MONOGRAPHIC SECTION

What death is. A literary approach between fears and hope

Natale Gaspare De Santo

Dipartimento di Medicina, Seconda Università di Napoli e Istituto Italiano per gli Studi Filosofici, Naples, Italy

Address for correspondence

Men "cannot link the beginning with the end that is to follow the circular path of motion which is followed by divine stars" (Alcmeon of Croton, 510?-440 BC).

"Lifelong one should learn the art of living, lifelong one should learn to die"
"Death chases me, life eludes me. Teach me how to handle the situation.
Help me to escape death, help me to keep life, prolong my short time.
Teach me that the value of life does not consist in his duration, but in its use".
(Lucius Anneus Seneca, 4 BC or 4 AD?- 65AD).

INTRODUCTION

Living and dead humans on Earth

In October 2011, scientists of the Population Reference Bureau in Washington announced that world population had increased up to 7 billion, and that life expectancy was increasing tremendously so that 100 years will be a normal goal for those born nowadays. They also reported that a total of 1,707,602,707,791 Homini sapiens sapiens ever lived on Earth, starting from the initial couple starting walking the planet 80,000 years BC. For every living person there have been 15 deaths [1, 2] (Figure 1).

According to World Health Organization (2000), some fifty-six million people die every year. Even if each death affects only five people we may say that in a year 300 million people meet death, which is one twentieth of the world population, five per cent. This renders end-of-life care a global problem of public health care just because of the huge number of people.

However, as reported by Pierre Caunu, the founder of quantitative history, an inquiry over the last 100,000 books (nonfictions essays), including medical books, showed that only two hundred (0.2%) looked at the problem of death.

For Richard Dawkins (Nairobi, 1941), the scientist defined by Prospect "the most important living thinker", "We are going to die, and that makes us the lucky ones. Most of the people are never going to die because they are never going to be born. The potential people who could have been here in my place but who will in fact never see the light of day outnumber the sand grains of the Sahara. Certainly those unborn ghosts include poets greater than Keats, scientists greater than Newton; we know this because the set of possible people allowed by our DNA so massively outnumbers the set of actual people. In the teeth of these stupefying odds it is you and I, in our ordinariness, that are here. We privileged few, who won the lottery of birth against all odds, how do we dare whining at our inevitable return to that prior state from which the vast majority have never stirred?" [3].

Rendering death reversible

According to George Church, a geneticist at Harvard Medical School, we are probably unable to defer death, however we might render it reversible. This possibility was disclosed by recent experiment with DNA of the Iberian goat (Pyrenean ibex) and it was now used to revive a small frog (Rheobatrachus silus), which disappeared 25 years ago. Going against the dogma of the irreversibility of extinction of species, this result was achieved via cloning techniques using the DNA of a species bearing great affinity with the extinct one [4-7].

Medicalization of death

Four fifths of deaths in rich countries occur far from home, at the hospital, in the hospice, and or in the nursing home. People die in the hospital assisted and sometimes shut up by nurses who, like family members, do never speak about death. There are hospitals refusing even family members when the time of death is certain (hora certa) and the trajectory of death well defined. There are no more Socratic deaths, there are no notaries to register the last will. Hospitals are not adequate for this. Often the dying are separated from the other patients just with a curtain, there is no privacy. "People go/will go to the hospital not for care but for death" [8].

All creatures are immortal for they are ignorant of death

In El Immortal (The Immortal, 1947), a short story of Jorge Luis Borges, we learn about Marcus Flaminius Rufus, a Roman soldier serving at the time of Emperor Diocletian, who after drinking from the sandy waters of the river flowing near the City of Immortals, becomes immortal. For Borges, "to be immortal is commonplace, except for man, all creatures are immortal, for they are ignorant of death; what is divine, terrible, incomprehensible is to know that one is immortal". "Christians and Moslems profess immortality but the veneration they render this world proves they believe only in it". [The immortals] "knew that in an infinite period of time, all things happen to all men". "Death (or its allusion) renders men precious and pathetic... every act they execute may be the last, there is not a face that is not on the verge of dissolving like a face in a dream. Among the Immortals, on the other hand, every act (and every thought) is the echo of others that preceded it in the past". "Nothing can happen only once, nothing is preciously precarious".

It is not a surprise that Borges declares his debt to Giambattista Vico and his wild giant beasts preceding present humankind.

Patriarchs were long-lived and fertile

From Genesis and Exodus we learn that Patriarchs were long-lived were fertile even at the age of five hundred years as was the case of Noah.

"When Adam was a hundred and thirty years old he fathered a son and he called him Seth... Adam lived for nine hundred and five years". Seth gave birth to Enosh at the age of one hundred and five years and "lived for nine hundred and twelve years"... Ishmael lived one hundred and thirty-seven years, Isaac lived one hundred and eighty years, Jacob died at one hundred forty-eight years, Moses at one hundred twenty, and Joseph at the age of one hundred and ten.

These strong examples from the Bible teach that the maximum was nine hundred and sixty-five years, however the end supervened and the death remained the last enemy.

At Vilcabamba, in Ecuador, there is a great prevalence of ultracentenaries

Ricardo Coler, Argentinean writer and physician in Eterna juventud. Vivir 120 anõs (Eternal youth. Living up to 120 years) [9] provides a comparison of the physical attitude of his eighty-six old father needing dialysis therapy for chronic kidney disease and the inhabitants of Vilcabamba in Ecuador, who marry very old and work till the very end of their life. People live from one hundred thirty to one hundred and forty years. Vilcabamba has been turned into the city of longevity since the number of centenaries is ten times higher than in any other part of the world. In that valley of Ecuador, people live forty years above the mean. The proof of this fact can be seen everywhere, in the street, when they are speaking, working or attending to their own affairs. They live a healthy, creative old age.

The modern death

Carl-Henning Wijkmark, a talented journalist and writer who analyzes ethical themes of our society, in 1978 published a novel – a modern tragedy – centred on a congress, organized in the district of resund by a Committee of the Swedish Ministry for Health, to discuss the need to reduce the access to national health services in a time of economic crisis, prolonged lifespan, and early retirement [10]. The problem is that "one out of four Swedish people is pensioned because of age, one out eight productive persons are allowed to retire in advance and seventy-five per cent of the health expenditure is utilized for chronic disease and patients without hope". Participants in the debate include physicians, economists and theologians, maître à penser, and politicians. All aim to protect the nation's social welfare by convincing old people to die because of their social non utility. Ageing persons, in a democratic country which grants lifelong political rights (voting), are thus classified taking into consideration their productivity and their relevance in the society (Nobel prize recipients are in the highest rank). Old people may be given the unique chance to contribute to public utility by dying and allowing the use their bodies, not yet destroyed by diseases, as spare parts for organ and tissue transplantation. Of course, also families "should be convinced not to oppose the social use of the bodies of the relatives, which might be used up to its 100% by drug industry, as chemical fertilizing compounds".

There is just one single voice against the committee and is that of Rönning, who is no longer present when the moderator concludes with the chilly menace "you will receive news from us soon". The book is provocative and "is a precursor of our times" (Hans Magnus Enzensberger) especially if one takes into consideration that it was written at a time a great economic growth throughout Europe, when Sweden was the symbol of the most perfect and workable social welfare, a role model. The book anticipates the modern debate about the dignity of life and on euthanasia. At the centre of the debate are the quality of life and the impossibility to satisfy all needs. When the quality of life cannot be kept at the maximum level, we have to sacrifice ourselves to benefit the community of which we are part.

In our times death is the most stressing event: a shut door. Beyond are no dreams left

Death is removed or denied since "people think that they may be able to escape it, or surviving by means of special pills, or by use of stem cells, which may start the era of immortality" [11].

"The end of every year is the perspective of what remains to limit our actions. Probably senility is just a walk in a corridor with many rooms where we stop to contemplate lived and negated emotions, this until the will for knowledge and living collides with a shut door. Beyond there are no more dreams" [12].

In the rural communities of Calabria nobody died alone

Even in the years 1950-1960 of the last century, neighbours, friends, family members used to sit around the bed of diseased/dying persons to support them. It was not rare that the moribund coming out shortly from a coma exchanged words with that particular audience and was lucky to experience the presence of this community around him. In that way, death still remained a tragic, personal event in life, but was also lived as a collective moment. The community at large did not allow the dying person to pass in solitude.

