A Natural Death

A 90 year old woman goes to sleep and never wakes up.

Her family gathers around in mourning.

“At least she died peacefully. She didn’t suffer.”

“She died a natural death.”

But did she really? And what is a natural death anyway?

What is it to Die?

Death itself is a tenuous concept.

Let’s define it as the irreversible cessation of activities necessary to life. This may seem circular or tautologic but it isn’t. The operative term here is “irreversible”.

The reversibility of any process is a function of the tools available to enact the reversal. It is not a fact intrinsic to a process itself (save where the laws physics are a constraint).

Approximately once a month, my team and I bring back someone who only decades ago would have been considered thoroughly dead.

It was once the case that if you could no longer breath you were dead. Not today.

It was once the case that if your heart stopped beating you were dead. Not today.

It is still the case that if you lose certain brain reflexes you are dead. This is a work in progress.

Given that what is irreversible today may be entirely reversible tomorrow, death is a moving target. In fact, it is an ever receding one.

Falling on your back is irreversible if you’re a 1 month old but not if you’re a 1 year old. Death may be the ultimate “fall on your back” but that’s because, technologically speaking, we are still infants.

What is Natural?

Natural describes what results from the ordinary course of events.

This can lead us to one of two views:

1. All death is natural: all death is a product of the dynamics of the laws of nature. In this view, a boulder falling from a height upon your head is as natural as septicemia after a scratch, or a heart attack in your sleep.
2. No death is natural: all death is a product of some aberrancy in how things ought to function. A bullet to the head ought not be there just as a blood clot ought not be in the coronaries.

In either case the term “natural death” is redundant.

In fact, worse than being redundant, the term has other more insidious effects.

Implications of “Natural Death”

The term “natural death” has three implications:

1. It implies that the deceased was old. A 12 year old does not die of natural causes.
2. It implies ignorance to the precise cause of death. A 90 year old struck by a bus does not die of natural causes.
3. It implies an ostensibly painless or asymptomatic death. A 90 year old who clutches her chest, screams in agony, and then folds to the ground is not said to have died of natural causes.

These features reveal two things about the term “natural death”:

1. It obfuscates our ignorance about the true cause of death
2. It reveals a shocking degree of apathy towards the terminal diseases of old age

We don’t know, and perhaps don’t care to know, what killed grandma and so we call it natural.

But what if we dug deeper?

A Deadly Moment

Let’s come back to our 90 year old.

She dies in her sleep precisely at midnight. At 11:59pm she was asleep yet alive, and at 12:01am she has expired. Clearly, something happened, something physically changed, in that interval to take her from one state to the other.

What changed?

No doubt some critical function in the body must have ceased.

There are countless possibilities but for many it’s an arrhythmia. Electric signals flowing through the heart become disorganized, heart muscles fail to adequately pump blood, and the brain and other organs are blood-starved and cease to function.

In these cases, if the electric signals were synchronized in time, for instance with medications or a defibrillator, our 90 year old’s heart would have kept pumping, her organs would have remained perfused, and she would have lived.

In fact, a patient of mine demonstrated this counterfactual only a few months ago. An 87 year old gentleman awoke from a deep slumber with a jolt of pain to the chest. He thought his implanted defibrillator was acting up and came to see me about it. Upon reviewing the defibrillator’s record I found that his heart had gone into a deadly, disorganized rhythm. If it was not for the defibrillator he would have “died peacefully in his sleep of natural causes.”

One might say an arrhythmia is “natural” for someone of that age. But that’s facile.

Instead we should ask why did the heart lose it’s rhythm? Was it scarring from prior heart attacks? What is an overly stretched atrium? Was it a new coronary thrombus?

At which point we will have arrived at specific pathologies. Specific physical ailments that lend themselves to prevention and treatment.

Ultimately, one dies from specific physical failures. All physical failures are pathology, and all pathology the purview of medicine and subject to prevention and treatment.

Psychology of Natural Death

The term “natural death” is intended to comfort.

It suggests that rather than being killed by a definite physical failure, one dies because, in a nebulous sense, it is “their time”. It suggests that the deceased likely did not suffer and evokes the image of their spirit leaving their bodies gently in the quiet of the night. The term “natural” has positive connotations.

To my mind, it’s abhorrent to associate it with a failure to survive.

It is a distinctly un-analytic perspective.

By failing to acknowledge that one’s death is due to a physical failure we imply that there are other ways to die; which brings us into the defunct realm of the spirit. Moreover, it suggests that there’s nothing to be done about such death. Whereas a dysrhythmia might be treated with antiarrhythmics, how does one treat death from “natural cause”? This sort of thinking leads to an intellectual cul-de-sac.

Death is tragic. It doesn’t matter that it happens to all of us. Its ubiquity and inevitability don’t diminish the tragedy. They magnify it.

This tragedy is good for us. It acts as the impetus for figuring how people die and how to do something about it. Today, amongst scientists at least, there is a consensus that the world is material. There is no room in such a world for “spirits” and accordingly no room for non-physical death.

This is good. It gives us a starting point. It gives us hope.

Summary

Death is the irreversible loss of one or more sustaining physiologic functions. This definition reflects the dynamism of death. What is irreversible today may be reversible tomorrow. Death is therefore an ever receding domain at the frontiers of life. At the moment of death there is a physical failure. This failure is called “natural” when it is (1) unknown (2) occurs in old age, and (3) appears painless or asymptomatic. The term “Natural Death” thereby hides our ignorance of the true cause of death and demonstrates an apathy towards the terminal diseases of old age. It implies a rightness or timeliness that should be abhorrent when speaking of death and disease. By rejecting the notion of “natural death” we insist on understanding the physical underpinning of death and the antecedent pathology. Then and only then do we place it in the purview of medicine, subject to prevention and treatment.