A Natural Death
The term "Natural Death" obfuscates our ignorance of and reveals a shocking apathy towards the terminal diseases of old age
A 90 year old woman goes to sleep and never wakes up.
Her family gathers around in mourning.
“At least she died peacefully,” they say.
“It was a natural death.”
But did she really? And what is a “natural death” anyway?
The term is not nearly as innocuous as it seems. To better understand why, it’s important to start at the beginning (or if you prefer, the end) and look at what it actually means to die.
What is it to Die?
Death itself is a tenuous concept.
Put simply, it is the irreversible cessation of activities necessary to life. This definition may seem circular or tautologic but it isn’t. The operative term here is “irreversible”. Countless activities are necessary to life from respiration and digestion to metabolism, excretion, and so on. These sustaining physiologic functions can and do fail all the time. But when they fail irreversibly, that is when we die.
The next crucial point is that something’s irreversibility isn’t set in stone. The reversibility of any process is a function of the tools and knowledge we have to enact the reversal. It is not a fact intrinsic to a process itself (except where the laws of physics are a constraint).
For instance, 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. Death is a work in progress.
Approximately once a month, my team and I bring back a patient who only decades ago would have been considered thoroughly dead.
Given that what is irreversible today may be entirely reversible tomorrow, death is a moving target. In fact, it is an ever receding one.
What is Natural?
The term “natural” describes what results from the ordinary course of events.
This can lead us to one of two views:
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.
No death is natural: all death is a product of some aberrancy in how things ought to work. A bullet in the head is just as aberrant and unnatural as a blood clot in the coronaries.
In either case the term “natural death” is redundant. It adds nothing.
In fact, worse than being redundant, the term has other more insidious implications.
Implications of “Natural Death”
The term “natural death” has three implications:
It implies that the deceased was old. A 12 year old does not die of natural causes.
It implies ignorance to the precise cause of death. A 90 year old struck by a bus does not die of natural causes.
It implies an ostensibly painless or symptomless 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”:
It obfuscates our ignorance about the true cause of death
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 passed on. 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 her body must have failed. There are countless possibilities.
One common cause is an arrhythmia. Electric signals flowing through the heart become disorganized, the heart fails to pump appropriately, the brain and other organs are blood-starved, and eventually irreversibly stop working.
In such 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 gotten their blood, and she would have lived.
It is our ignorance of the exact cause of death and a certain apathy towards the terminal disease of old age that leads us to call her death “natural.”
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 he have an arrhythmia? Was it scarring from prior heart attacks? What is it an enlarged heart from years of high blood pressure? Was it a new heart attack?
Only by digging deeper can we arrive at specific pathologies, specific physical ailments that lend themselves to study, prevention, and treatment.
Ultimately, one dies from physical failures. All physical failures are pathology, and all pathology the purview of medicine and subject to prevention and treatment.
Rejecting Natural Death
The term “natural death” is intended to comfort.
It suggests that one dies because, in a nebulous sense, it is “their time.” It suggests that the deceased likely did not suffer and evokes an image of the spirit going “gentle into that good night”. The term “natural” has positive connotations of rightness and timeliness.
To my mind, it’s abhorrent to associate such attributes with death and disease.
It is distinctly unanalytic and unscientific.
By not acknowledge that a death is due to a specific 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 an arrhythmia 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 drives us to dig deeper, ask more and better questions, and to ultimately discover how people die and what to do about it.
Rejecting the notion of “natural death” 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. The term “natural death” thereby masks 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. 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 return death to the purview of medical science, subject to prevention and treatment.