After death, traditionally friends, neighbours, family members at large took care for a week or two of foods and beverages, and of the essential activities of the family [13].

The loneliness of dying

Elias raised the point that in our times people die alone, without comfort and tenderness. "It is surprising that people around dying persons, are unable to comfort them with love and tenderness. They have difficulty in shaking hands with a dying person. Many of them are unable to dress, to wash a dead body. There are specialized people for this. Even The Mercy of Michelangelo, where the mother hands the body of the dead son, is not actual, it is something peculiar for Michelangelo's times. Today nobody carries on his hands a dead body. Die in loneliness, and our individual dreams blow out. Oh! Our small world" [14].

DEATH IN THE MYTH

All started with Pandora's box

From Hesiod, we learn that humans and gods lived together on Olympus. After the battle between Zeus and Chronos, which ended with Zeus' triumph, a new order was established, with Zeus at the apex of the pyramid. Zeus, at that time, could no longer tolerate human males in Olympus. To expel them from Olympus, he took the occasion by a deception that occurred to Prometheus ("he who understands in advance"). Prometheus, dividing the sacred ox after a sacrifice, made two packets. One was made of bone covered by fat, a very attractive packet; and the other, of all eatable parts of the animal covered by the skin of the ox and further enveloped in the disgusting interiors of the animal. Zeus was invited to be the first to choose and selected the fatty part containing with bone, which was nothing eatable. So humans had the meat to eat and in any sacrifice in Greece, bones sprinkled with wine and fat were burned and the gods received the smoke generated by the bones – entailing the essence of life –, while men ate the meat, which needed fire to be cooked. Thus, Zeus decided to deprive humans of fire, so they could no longer eat their cooked meat. Prometheus again stole fire from Olympus and brought to humans a branch of wild fennel, green on the outside and dry inside, and therefore capable of perpetuating fire. By this Promethean trick, humans had the fire to cook their foods.

Zeus decided to end the dispute with humans and asked Hephaestus to produce in his forge a splendid human parthenos, a virgin, Pandora ("gift of all gods"), a female artefact, further embellished by various goddesses including Aphrodite and Estia. This was the birth of Pandora, which was sent to Epimenides ("he who understand after"), the brother of Prometheus. Epimenides was attracted by her beauty, thus he welcomed her, with open arms, in his home, as the first known spouse. Pandora also brought with her a box in which Zeus had concentrated all illnesses. One day, at Zeus' command, Pandora took the lid off the box, all noxious things came out including the most important of all: death. With death, all that is achieved during life is lost, unless one lives with a woman, and generates a child "similar to the father," who will grow up to become adult and also die and so on. Life and good may be kept through the new generations.

In the box only hope (in Greek Helpis) remained since Pandora closed the box by putting the lid on. Hope a specific gift, not for gods but for humans. Thereafter men and women knew they would work hard to live, delivery would be painful, men and women would undergo diseases of various origins, and acquired the certainty that early or later they would die. However the date remains unfixed, unpredictable and speculative. But men, although no longer immortal, have the destiny to live in the company of a female being of divine origin.

Klotho, Lachesis and Atropos. The Moirai – goddesses of destiny

Hesiod chanted "and the Moirai, to whom wise Zeus gave most honor/ Klotho, Lachesis and Atropos, who give/ mortal men both good and evil". They determined lifetimes: Klotho was the spinner, Lachesis measured the thread of life, and Atropos fixed at the measured length and cut the thread. The cutting was pre-determined; nobody could oppose, not even Zeus, as it was against the principle of justice [15].

At Delos, it was forbidden to become old, to die and to be born. There was a ban of Hera against Leto (7^th and 6th wives of Zeus). So it was necessary to create an isle where Leto could deliver Artemis and Apollo. When the isle was later consecrated to Apollo women delivering babies and dying persons were carried out of the island. As a result, forbidding birth and death caused the progressive decline of Delos.

SPECIAL DEATHS

Death of Moses

Death may be even sweet, as it occurred to Moses who died while being kissed by God (Midrash on the death of Moses). From that Midrash we learn that at the end of his life Moses the great leader, the greatest prophet, receives a veto from God. He is not allowed to enter into the Promised Land, just for a question of generational change: Joshua was designed. Moses begs, prays, God to let him pass. He asks and asks, behaves as any man would behave, he cannot accept that having humbly and courageously served hard for forty years, now at the time the Promised Land is within his reach, he cannot enter. But when a divine voice comes forth and says, "Within half a moment you are to depart from the world", Moses lifts both his arms, places them over his heart, and calls out to Israel, "Behold the end of flesh and blood". Moses arises and washes his hands and feet, and thus becomes as pure as seraphim. Then, from the highest heaven of heavens, the Holy One comes down to take the soul of Moses, kissing him and taking his soul with that kiss. At that, God wipes along with the heavens, the earth, the ministering angels and all of Israel ...They wipe for Moses and we weep for our de ad. We weep, we remember, we long for more life, we struggle, we do battle even, yet we all must die, even Moses; it is the way of humanity, the price we pay for living [16].

Death of Socrates

Death has been de-legitimized. In the past men used to die as expected, according to the script, the prompt book, which all were called to recite, to play. Everyone knew his role, how to behave. Death was ritualized, domesticated, it was a show left in the memory, for future memory.

Even Socrates did not die as the revolutionary he had been, but according to the script of the good death, according to traditions. His last words were: "Crito, we ought to offer a rooster to Asclepius. See to it, and do not forget" (Plato, Crito).

Death of Jesus

Christianity is a religion based on the death of a man called Jesus, who was counted as one of the rebellious, and arrested, wounded, mucked, betrayed, offended in dying. He resurrected. Although he was precipitated into difficulties, he had doubts about his Father's assistance: "If you are willing, take this cup away from me. Nevertheless let your will be done, not mine. Then an angel appeared to him, coming from heaven to give him strength"... (Luke, 22:42) "When they reached the place called The Skull, they crucified him". Jesus said "Father forgive them; they don't know what they are doing" ... (Luke, 23:34) "It was now about the sixth hour and the sun's light failed, so the darkness came over the whole land until the ninth hour. Jesus cried out in a loud voice saying "Father, into your hands I commit my spirit" With these words he breathed his last" (Luke, 23:44-46).

Death of Frederick II of Hohenstaufen

At the end of November 1250, Frederick II fell ill because of a serious disease which manifested abruptly. [17]. "...It appears plausible to attribute death either to typhus or blood poisoning", in any case a disease for which Giovanni da Procida – the personal physician – did not find a remedy. "The Emperor asked to have with him the most trusted advisors, first of all Berardo of Palermo, who was a friend since youth and took the decision about the future, by preparing the last will", that was dictated to the notary Nicholas of Brindisi.

"He wanted to die as a Christian and Catholic as he had always been, notwithstanding the lightning of the Church excommunications and conflicts" [18]. Frederick, confined to bed, made his confession to the archbishop Berardo who absolved him. Dressed in the "very humble clothes of Cistercian monks" [19] – as we learn from the historian Matteo of Paris – he received the viaticum from Berardo thus following the script "as in life, also in death. He behaved as a typical Christian Roman emperor" [20] and died on December 13^th 1250, the day of Saint Lucy.

The death of Ivan Ilych Golowin

Ivan at the time he was achieving a new social status became seriously ill. Doctors were unable to cure, and even to explain the disease. Ilych realizes that he is going to die and the idea of dying oppresses him.

"I have been here. Now I am going there. Where? ... No, I won't have it".

No one around him was telling him the truth, and he was left in solitude. Only Gerasim, the old servant was loyal to him and assisted him with tenderness.

One hour before the end finally he felt pity for the family, for all his beloved.

"Yes, I am making them wretched, they are sorry, it will be better for them when I die".

With that thought pain disappeared. He heard someone saying "He is gone" and he whispered to himself "Death is finished" and drew his last breath (The death of Ivan Ilych, Leo Nikoleyevic Tolstoy, 1886).

Death in Nazi camps

At Auschwitz nobody used to speak about death

"For the rules of etiquette... in the lager it was considered an insult to speak about the crematorium. Those who dared were immediately shut up. Death was not perceived as immediate, thus people used to clear it from their minds. In my camp, the gas crematorium was a presence everybody used to remove from their thoughts. The same occurred in other camps, even at Birkenau" (Primo Levi, If this is a man, 1947).

