When did you first encounter Becker’s work, and how did you engage with it?

I first encountered Ernest Becker’s ideas after hearing Sheldon Solomon speak in 2016. These ideas about death denial and culture seemed self-evident; perhaps they were already there in my subconscious for decades. I had the additional reference of my time in East Africa where a very abrupt and premature death from otherwise treatable infections like malaria was so commonplace that even a youthful death caught no one by surprise. The existence of symbolism around death denial is clearly ancient, but perhaps it is dramatically exaggerated in the wealthy Western world, where advanced old age is seen as a birthright.

The existence of symbolism around death denial is clearly ancient, but perhaps it is dramatically exaggerated in the wealthy Western world, where advanced old age is seen as a birthright.

Has your knowledge of Becker influenced your practice as a physician? If so, in what ways?

Physicians working in hospitals marvel at how unprepared many chronically ill people are for death when it finally looms large. In the confines of the patient’s room we see the magical thinking about survival against all odds as a familial theme in which death is only failure. Becker’s ideas provide a framework for understanding how deeply entrenched that shared denial of death can be in the culture at large. At the same time, there are many other patients and families who cultivate a different narrative in which death is the natural and inevitable capstone on a meaningful life. When I first walk into the room of any sick person, I anticipate a need to establish early which side of this Becker duality my patient and their family may be coming from. These divergent belief systems have a strong correlation to ethnicity, socioeconomic status, education, and religion.

What are the biggest challenges in medicine in talking to patients about their mortality?

Western medicine was never developed to keep people alive forever. It was designed to prevent needless suffering, disability, and a premature demise. Yet it has been harnessed to the immortality wagon and needs to be reclaimed. We are creating a tragic subset of “chronically critically ill” patients who leave the hospital marginally better, but sick enough to be readmitted soon thereafter. Their destiny is now taken over by family members and the prevailing culture, unwilling to even consider death as an option. Other countries with less money to spend on health care limit access to care by strict age cutoffs. But that is itself an unpalatable criteria as I can attest when I travel with my healthy and delightful 94-year-old father who had his aortic valve replaced five years ago. We wait for the miracle of a reliable metric for judging quality of life and a crystal ball for determining who will achieve that benefit. Neither of these is on the immediate horizon.

What is the line between scientific progress to extend life and quality of life itself?

We have had an explosion of radically effective science and technology innovations rendering many untreatable diseases curable, and adding decades of health back to those who throughout all of the rest of history would have had their life cut short. At best, the impact of health innovation may be the most important determinant of prosperity for modern civilization. Yet there is no dividing line between a treatment administered early that restores years of good life and that same treatment applied late to prolong dying.

The most experienced physicians pause on the care of many of their patients to wonder if what they’re recommending will prove to be a blessing or a curse. And patient expectations figure big in that decision. Our rising costs of technology and science have long ago outstripped the ability of our health-care system to afford itself. As a boomer generation ages and demands platinum health care to the end, we may invert the traditional Ponzi scheme of health insurance and bring the system crashing down.

If our remarkable health science is chained to the immortality project of an entitled society then we are in trouble, and not simply because of the economics. Science can bring hope to dreams of immortality, but cannot add or restore meaning to life. A dystopian vision is that our last years might be spent in pursuit of yet another miracle, but only to find ourselves filled with replaceable parts and obsessed with immortality as an end purpose in itself.

If our remarkable health science is chained to the immortality project of an entitled society then we are in trouble, and not simply because of the economics.

What do you think needs to happen for Western medicine to improve its ability to have dialogues around mortality and reduce the stigma?

I think it’s important to talk early and often to young people about all of life’s crossroads. The dinner table of family members everywhere is one place where these crucial conversations start and evolve. Certainly we need role models in our media and entertainment who go against the social current of denial. The medical profession can also extol these values and be clear about the perils of a request to “do everything.” But the children of every family should see the adults embrace a rational life in which all ages are celebrated and the topic of death is discussed often and easily without fear or opprobrium. Families that face the death of a loved one gracefully 50 years hence are probably those that covered the subject from all angles around the dinner table for those 50 years.

Finally, have your own personal thoughts about death changed since you first encountered Becker, and how?

Becker created an intellectual framework for thinking about death that was already well evolved from my childhood with a physician father and a mother who spoke freely about how important it was to arrive gracefully at the end of life, dignity intact.

Becker is a great starting point for having this conversation with friends who find oblivion unthinkable and can’t imagine that life could exist without some universal purpose and meaning. After all, we spend an eternity not existing before we briefly emerge in this high energy state to walk the earth. What could be more peaceful and desirable than to return gracefully to that low energy state of oblivion once again?