By Daniel Tarade

There is a popular joke, attributed to the British comedian Bob Monkhouse,[i] that goes like this; I'd like to die like my old dad, peacefully in his sleep, not screaming like his passengers. Like most good jokes, it is funny because it touches upon something true. Many people would prefer to die peacefully in their sleep, even if the alternative is not as terrifying as a fiery car accident. I have had my fair share of experience with existential dread. For most of my life, I think I would have agreed that a peaceful death whilst being blissfully unaware of the process taking place is ideal. However, as I continue to ponder the topic, such a death appears to rob the individual of something of importance. Dying is not necessarily a comfortable process but a life event that is important to experience firsthand, akin to your first breakup or moving out of your parent’s house. My curiosity surrounding this subject has lead me to create a thought experiment.

Imagine that you are at the doctors for your annual checkup. You do not have any reason to suspect that you are ill in anyway. After completing some routine tests, one of two things will occur. One, you are informed by your doctor that you have a terminal illness. The exact nature of this illness will change depending on the scenario but there is no cure and you will die of the disease. Conversely, you, at the exact moment you would have otherwise received your diagnosis, suffer a ruptured brain aneurysm, which kills you instantly. The question is this. Would you rather die in a split moment, at no point aware of your impending demise, or would you rather face the diagnosis of terminal disease?

I can imagine three groups of people. One for which having to face their own mortality would be a special kind of hell with little to no redeeming qualities. For this group, regardless of which disease would ultimately kill them, the death via brain aneurysm would be an infinitely more desirable outcome. The proverbial peaceful death during sleep. The second group would be an equally radical group, in that they would choose to face terminal illness regardless of the potential for debilitating pain rather than be blindsided by death. To be honest, I do not personally know of anyone who would choose to go down this route. The third group would be those on the fence for which the nature of terminal illness would be important. I find myself in this group.

If I were to be diagnosed with terminal cancer, putting aside the fact that different cancers advance with different trajectories, I imagine that I would prefer that to death via brain aneurysm. In most instances, it would take the cancer several weeks or months to begin impacting my day-to-day life, particularly if I refused aggressive chemotherapy in light of a terminal diagnosis. Those remaining good months, weeks, and days would be the wellspring from which I continually pull the knowledge of my impending death and during which I would address the final chapter of my life. I imagine I would constantly surround myself with family and friends, ensuring that they know exactly the place they hold in my life. I would take pride in my accomplishments while perhaps trying to finish off a few exciting scientific experiments. I would say the goodbyes that were necessary and contemplate the void, realizing that the only advantage I have over the cold and uncaring universe is that I realize how overmatched I am. I would reflect on the reality that I am the outcome of millions of years of uninterrupted mating and copulation, a product of meandering evolution, and that I was to die (potentially quite young – depends on the scenario).  I would bask in the sublime, that I would not be worth mentioning in even the most comprehensive of histories regarding the universe but that despite how little one life matters in the grand scheme of things, which is unfathomable really, I tried my best and had some impact on those nearest me. Or I wouldn’t and I would just be frozen by fear and panic as the days waste away. But I know that it would be an opportunity to grow. Just because you are dying doesn’t mean that you cannot try to grow just a bit taller and it is the great challenges in our lives that provide the greatest opportunities for growth. Any extent to which I can grow comfortable with my mortality would be an immense accomplishment

However, what if the diagnosis was of Alzheimer’s disease or Parkinson’s disease. For the sake of this scenario, the neurodegenerative disorder was particularly aggressive and would rapidly progress until my death in a mere three months. Think Lewy body dementia, the likes of which terrorized and prompted the suicide of Robin Williams.[ii] I have a hard time justifying the absolute agony of continually living within your own fracturing mind. My ideal death requires that my mental faculties be intact and perhaps naively believing that modern palliative care could allay the physical pain. This ideal unravels as the mind unravels, a ball of yarn becoming soft and formless. At writing, I would prefer the singular moment of my mind being exploded via a ruptured aneurysm than the slow motion implosion of Lewy body dementia.

I know not everyone would prefer to face terminal cancer if given the choice of unforetold yet painless death. But, for the sake of discussion, imagine that the brain aneurysm is detected by the doctors. They know that it will rupture in precisely one week or one month or one year. They are helpless to fix the aneurysm but until it ruptures and kills you, will provide no physical pain or otherwise interrupt your ability to go about your daily life. Would you choose to confront your mortality or prefer to die unaware?

The fact of life is that we do not know how we will die. I can die unaware one hundred times a day. I can be struck by a car, killed in a gas explosion, or die of a ruptured brain aneurysm. Each of these scenarios can prevent my facing death and experiencing what is the ultimate moment of my life, to which all else is penultimate. The only safeguard is to confront mortality throughout your life, without being prompted by the fear of or the actualization of illness or accident. Growing to be comfortable with the finite nature of life is one goal of mine.

Postscript on Lewy Body Dementia

For those of you who are curious, dementia presenting with Lewy bodies (DLB) is the second most common cause of dementia, representing approximately 20% of all cases of dementia.[iii] The symptoms associated with DLB are reminiscent of aspects of both Parkinson’s disease and Alzheimer’s disease. The major symptoms include dementia (more prominent in Alzheimer’s disease than Parkinson’s disease), visual hallucinations (unique to DLB), and parkinsonian symptoms (including postural instability, facial immobility, rigid gait, etc). Although in my thought experiment I would be diagnosed with DLB, in reality, a diagnosis of DLB is only possible during autopsy. Widespread Lewy bodies would need to be observed for a diagnosis of DLB. Lewy bodies are intracellular protein aggregates (the major protein component of these aggregates is α –synuclein) in the subcortical and cortical neurons.

[i] https://www.theguardian.com/news/2003/dec/30/guardianobituaries.artsobituaries

[ii] https://www.scientificamerican.com/article/how-lewy-body-dementia-gripped-robin-williams1/

[iii] Hanson & Lipa. (2009). Lewy Body Dementia. International Review of Neurobiology, 84, 215-228.