Etty Hillesum

Etty Hillesum, a Jewish Dutch woman in the concentration camp of Westerbroek, prepared herself to die asking for God's help, a God initially unknown to her. Later making reference to the God of the Bible – symbol of non-violence – she prepared herself to die at Auschwitz where she was transferred with the whole family.

In her diary we read: "Life and death, pain and happiness, the blisters on the feet exhausted for the long running, the jasmine in the garden, persecutions, atrocities, all together within me have generated a powerful whole. I did not know before how to behave with death, I am virgin in this respect". However death big as it is and simple as it is, natural as it "entered in my life. Life is a splendid and great thing".

When she speaks about the only man she deeply and tenderly loved she points out that he died of a natural cause. Preparing for the final trip she is proud of the courage of her family "I am proud of them".

"Singing we left the camp, my mother and my father very strong and calm... thanks for your good care" she wrote in a postcard she let fall from the train directed to Auschwitz where she died on November 30^th 1943 [21].

Let me go the house of the Father: death of Johannes Paul II

The last months of Johannes Paul II were a testimony a continuous suffering. He had difficulty in speaking and swallowing because of Parkinson's disease. Thus, on January 24^th 2005, audiences were suspended. On February 24^th surgery was needed to position a breathing tube. Respiration improved at some extent, but nutrition was difficult and poor. Although physicians had preferred a transfer into the clinic centre of the Catholic University, the hypothesis was rejected by the Pope, as reported in official books from Vatican City. The Pope and the people around him knew that he was reaching the end. The second of April was the last day of his life. At 3.30 PM the Pope whispered in Polish to the attending sister "Let me go to the Father's house". It was a decision about life, about death, for a man of faith was just a transition, he was aware that the last call was nearing and he was prepared for that as written in the testament.

On the death of Cardinal Martini, archbishop of Milan

"You had expressed your decision on the cures you were prepared to accept. You feared to lose the control of your body, to die from suffocation. If you were able today to speak, you would say that it is necessary to speak to the patient about his end, to share his fears, to listen to his desires without terror and hypocrisy. When you were no longer able to fight, you asked to be put to sleep".

The key for you – and for us – was the abandoning of the claim for healing and the idea of living in any case, against the evidence that there was nothing to do. You would say "to surrender to Divine will".

DEATH'S IMPACT ON PHILOSOPHERS

Death and dying according to Montaigne (1553-1592)

Montaigne discusses extensively death and dying in the Essays [22, 23], especially in Book I, 20. There are difficulties in understanding whether his attitude was that of an atheist or that of a believer. Charles Augustin Saint-Beuve and André Gide charged him with disbelief. For Pierre Villey he was a sincere Catholic, for others a soul ready for Reform (Geralde Nakam), for others a fideist (André Tournon and Michel Onfray), for others a new Christian. Was his religion a practical exteriority harmonized with faith? Or did he just adopt the religion of his country since he writes "Are we Christians as we are Périgourdins or German?".

Concerning death Montaigne is very precise quoting his sources, he is meticulous, just to show that he respects his predecessors and transmits their thoughts correctly to the new generations. Cicero the Stoic of Tusculanae, Ovid the Stoic of Amores and Metamorphoses, Titus Lucretius Caro the Epicurean author of On the nature of things, Seneca the Stoic of Letters and Essays, are the most quoted sources (Table 1).

To philosophize is to learn to die. The goal of our career is death

"Cicero (Tusculanae disputationes, 1, 30) says that to philosophize is nothing else but to prepare for death. This is because study and contemplation draw our soul out of us to some extent and keep it busy outside the body; which is a sort of apprenticeship and semblance of death".

"The goal of our career is death. It is the necessary object of our aim. If it frightens us, how is it possible to go a step without feverishness? ... Let us have nothing on our mind as often as death. At every moment let us picture it in our imagination in all its aspects" (Essays I, 20).

Knowing how to die: a freedom

"It is uncertain where death awaits us; let us await it everywhere. Premeditation of death is premeditation of freedom. He who has learned how to die has unlearned how to be a slave. Knowing how to die frees us from all subjection and constraint".

"Since my earliest days, there is nothing with which I have occupied my mind more than with images of death. Even in the most licentious season of my life, amid ladies and games..." (Essays I, 20).

Waiting death at work

"We must not plan anything that takes so long, or at least not with the idea of flying into a passion if we cannot see it accomplished. We are born to act: when death comes, let it find me at my work" (Ovid, Amores, II, 10, 36).

Fear death less than nothing

Since there is no afterlife he does not foresee the reasons to abstain from pleasure of life, any pleasure, from the simplest to the most demanding. "We cannot do anything to prevent death". We must accept it. Philosophy is man's strongest resort. So his Epicureanism was not only theoretical but lived.

Living not measured by length

The advantage of living is not measured by length, but by use; some men have lived long, and lived little; attend to it while you are in it. It lies in your will, not in the number of the years, for you to have lived enough.

"The whole life of a philosopher is a meditation on death" (Cicero). But it seems to me that death is indeed the end, but not therefore the goal, of life; it is its finish, its extremity, but not therefore its object.

On palliative care

He justifies suicide and active euthanasia. Death is a going out in loneliness. Thus disease is an occasion to understand death, and to become familiar with it. He speaks about the perniciousness of the healthy state (salubritas perniciosa) and the benefits from diseases (maladies salutaires). Thus he fully adopts a Middle Age concept which values disease as wholesome (infirmitas salubris). Death however is not caused by disease, it is still a living act. He anticipates the concept of modern hospitals and especially palliation places where the nursing staff should assist patients till the very end and meet their minimal needs, and possibly with a smiling face. He fully adopts Epicureanism and in this he is not very original (Essays I, 20).

In the letter to his father on the death of La Boétie [24], in August 1563, one learns of "the unique and brotherly friendship" of Montaigne and de La Boétie. La Boétie – not different from Don Quixote – calls his uncle and his wife and thanks them and declares his acceptance of "whatever his holy Majesty will be pleased" and consoles the relatives stressing "that life is smoke and mere nothing".

Finally, La Boétie asks "God forgive me for my sins" and "guide my steps and make me better than I have been". He admits that "it is a great thing to be alive" (Essays III, 13), although I am "not a man but a semblance of man". "Good night my wife". He gave up the ghost at about 3 o'clock on August 15^th, 1563. The adherence to the prescriptions of the Council of Trent was total.

Death in the "Small moral works" of Giacomo Leopardi (1798-1837)

Death, or better, the idea living human beings have about it – as the absolute negative – is the main character of the Small moral works of Giacomo Leopardi, a world poet. Before analysing some passages it should be stressed that for a long time Leopardi was considered an atheist, an enthusiastic follower of Rousseau, a thinker not negating the reason of Enlightenment, and also invariably pessimistic and–at a certain extent – a Romantic. In recent times, however, the roots of his Christianity have been disclosed and worked up by Divo Barsotti and Luigi Giussani. For the former negating his religiosity is negating his poetry, since Leopardi was a lifelong God seeker.

In the Dialogue between fashion and death, death and fashion are represented as sisters, two frail sisters. In the Dialogue between Nature and Soul, the latter understands that immortality and glory do not nurture happiness, but just do the opposite. Thus the soul renounces to glory and expresses a preference for an accelerated death. In the Panegyric of Birds everything in life is old, decrepit, on a slippery road to death, everything runs toward death. In turn in the Dialogue between Plotinus and Porphyry, the question is about the governance of death through reason, and Porphyry says "Why then should suicide alone be judged unreasonably, and from the aspect of our primitive nature? Why should this latter, which has no influence over our life, control our death? Why should not the same reason, which rules our life, govern our death? It is a fact, whether due to reason or our unhappiness that in many people, especially those who are unfortunate and afflicted, the primitive hatred of death is extinguished, and even changed into desire and love. Such love, though incompatible with our early nature, is a reality in the present day. We are also necessarily unhappy because we live unnaturally. It was therefore manifestly unreasonable to assert that the prohibition which forbade suicide in the primitive state should now hold good. This seems to me sufficient justification of the deed. It remains to be proved whether or not it is useful".

