked hard to prepare for my turn.
The big day arrived. I walked into the auditorium early to make sure things were ready. The presentation included dazzling Kodachrome slides (yes, this was before the Age of PowerPoint) and lovely CT scans (uh-hum, also before the shift to digital imaging) that I hung on a view-box at the front of the room. I was introduced and began my formal lecture. Unfortunately, what no one bothered to tell me was that, on the last Tuesday of every month (which was that very day!), the hour was not dedicated to a formal didactic lecture but to a more creative presentation in which the young moderator was expected to find novel ways to pose questions to senior faculty members in a kind of "stump the expert" format. When it became clear that I had missed the boat, the sharks jumped in. Senior and junior docs alike began firing questions. The questions seemed interesting and I wondered who would answer them. Then came the epiphany - - I was expected to answer them! As my blood began to saturate the waters, more sharks arrived. My hands became clammy as my autonomic nervous system – stupidly thinking I was involved in some life-endangering "fight or flight reaction" – revved up. What''s worse, I had to endure the thrill on the faces of the other students who quickly deduced that I was no longer going to be one of their competitors to land a spot in a sought-after residency training program.
If you''re old enough to remember - or young enough to Google – Gilda Radner''s famous Roseanne Roseannadanna character who tended to exaggerate her tribulations, then you''ll understand when I say, "I thought I was gonna die!" But wait, there''s a little more. As I returned to my chair, sulking with tail between my legs, I felt a thump on the back of my neck. One of the senior physicians (whom I thought might have been coming over to console me) instructed me to get myself back up to the front of the room and remove my CT scans to make way for the next student’s presentation. How''s that for an extra little dis? It seemed a safe bet that I would never be affiliated with that Ivy-League institution.
Death terror, as I mentioned, can lurk in unlikely places. I wasn’t about to die, not literally, but to me, that morning seemed tantamount to an end-of-life experience. I was convinced that my career was over before it had even begun. I felt mortified, having proven, so I thought, that I didn''t have the intellectual heft to play at the big-league level.
But where did those fears come from, and why associate them with death? At a tender age, I’d memorized the Talmudic adage, "He who causes his friend''s face to whiten in public, it as if he has spilled blood" (Tractate Baba Metzia 58b). The rabbis interpreted "whitening of the face" to be both inducing embarrassment and causing blood to vanish from the vessels as a symbol of murdering. In my perception, those professors who had shamed me in public had, figuratively, murdered me. Death terror was my response.
“Death terror," according to Irvin Yalom, is the component of death-related fear that we can overcome by discovering solutions that work for our particular situations. We can subdue death terror by determining what it is that we find scary about death or death-like situations. Then, when we understand our fears, we can take action to address them.
For some people, death terror may arise from contemplating the effects of our deaths upon our surviving loved ones or from considering what may happen to us, ourselves, when we meet our end. Some people may offset death terror by bonding more with friends and family. Others may benefit from revealing concerns to a confidant or therapist. Religious individuals may find peace in the belief in eternal afterlife.
I was able to recover from my episode of death terror by recognizing what had caused my reaction, and then realizing that the most important thing to me was not padding my resume with the name of that academic institution. In fact, I reminded myself, I didn’t need to care about people who got their jollies by humiliating me. What mattered—and still matters--to me, as both human being and physician, is to be a good person. A mensch. And nothing that had happened on that morning, I came to realize, had interfered with my quest toward becoming that good person. Having done that work to understand and come to terms with my fears, I can even blog about them. The incident no longer bothers me.
Death terror--something, perhaps, for us all to think about. By isolating our fears, we can devise an antidote that will soothe us.
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