He was a therapist and friend who was dying of metastatic cancer. When he asked if we could talk, I began to go by his hospital room, ultimately spending an hour or so with him at the end of each day. During more than 30 such visits we talked about many things—his wife and family, his career, and, at times, his dying. I tried only to be there, to be with him in a way that gave him some relief from his aloneness.1
Courage was an important theme in his life. He was a decorated veteran of the Pacific Island invasions during World War II and an outspoken public speaker on current social injustices. I knew this about him and as death became imminent his anxiety about losing control and "becoming a baby" became obvious. Several days before he died he asked me if it got too much for him would I step on his oxygen tube? Without a moment's hesitation I said, "Yes." Such was not necessary, since he lapsed into a coma and died a day later.
The other occasion on which I was asked if I would help if dying became too difficult was also some years ago. This situation developed in the context of a doctor-patient relationship. I had seen this middle-aged woman and her husband in couples therapy 6 years earlier, and our work together had been successful. She called and asked if I could help with her dying as much as I had helped with her living. She, too, had metastatic cancer. During the 6 months longer that she lived, I saw her and her husband weekly, alternating individual sessions with couples work. She had been the more distant, analytic spouse whose difficulty with intimacy appeared related to childhood experiences with what sounded like a chronically depressed mother, herself a Holocaust survivor.
About a month before she died and during a session that included her husband, she asked whether, if dying became too miserable, I would help her with it? Again, my response was immediate, "Of course," I said. I will not describe in detail the subsequent events— including my discussing the situation with the executive director of my local medical society and his suggestion that I talk with the recently retired pathologist-director of the medical examiner's office about how to help if that was my decision. For present purposes all that is relevant is that she never asked; rather, she, too, slipped into a terminal coma. I have thought often about these 2 situations, particularly in the context of the ongoing legal conflicts about Oregon's physician-assisted suicide law. What has particularly occupied my self-explorations has been the immediacy of my affirmative response to both my friend and my patient. Why—without any thoughts about the implications of what I was being asked to do—did I respond so quickly and emphatically?
One line of my thinking concerns the demands of the context. With both friend and patient in such dire circumstances, how could one have said, "no," or "maybe," or "we'll see?" The context demanded an affirmative response. The dying person needed to hear that help would be available if requested. My immediate and affirmative response reflected my understanding of that context and its demand quality.
I suspect that responding to the context played a role in my response, but there is almost certainly more to it than that. It is hard to avoid the conclusion that my underlying anxiety about my own death must have influenced my response. If my death were unusually painful wouldn't I want someone to slip me the requisite pills?
Death anxiety is considered by many existentialists to be an ultimate concern, one of the most fundamental processes in the entire psychology of the self. Becker,2 in his famous The Denial of Death, proposed that it is the most basic font of all psychopathology, and that we defend vigorously against directly experiencing it. Subsequent research efforts have distinguished conscious death anxiety from unconscious death anxiety. The former is considered multifaceted. Some persons' conscious death anxiety involves separation from loved ones; for others it might be fear of the unknown; there are a handful of interrelated themes involved in conscious death anxiety. Unconscious death anxiety is, of course, more difficult to study. One approach uses a sentence completion format and demonstrates that there are clear distinctions between the 2 types of death anxiety,3 although I think consciously about my own death (after all, I am approaching 82) without severe conscious anxiety, some idea of the extent of my unconscious death anxiety was revealed to me some years ago when I said goodbye to my wife on the way to the operating room for major surgery. So, I know it's there—and that it has to do, at least in part, with separation from her. Is it that deep dread within me that prompted my immediate responses? Is the idea of a prolonged and painful dying so frightening at an unconscious level to me that I leap to assuage those fears in others? This is a reasonable hypothesis, and I suspect it is part of the picture. I say this because my more usual behavior is far more cautious than impulsive, and my immediate and emphatic response to the request for help in dying is not at all typical.