Finally, in the Dialogue between Ruysch and his mummies, death becomes a fall into sleep with an absence of pain. "It is rather pleasure than anything else. You must know that death, like sleep, is not accomplished in a moment, but gradually. It is true the transition is more or less rapid according to the disease or manner of death. But ultimately death comes like sleep, without either sense of pain or pleasure. Just before death pain is impossible, for it is too acute a thing to be experienced by the enfeebled senses of a dying person".

Death for Benedetto Croce

Before dying, Benedetto Croce dictated to his daughter Ada a sublime thought: "Although death may be seen as sad and gloomy, I am a full philosopher and I cannot omit to clearly understand that it would be terrible for men not to die, convict in the prison which life is, and continually repeating always the same vital path... The whole life is preparation to death, and there is nothing to do till the end except to continue living waiting with zeal and devotion and pursuing all our duties" [25].

In a letter to Alma Everts (Letters, vol.1 ), at the time of the death of her mother, Croce writes: "When a tree is eradicated, a tree with great and strong roots, a chasm remains opened in the earth. What shall we do? Our feelings are like a set of bill signed by pain which must be paid. The greater the love, the greater the pain... Please do not think about death. The real problem is life, which continually sprouts problems".

Finally, Benedetto Croce in The deceased speaks of "those persons who were dearest to us, as our own parts"... "that pain is more or less madness". "We are eaten with the remorse of living, we have the impression that we are stealing something which is not our property, we would like to die with our dead. Unfortunately, none exists who had not had this experience".

DEATH IN THE WORKS OF GREAT WRITERS

Just out of here. Out of here – that's my goal

For Kafka, death was an undefined goal [26], a journey without a definite finish, something unknown, impossible to know, definitely marvelous, it was a "going out from here".

"Where are you going? I don't know. Just out of here, just out of here. Out of here, nothing else... going out of here - that's my goal".

The appeal to those who died before us

Eugène Ionesco (The Lessons) asked the dead to teach the process of dying. "People dead before me, tell me how you were capable of dying, help me to cross the threshold you have crossed. Just for an instant come back to the Earth, please help me. The dying person dies alone, and in loneliness faces his own death, the death everyone experiences. No one can walk that step for us, everyone must go on his own two legs, individually. No one will wait for us on the opposite shore. No one will welcome us at the door of the night. There will be no fellow travellers".

The quick and immediate death

Philip Roth (Everyman) describes the quick and immediate death, without suffering, of the protagonist, through the pleased words of his third wife who recounts that he had a beautiful end. It happened all of a sudden, without additional blows which might have debilitated him and pushed him into the hospital ward.

Roth aspires to a death without suffering while sleeping as the highest of expectations. Because our own death is not just the inevitable event from which each of us escapes. We cannot accept our own death, which is most outrageous. And Roth describes effectively the waiting for the final time, the time when we lose something everyday "we become less and less. The time for waiting is waiting for nothing".

Death, singularity and irreplaceability

For Jacques Derrida "death is very much that which nobody else can undergo or confront in my place. My irreplaceability is therefore conferred, delivered, 'given', one can say by death. It is from the site of death as the place of my irreplaceability that is of my singularity, that I feel the call of responsibility. In this sense, only a mortal can be responsible" [27].

Michel Onfray

Michel Onfray, the founder of the Popular University at Caen, who has been ranked as 21^st in the list of the most relevant atheists of our times in Féeries anatomiques (Il corpo incantato, Milan, Ponte alle Grazie 2012) developed a manifesto of libertarian, atheist bioethics based on technology and science against the market, the religions – Catholicism in particular – and favouring divorce, birth control, abortion, cloning, transplant of organs and tissues and euthanasia. In the first chapter he deals with the lymphoma of Marie-Claude, a woman who fails in a suicidal attempt, and describes the routine connected with such a diagnosis. He remarks that once one enters "in such adventures there is a lot of waiting. Waiting for results, appointments, decisions, conclusions, diagnoses, prognostications, examinations... waiting for the moment when there are no more expectations and life is accepted as it is".

Concerning death, Onfray departs from Freud's compulsion to death and lands in the realm of apoptosis, having in mind to de-Platonize death, to support euthanasia. He says that life begins with death, since at the time the first sperm cell enter into the oocyte all other sperm cells are destined to die. Thus, "there is no possibility to escape it".

"Learning to die? This is an idiocy. Between the duty of death and our personal death an abyss exists". "Domesticating death? Another stupidity. This is supported by those who favour palliative care. However a wild beast – let's follow the metaphor – does not allow domestication. The terrible beast cannot be domesticated".

"We need to face death directly, having clearly in mind that the fight is lost" (Epicurus).

The fear for death

Cardinal Martini discussed continuously the fear of old age, sickness and death [28]. For him "The fear of death is existential and cannot be removed; it is a protection for life since it mobilizes our instincts for preservation, resistance and vital aggressiveness". "...Death is the final step which follows other dramas. Humans have to face disease, old age especially when associated with other aches and loneliness, fatigue, breakdowns, loss of interest in work, encounters, nature, and furthermore social deprivations, failures, loss of fame, of prestige diminished. All anticipate the fear of death and for this reason we live them in fear and horror with the wishful thought that they may not occur". Even Jesus in the Gethsemane "offered prayers and supplications with cries and tears to God who could save him from death, and for this total abandonment in the father the wish was granted" (Eb 5, 7).

The fear of loneliness

For Giulio Giorello [29], research and love are the best answer to fear, which is not only fear of death, but for the more worrying loneliness. "Loneliness is the most dramatic characteristic of life nowadays for human beings... Man needs more energy to oppose, to overcome". However with Benedictus Spinoza (Ethics, V, Proposition 23) "nevertheless we perceive to be destined to eternity".

According to Paul Ramsey [30], "if the sting of death is sin, the sting of dying is solitude... Desertion is more shocking than death and more feared. The chief problem of the dying is how not to die alone".

Death of the writer Christopher Hitchens

Mortality (2012) is the posthumous piece of Christopher Hitchens, a brilliant writer who died at the age of 62. Hitchens states: "I have more than once in my time woken up feeling like death. But nothing prepared me for the early morning in June when I came to consciousness feeling as if I were actually shackled to my own corpse. The whole cave of my chest and thorax seemed to have been hollowed out and then refilled with slow-drying cement. I could faintly hear myself breathe but could not manage to inflate my lungs".

The disease came while he had many projects:

"I had real plans for the next decade ... Will I really not live to see my children married? To watch the World Trade Center rise again?"

He died an atheist as he was lifelong, since "think being an atheist is something you are, not something you do", and refused religion, any religion till the very end: "A human being in fear and doubt who is openly exploited to believe in the impossible" [31].

In the television debate with Tony Blair in Toronto, in November 2010, the terminally-ill Hitchens said: "Once you assume a creator and a plan, it makes us objects, in a cruel experiment, whereby we are created sick, and commanded to be well". "Religion forces nice people to do unkind things, and also makes intelligent people say stupid things".

WHAT MORTALITY IS: DEFINITIONS

"Death has been always a sign of human nature, thus the adjective mortal has been reserved to human beings, starting with Greek thought. Two meanings merge in this attribute to mark that humans are continually exposed to death and that at the end mortals have to die"."Death is the most personalized action of our life, that for which one cannot be replaced. A very personal event. No one can take on his own the death of another person". "Death cannot be separated from life and it should be considered as the definite destiny of man. Behind death no decision can be taken" [32].

On life and death

"Life is a drop of water. When it falls in the sea is no longer a drop, it reunifies with the sea without losing its nature" (Raymond Panikkar, 1918-2010).

The people of Orphalese asked the Prophet "how do we catch and understand the secrets of death?".

"Look into the heart of life since life and death are indissolubly connected as are the river and the sea. Dying is to stand in the wind and melt into the sun" (Kahlil Gibran, The Prophet, 1923).

Death is a secret

"Death in our times is a private condition, it sometimes becomes a reason for shame and is announced after burial. The life of the dying person is guarded in strict privacy and silence. Death is secret. Dead persons start to be absent before they die" [33].

Learning to die

For Ludwig Wittgenstein, "Death does not belong to life. We cannot live our death. In our present life there is no place for death", whereas for Heidegger "Death escapes experience. We do not learn from the death of other persons. Death is the end of being. Death is a constitutive dimension of the living, it is innate in human existence" (Heidegger, Sein und Zeit, 1927).

"Death is seen as intolerable violence, and is a constant menace when we receive a diagnosis of a serious disease and when we lose our autonomy. So it is injustice, lack of equity, humiliation, abandonment. We should counteract this attitude, especially the indifference. Our society has no time for the diseased, it is intimidated by them. So death which was part of everyday life is now silent and we accept, we impose this kind of silence, we suppress it" [34].

To die sweetly

For Roger Scruton, professor of the Birbeck College, "There are three different approaches to death – religious, scientific and philosophical – which are not easily reconciled." From the religious point of view, death "represents the incoming in the kingdom of judgement and in the world which will come". For science, "death is something which arrives for all living organisms, at the time their vital mechanisms collapse...life after death is neither observed nor visible and science cannot explain it". "Philosophy has the duty to discover the meaning of death in order to derive a kind of guide on how we might live with our mortality and stopping our desperation in our thinking about it". It is evident that "in a society negating death one cannot even name it and the attempt to deal with it is absurd", there is a need "to have laws capable of protecting the value of human life against the process which can be defined as the medical erosion due to medicine" [35].

The sense of disease and death has changed

Disease and death have changed their sense, instead of being part of life they became aliens. Physical decay and death are perceived as obscenities. The technological progress in medicine and its victory against numerous diseases sometimes have perverse effects to the disadvantage of patients affected by incurable diseases [36].

Now it is my time

"When the parents die, death comes near to our life and we are forced into a confrontation. Now it is my time" [37].

This is like in a postal office, a train station, in a bank when on the board our number appears and tell us that it is just our turn and we cannot back out.

DEATH IN MODERN PIECES OF ART

Edvard Munch's "The Scream"

Lifelong Edvard Munch depicted passions, diseases, insanity, anguish, loneliness and death. The screaming man is an emaciated figure – nearly a garbed skull – holding the head with both hands, behind him the friend going in the opposite direction. Nothing to exchange. Was the cry an echo of the cries from the insane and/or of the animals slaughtered near the clinic? Is it a representation of Nietzsche's "God is dead and we have nothing to replace him?".

However, The Scream gives the same message as the Death of Marat, and Golgotha. He personally reported on the generation of The Scream as it follows: "I went along the road with two friends – / the sun set, suddenly the sky became blood and I felt the breadth of sadness. / I stopped leaned against the fence – deathly tired. / Clouds over the fjord dripped reeking with blue/my friends went on but I just stood stand trembling with an open wound/in my breast I heard a huge extraordinary scream pass through the nature" [38].

For the love of God of Damien Hirst

Damien Hirst is one of the most important and best-selling artists of our times. He authored a manifesto on "The physical impossibility of death in the mind of someone living". In 2007, Hirst has produced a piece named For the love of God. It is made of a platinum skull cast on the skull of a man living in the years 1720-1810, implanted with true human teeth and covered with 8601 diamonds. All together they make 1,110.18 carats (221.24 g). It is a resplendent piece of art, and although it remains a memento mori (remember that you have to die), it is the most costly piece of art [39]. "The skull is out of this world" – says the Dutch arts expert Rudi Fuchs. In fact, "It proclaims victory against decay and at the same time it represents death as something more relentless". Death is glorified, it is immersed in light, it is resplendent and blinds. It exalts death, it stimulates the love for death, it also explains why humans are attracted to death. Made of materials which do not decay with time, they inspire immortality.

LIFE AND DEATH

Life flourishing in death

Nicholas was a seven-year old boy, the son of Reginald and Maggie Green, and was visiting Italy, a country he loved. For a seven-year old boy he had seen a lot of it, all the way from the Dolomites and the chessboard at Marostica to Paestum and Portofino.

On September 29^th, 1994, around 10.30 PM, Reginald was driving on the highway from Salerno to Reggio Calabria. Nicholas was sleeping on the back seat of a rented car next to his four-year old sister. Maggie was dozing next to Reg, who was just thinking – as he frequently did those days – "How can anyone be so happy?" [40-43].

The story progressed to a tragic conclusion: two criminals mistook the rented car with its Rome license plate for another one, scheduled to come along that road that night, delivering jewellery. "There was a deafening explosion and a bullet blew out the side window by the back seat. Maggie turned round quickly to make sure the children were safe. Both seemed to be sound asleep. At that moment there was another explosion, and the driver's window disintegrated, the bullet missing Maggie and me by inches". The Green family eventually escaped and raced along looking for somewhere to contact the police and happened to come across an accident where there was already an ambulance. Then the full tragedy became evident:

"As I opened the car door and the light came on Nicholas didn't move. That was the first time we knew anything was wrong. He was taken to a small hospital and later to the nearest general hospital in Messina, because he was too seriously wounded for them to deal with".

"At Messina the chief surgeon introduced himself. Without preamble he said simply, 'The situation is very dramatic'. The bullet had lodged at the stem of the brain. It was too deep to operate on. The only hope was that his condition would stabilize and that in time they might be able to do something. The end came undramatically. We were called to the hospital, and the chief neurologist said in a flat voice, 'I have bad news. We can find no sign of brain activity!'. A half hour or so passed while we sat and held hands in that sunny room, not speaking much and grappling with the realization that I would never go out with him for one of our walks again, never hear him say 'Goodnight, daddy'. The result of the scan was brought in: there was still no activity. He had died, like one of his classical heroes, on the shores of the straits of Messina".

The removal of the organs and the transfer in the places they were implanted occurred smoothly:

"Within a few hours we received a message from the mayor of Rome, expressing his sympathy and gratitude. From this we learned Nicholas' pure heart had gone to a Roman boy, who had had five operations on his heart, all of which had failed. Soon the names of all the others became public. There were seven of them in all. Four of them were teenagers with all their lives ahead of them" [40-43].

Nicholas' shortened life, by the hands of criminals, has now been turned into a paradigm in order to teach what organ donation is, even to children attending elementary school [44].

The baby born from a brain-dead mother

Carolina Sepe, a 25-year old pregnant woman, was shot by her neighbour, Domenico Aschettino, for futile reasons connected with the priority order in the occupation of places in a parking area. The event occurred at Lauro, a small town in Province of Avellino, on August 26^th, 2013. Carolina was admitted – as brain dead – to the Cardarelli Hospital in Naples. The brain was compressed by bleeding and she needed surgery in order to allow completion of pregnancy. There Carolina delivered, by Cesarean section, on the 27^th week of pregnancy, six days before Christmas, Maria Liliana. The baby has been adopted by the Municipality of Lauro – till the legal age – "which will also provide her all means to live and develop", with the aim to turn a tragedy into a positive symbol. Carolina died 133 days after the criminal act [45].

The beautiful death of Monica, the mother of Augustine

In the Confessions (ninth chapter), Augustine speaks of the death of Monica, his mother [46]. Monica was spiritually serene, she used to discuss with Augustine the Kingdom of Heaven and the eternal life. Suddenly she became ill. An unknown feverish disease. She was prepared to die, having finally seen Augustine turning into a Christian Catholic. She, in fact, asked "what is more to do, here ?".

During that sickness, one day "she fell into a swoon; being for a while taken from visible things. We ran to her, but she quickly came to herself again... and asked 'where was I?"Here, said she, you bury your mother. I held my peace and refrained from weeping... Son... I have no delight in anything... my hopes in this world are vanished... what am I still doing here?".

"In the ninth day therefore of her sickness, and fifty-sixth year of her age, and the thirty-third of mine, that religious and holy soul was released from the body"... Augustine stopped weeping, lamentations seemed inappropriate, since Monica had successfully spent her life and fortified her faith.

Finally, Augustine begs "God, let her rest therefore in peace with her husband, before, or after whom, she had never any other; whom she obeyed, through patience, bringing for fruit unto thee, that she might bring him also unto thee".

Amortality – 10 Ideas Changing the World Right Now

Following the article of Catherine Mayer, "What is next 2009. Amortality" (Time Magazine, March 12, 2009). The Collins dictionary defines amortality as "the trend to living agelessly, often in denial of mortality". Therein Mayer stresses "I coined the word in the 2009 article in Time Magazine and later wrote a book, Amortality. The pleasures and perils of living agelessly [47]. The word has now passed into widespread usage along with the noun 'amortal' to describe someone who lives agelessly or appears age resistant".

"Amortality is about more than just the ripple effect of baby boomers' resisting the onset of age. Amortality is a stranger, stronger alchemy, created by the intersection of that trend with a massive increase in life expectancy and a deep decline in the influence of organized religion – all viewed through the blue haze of Viagra". "Amortals live among us. In their teens and 20s, they may seem preternaturally experienced. In later life, they often look young and dress younger. They have kids early or late – sometimes very late – or not at all. Their emotional lives are as chaotic as their financial planning. The defining characteristic of amortality is to live in the same way, at the same pitch, doing and consuming much the same things, from late teens right up until death. Amortals don't just dread extinction. They deny it". For them, age does not count, what counts is how do people feel, what any single man or woman thinks. Amortals practice sports, any sport, even Marathons and train intensively for that, convinced that being youthful is just a mental disposition, which supports the capability of looking forward. The list of famous people who behave as amortals, is long. Furthermore amortality is not seen a transient phenomenon for the happy few, rich and beautiful.

ON HOPE

What hope is

In the Italian Vocabulary of Devoto-Oli, "hope" has many meanings: a) Trusted waiting, more or less justified, for a welcome, favourable event; b) Aspiration – often vain – for a vague future full of good and happiness; c) A bold attitude towards life; d) An encouraging and consoling state of the soul; e) A trusting and optimistic conviction; f) A set of ambitions and projects into the future; g) A favourable and positive prospect or possibility.

In Catholic morality it is the second theological virtue according to which believers aim to God's beatific vision.

For the Merriam-Webster Dictionary, hope is trust, reliance, desire accompanied by expectations or belief in fulfilment, someone or somebody on which hopes are centred, something hoped for.

Heraclitus of Ephesus (floruit c500 BC), in oracular language, wrote "if one dose not hope, one will not find the unhoped-for, since there is no trail leading to it and no path" (Fragment 18).

"When they [men] are born, they are willing to live and accept their fate [death], and they live behind children to become victims of fate (Fragment 20).

For the philosopher Emanuele Severino [48], Fragment 18 supports the notion that one can find the exit, the solution, even in difficult conditions, and Fragment 27 supports a great eternal destiny to humans after death. For him humans do not come from nothing, and will not precipitate into nothing. All that existed, exists and will exist in eternal. The eternity has nothing to do with the fact that we are born, live, have pain, suffering, agonize and die, it is an event, is part of the cumulative experience. It lives in the memory, however dead will not be living again.

Hope of Thomas Aquinas

For Thomas Aquinas (1225-1274), (Summa Theologiae, Vol. II, q. 40 a. 1), hope has four main characteristics, which he details: "Now in the object of hope we may note four conditions. First, that it is something good, since, properly speaking hope regards, only the good. Secondly, that it is future, for hope does not regard that which is present and already possessed... Thirdly, that it must be something arduous and difficult to obtain... Fourthly, that this difficult thing is something possible to obtain...".

Hope is a bridge

Maria Zambrano [49], a pupil of José Ortega y Gasset, discussed the roots of hope. "Hope sustains all events in life, trust sustains hope. Hope becomes available and evident during dejection and exasperation following events generated in the intimacy of someone being left to his own resources or imprisoned in a hopeless position when no exit exists. In that eventuality, by nurturing hope it is possible to find an exit even when an exit is not available. In that context the whole life is turned into hope which climbs over and clears the insurmountable hurdle. In difficult situations hope takes place, has a role. When life is going to give up, the earth comes in to rescue and sustain, even in the case where we do not appreciate it".

Laic and Christian hope

According to Luigi Bettazzi [50], we may distinguish between a laic and a Christian hope. Instilling laic hope in human beings means to help them to adhere to a project in order to realize the goal of good health by playing the appropriate role. There are paths to be followed, this may occur with pains, however when the route is traced, the program detailed, it must be followed remaining centred on the final goal [51]. Hope in such instances is directed to the goal, having clearly in mind that the goal is reachable if the patient agrees to full collaboration, to all manoeuvres indispensable to achieve the desired goal. Thus, opening the door to hope increases trust, confidence and serenity.

Hope as a psychological construct

Snyder, Rand and Sigmon [52] have elaborated a modern theory of hope moving from the old view that hope "is the perception that one can reach the desired goal". In their theory "hopeful thought reflects the belief that one can find pathways to desired goals and become motivated to use those pathways".

For this theory human actions are goal directed. However goals must be attainable, even in the presence of uncertainty, which is not at variance with Aquinas. Goals will be achieved by developing one or more workable routes, a process defined as "pathways thinking". High-hope persons are those who can develop alternate routes when a block is encountered. Agency is the other pillar supporting the core of the theory, and the agency thinking is the capacity of using one's pathways. Pathways and agency thinking include the capacity of envisioning new routes and the energy needed to reach the goal. Thus to reach a goal pathways and the energy to walk them are both indispensable and empower each other. Therefore positive emotions are generated when the goal is achieved by utilizing the envisaged path and, vice-versa, negative emotions are generated when the goal is missed.

Hope influences psychological adjustment, increases positive effects and decreases negative effects. Hope affects coping, which is "the ability to effectively respond to a stressor so as to reduce psychological and physical pain". People "with high hope are flexible enough to find alternative goals in the presence of an immutable goal blockage. In contrast, people with low hope tend to ruminate unproductively about being stuck... and do not learn from past experience".

Hope as a viaticum

For Virginia Woolf, hope had a special role in caring for dying persons: "We have to assist the dying person till the penultimate instant, however we cannot accompany him in the last tract. At that point he will walk alone. Before the dying persons there is a field covered by snow, without traces of humans and animals. We will be with the dying person till the threshold of the afterworld, but then he will be alone, having hope as viaticum".

Hope in chronic disease

Hope is of great importance in patients with chronic disease. Patients take in great consideration the opinions of health care professionals. Of course what the professionals do is much more important than what they say. The problem is not related to telling the diagnosis to the patients. It has shifted to telling him the truth. In a certain sense – as Elliot and Richards have detailed [53] – "Health care providers have an obligation to promote, instil and maintain hope since an enhanced level of self may have beneficial effects on psychological adjustment" [although] "the palliative aspects of this process may wane the longer an individual lives with realities of physical disability". This is not against "the necessity of accurate reality contact" and the necessity to understand that patients "may harbour many biased – if not illusory – perceptions of themselves, their future and their environment".

Maintaining hope when clinical conditions deteriorate

Hope is thought to be of benefit to patients since it reinforces the coping process, lessens anxiety and enhances quality of life. However Jennifer Beste in a chapter (Promoting authentic hope) in Yale Manual on What is the point?, explains that instilling hope "fuelled the pursuit of medically futile treatments and resulted in greater despair for patients who did not respond positively to treatment". Therein one also learns that the death of patients – a frequent event in hospitals – usually does not modify the doctors' attitude towards hope. They continue to instil hope since it is thought a sine qua non for recovery. However there is danger in this attitude, since it may drive to a softening of the truth, truth which is essential to the patient's decisions. Unfortunately some doctors even think that instilling hope should prevail over telling the truth [54].

In a study of Miyaji, 50% of doctors, when clinical conditions deteriorated, softened the information: thus the patient asks for more technology and innovative drugs instead of adopting palliative care [55]. This attitude denies the patient the rights to actively participate in decisions concerning his disease, and forces him to take wrong decisions which have also consequences on his beloved ones. Prognostication is indeed the first moral obligation for physicians since Hippocrates. Negating the prognosis is contrary to the oath without considering that optimistic prognostication causes patients "bad deaths" after having lost the trust for doctors.

From breezy optimism to the darkness of pessimism

Alexandru Tocilescu, Director of the Rulanda Theatre in Bucharest (Romania), a great artist of international reputation, in 2011 gave a talk for the World-kidney Day/Survival is not enough, and wrote a paper entitled After 23 years [56]. He died that year of a heart attack on November, 29^th.

"23 years ago, when my kidney condition kicked in, I learned that I would have needed dialysis for the rest of life. As anyone else, I stubbornly refused this treatment, due to the fear of it taking over my life and I resolved that I would much rather die than allow that to happen to me. Two days later I was flying to Germany where a doctor, who later became my personal physician, told me that after I had been in a coma, it was sure that unless I had begun dialysis treatment, I would see things differently. I never went into coma but after one and half hour of dialysis I did start to see things in a new light. Although I was desperate at first, and continuously fostered by the thoughts that I would spend the rest of my life attached to a machine and – as I saw it at that time – to a certain place, I felt a little better every time.

I had wasted my time all my life, my youth and strength doing things like drinking, mingling with dubious individuals... When I learned that a dialysis patient could live up to 20 years I realized that my time in this planet had become limited, I finally knew that I had to make that period worthwhile, meaningful, I had to create goals for myself and fight to achieve them. This was the fight against my disease, against my physical conditions, and most of all, against my way of thinking. I do not want to impress people. All I want is to make you understand how easy is to fall from easy, breezy optimism to the darkness of pessimism" [56].

Hope is not a synonym for illusion

Edgar Morin, in his last work [57] has a short chapter on death purposely written for non-believers. "Death is inexorable, whereas The chant of chants grants that love is stronger than death. The truth is that love is very strong, however it cannot win over death". Morin makes the point that, in present times, death obliges the living person to be acquainted with its individuality and its mysteries. He is aware of the potential of cells regenerating and modifies Bichat's tenet "life is the addition of functions opposed to death" by adding "by making, at the same time, full use of death". "Not only life is present in the mortal world, but death is to be found in the heart of the living world, thus death is our enemy, but is not an alien". "The Milky Way will die, the Universe will die. However recognizing death as the supreme queen is not a fatalistic resignation. Human beings must continue to fight what is more horrible in nearing death, namely pain and loneliness". "Accompanying dying persons is a new humanistic mission of the laic world. It is an ethical imperative to let the other escape the loneliness of death". "During crisis, in addition to regressive and disintegrating forces, creative and regenerative forces awake".

Adopting hope-espérance

Eugenio Borgna – the outstanding Italian psychiatrist and fertile writer – makes full use of the concept of time, not that measured by the watch and sand-glass, rather our internal clock, the marker derived from our personal experience, the time defined by Augustine in the twentieth chapter of Confessions [58]. "There are three times; a present of things past, a present of things present, and a present of things future". For these three do somehow exist in the soul, and otherwise I see them not: Present of things past, memory; present of things present, sight; present of things future, expectation. If of these things we are permitted to speak, I see three times, and I grant there are three [59].

Borgna reflects about essential problems of the human condition including melancholy, anguish, and hope. Melancholy is living a difficult present after a luminous past. Thus it kills hopes, wishes and nostalgia, meanwhile the patient is immobile, silent, does not need to speak. Anguish – by contrast – accelerates the future, the march to death and nears us immediately to the final point. Borgna thoroughly discusses hope departing from philosophers "who have cancelled the idealist roots of philosophy dipping them in the concreteness of life" including Augustine, Pascal, Heidegger, Husserl, Kierkegaard, Stein, Max Scheler. "When we hope and wait for our hopes to become reality, we see the future nearing us like a dizzy star nearing the earth. Thus the time of hope (espérance) liberated from worry about our immediate future, which is connatural to the wait, makes us experience a broader farther future, promising more than the wait per se, so that the infinity of the future is disclosed to us". The time of hope-espérance does not coincide with the time of each single hope-espoir marking life's route through the daily and trivial sequences. So the time of hope "is that of the infinite future, not linked to one or more coincidental hopes-espoirs". Borgna quotes Eugène Minkowski [60] for whom hope-espoirs have to do with practical aspects of everyday life, being tangible and hard facts. Hope-espérance is not above or against hope-espoirs, it encompasses them and is opened to the becoming, to the future. Espoirs, of course, have a meaning since they entail a reflex of hope-espérance. Borgna concisely and nicely explains that Gabriel Marcel, in Homo viator (Aubier, Paris, 1944), negates the identity of hope and optimism, and makes full use of French language which allows a differentiation between espérance and espoir. The former is the absolute hope, is transcendence, is communion, allowing us to say "I trust you for us".

Borgna aims to a hope-method, a hope-interior-attitude, a hope-transcendence "capable of reviving the hidden internal resources while floating in the interior life of the patient". Hope as rule, as in Maria Zambrano's metaphor of the bridge. "A creative hope originating in the abyss, during adversity, in the opposition ... creative while suspended over reality, although without ignoring it, and capable of giving origin to a new kind of hope, for which the appropriate word has not been coined, that is the revealing hope" [61].

Maria Zambrano links hope and mercy. Mercy (from the Latin stem Pietas) is for the Italian Dictionary of Devoto-Oli a "feeling of solicitous participation into somebody's unhappiness" and also "a reverence or devotion due to affection or domestic, social and religious duties".

For Zambrano "Mercy is the most difficult to define" although it "is the deepest and broadest emotion, something which can be defined as the home of all other emotions". "It disappeared rapidly with the azimuth of rationalism". "It does not correspond to delicate handling of our neighbours, animals and plants. Mercy is neither philanthropy nor compassion for animals and plants. Mercy is the capability to handle those radically different from us". "We became intolerant and incapable of accepting what is different from us" this in opposition to what happened in Middle Ages. The men of the Middle Ages "were capable of handling different things, with the diseased, the monsters and criminals". "Mercy is the emotion of the heterogeneity of being, of the quality of being, and therefore the emotion which allows them to catch all the aspects of the multiplex reality". "Will human progress damn definitely Mercy? Modern ethics has substituted for it different virtues or values: Philanthropy, cooperation, justice. Justice is now what is given and is done, everything is done in its name" [61].

Ernst Bloch: The principle of hope

Bloch [62] says that a dream remains dream, and hope is a half-open door on the world which is not a prison. Hope does not exist without anguish, and anguish does exist without hope. They support each-other reciprocally. Hope however may be deceiving, thus we need a wise hope, well balanced in advance. The saga of Pandora says that hope was brought to humans by a female in a demonic way. Thus in Antiquity Helpis was described as tender, covered by veils, while running away. However, at the time of death hope is turned into desperation as in the case of the unforgettable hope (Spes) sculpted by Andrea Pisano on the Baptistery of Florence were hope, although winged, waits sitted, and her arms, notwithstanding wings, are put up, like those of Tantalus, towards an unachievable fruit.

Remo Bodei [62] adds that "hope's movements characterize the continuous search for either a new space where the being may expand, or new exits from the difficulties" and asks "why shall we believe in the powers of hope and perfection and, why not believing with identical motivations, believe in the powers of the nothing and of the final destruction of all things?". Why, also from the point of view of the faith in the hope, don't we take into consideration the touching words of Vasily Rozanov, who makes the Christ of the Gethsemane and of the Golgotha speak "My son can free you of your pains, I can't, and it is a terrible pain for me; however, look at me crucified and you may be comforted, you may have some form of consolation and of relief, since I too suffered a lot?" [63].

Bodei advances a great argument. "Against nihilism and anguish typical of this century Bloch does not promise the redemption of rescue but he also considers unilaterally sided the emphasis on anguish of the "being for that Sein und Zeit of Heidegger of which the Principle of hope is the counterpoint voice". "Anguish carries along, as a secondary effect, desperation, which narrows the horizons of each single person within the frontiers of death. Individuals are secluded and creased, their own capabilities are frozen, impeded... Hope is a resource... Not always hope was considered a virtue, many philosophers have condemned it, from Stoics to Spinoza [64].

COMPASSION/MERCY/SYMPATHY

For M.A. Farley "Compassion is a powerful response to human need and human suffering". "Compassion is suffering with the ones in need. ...It awakens in us a moral response to alleviate or ameliorate it, prevent it in others, or if none of this is possible, to companion and literally bear with the sufferer in love and respect". "Respect can sharpen the focus of what we see and keep our compassionate responses fitting and true".

"Pity is more passive, it stands outside of the one in need, and does not move to alleviate". Mercy includes – at variance with compassion – condescendence. Sympathy is imaginative identification, but carries a connotation of impotence and may even overwhelm reason. Empathy is a more controlled response, in that it does not incapacitate the one who feels it.

For Nussbaum, compassion is a "painful emotion occasioned by awareness of another person's misfortune". And it represents "a bridge between individuals and the community". "The basic social emotion is a desire to relieve another's suffering and a disposition to perform beneficial actions" (Lawrence Blum). Compassion is "a sharing in the pain and suffering of a need unfulfilled, an injury not healed, an injustice not rectified... however it is not only a response to a need. It is a response to a person. Care is the form that love takes when the beloved is in need. But this means that the first response is love. It only secondly modulates into care and compassion". "Mercy is love for those who are in need, it is the gift which fulfils the need of those who are in misery, as bread is mercy to the hungry, warmth to the ones who are cold, a word to the ones who are lonely. Mercy is giving and giving with love". "If mercy is love for the beloved in need, and love makes the misery of the beloved our own, then we cannot understand mercy unless we understand misery" [65].

RESPONSES TO STRESSFUL EVENTS

Various trajectories

Bonanno et al. have identified four trajectories of psychological response after a stressful event [66]. They are: Resilience, chronic dysfunction, recovery and delayed reactions. About one third of patients have the typical resilience response, indicating stability of psychological and physical health functioning. Ten to thirty per cent follow the chronic path with persistence of high levels of symptoms. Five to fifteen per cent follow the path of delayed reaction initially showing moderate reaction and subsequently experiencing an elevation in symptoms. The recovery path is typically that of people who at the start have a high level of symptoms and subsequently return to normalcy. Hope is a significant predictor of adaptation in healthy subjects and in patients undergoing a chronic stress. The same conclusions have been reached in patients with colorectal cancer following genetic testing [67].

MEDICAL FUTILITY

For Margareth Farley, cases that come under the rubric of medical futility are those "where medical professionals believe that continued treatment – including support of basic life functions such as breathing, taking in nourishment and water – holds no benefit for a patient" [68].

Ordinary/extraordinary cures, euthanasia

The distinction between ordinary/extraordinary has been indicated also as "beneficial/burdensome, medically indicated/not indicated", "it refers to the proportionate benefit and burden of a particular treatment relative to a particular patient" [68].

The simplification used is related for example to "where action is taken to alleviate pain even though the medication given may hasten the process of dying". This has to do "with the death of people whose death is inevitable, when medical treatment is deemed unreasonably burdensome to them, and people for whom the obligation to care in a medical context focuses on providing them comfort in the face of terrible pains". However now the real discussion "is related to the possibly of killing persons who suffer a lot and there is a quest to decriminalize it".

"To more and more persons it appears that the only way to retain some control over our death is to take our death into our own hands – to die a death marked by conscious self-awareness, with knowledge of our ending, surrounded by those we love. It begins to make sense that while science has made death an enemy (to be fought on the battlefield of medicine), so science must come to befriend death, to assist us scientifically in dying as we choose. This is part of the point of proposals for physician-assisted suicide and for voluntary active euthanasia".

One should distinguish between active and passive euthanasia. The first is "actively taking life", the latter is "letting someone die (omitting what would otherwise preserve)". However, letting die nowadays "means pulling a plug, it is not simple to distinguish it from a lethal injection intended to kill", so some say that the distinction is "speciously maintained in bad faith". Letting die is to accept death, to accept that it supervenes because of the disease process [68].

Ordinary and extraordinary means to protect life and prevent death

Pius XII speaking in 1957 to the International Congress of Anaesthesiologist said: "Normally one is held to use only ordinary means according to circumstances of persons, places, times and culture – that is to say that means that do not involve any grave burden for one or another. A stricter obligation would be too burdensome for most men and would render the attainment of the higher, more important good too difficult. Life, death, all temporal activities are in fact subordinated to spiritual ends. On the other hand, one is not forbidden to take more than the strictly necessary steps to preserve life and health, as long as he does not fail in some more serious duty" [69].

As thoroughly discussed by Donald E. Henke [70] in the history of Catholic Church, hydration and nutrition have not been always ordinary means. For Thomas Aquinas, "A man has the obligation to sustain his body, otherwise he would be a killer himself [...] by precept, therefore he is bound to nourish his body and likewise, we are bound to all the other items without which the body cannot live" [71].

However, Francisco De Vitoria (1483/86-1546) also supported the idea that people have to preserve their life and eat, however "if the depression of the spirit is so low and there is present such consternation in the appetitive power that only with the greatest of effort and as though by means of a certain torture, can the sick man take food, right away that is reckoned in a certain impossibility and therefore he is excused at least from mortal sin, especially where there is little hope of life or none at all" [72]. "One is not obliged to use foods which are the best, the most expensive or the most exquisite. Neither is one bound to live in the healthiest climate ... those who refuse to take some particular medicine are not to be condemned since one can rarely be certain that it will work" [73].

Thus the duty is not absolute, no fixed rule, circumstances have to be taken into consideration. The obligation is not valid if expensive foods are needed and when drugs will not grant healing of the patients. Subsequently, according to Henke [70], Dominic de Soto O.P. made an interesting point about the acceptance of amputation [74]: "Whether one is bound to undergo amputation of an arm or leg to preserve or prolong life". His answer supported the idea that none can be subjected to torture [74].

In the subsequent centuries, the concept that the sick were not obliged to use extraordinary means remained valid, even the discussion went on when narcotics became available and pain reduced. The key for obligation was the linked to the real possibility that the cure had to be potentially sure.

Now ordinary means are those potentially capable to be effective, or the cures are not offering a real benefit. "Be worthwhile in quality and duration. Furthermore it must be worthwhile in consideration of the effort expended in using the means" [75], and must be common [70] and not difficult to obtain, and not linked to unreasonable costs and causing not excessive fear. The idea was finally best extrapolated in terms of proportionate and disproportionate means [76].

Artificial nutrition hydration

"Hydration and nutrition are not morally obligatory either when they bring no comfort to a person who is imminently dying or when they cannot be assimilated" (The Conference of Catholic American bishops in 2001). Pope John Paul II in 1998, speaking to Bishops of California, Hawaii and Nevada, stated "A great teaching effort is needed to clarify the substantive moral difference between discontinuing medical procedures that may be burdensome, dangerous, or disproportionate to the expected outcome and taking away the ordinary means of preserving life, such as feeding, hydration and normal medical care". Also, on the occasion of an audience in 2004 to a conference on hydration and nutrition and the vegetative state, he stated that "Sick people in a vegetative state, waiting recovery or for a natural end, have the right to basic health care (nutrition, hydration, hygiene, warmth)". "The administration of water and food, even when provided by artificial means, always represents a natural means of preserving life, not a medical act. Its use furthermore, should be considered, in principle, ordinary and proportionate and as such morally obligatory, insofar as and until it is seen to have attained its proper finality which in the present case consists in providing nourishment to the patient and alleviation of his suffering".

CONCLUSIONS

Hosting death with steam of hot loaves: the beautiful end of Democritus

From Diogenes Laertius (Lives and opinions of eminent philosophers) we learn that Hermippus described the beautiful death of Democritus of Abdera (floruit 420 BC), the discoverer of atoms and vacuum (nothing originates in not being and nothing ends in not being, atoms are infinite in number and size and move vortically) as follows: "He was exceedingly old, and appeared at the point of death; and his sister was lamenting that he would die during the festival of the Thesmophoria, and so prevent her from discharging her duties to the Goddess; and so he bade her be of good cheer, and desired her to bring him hot loaves every day. And, by applying these to his nostrils, he kept himself alive even over the festival. But when the days of the festival were passed (and it lasted three days), then he expired, without any pain, as Hipparchus assures us, having lived a hundred and nine years".

Palliative care

Palliation is for the final trajectories of diseases, when death is imminent. The term derives from a Latin stem, pallium, which means mantel, the mantel of solidarity needed by the dying persons.

So the terms points to indication of protection, affection, participation in the pains of persons who cannot make use any longer of present potential for cure and must be encircled with our warmth. In English we can distinguish between to cure finalized to heal and to care that is just to take care, without aiming to heal, having accepted that the battle is lost. Palliation was initially applied to patients with cancer after all means had failed. This means that caring is the last resource when the potential for stopping the disease has been exhausted. However physicians have been educated, trained, motivated to cure for healing. For them palliation is a failure, a personal failure.

Marie De Hennezel [77-79], psychologist and psychoanalyst and chief of palliative care at the Paris University Hospital, the personal palliating physician to François Mitterrand, says "The dying person and his/her family which is suffering too, must be accompanied, helped to find a sense for the last phase of life and to become the subject of decisions which are inherent in his person and characterize the end of personal existence... In the Koran we read the suffering might cover you, the other, like a mantle. However, therein patients are exiled so they must be granted love and tenderness. In the place where I work, mean admissions last 23 days". "The real problem is to be clear-headed in the presence of death by making projects of life, simply to be alive till the end". However it is difficult for a physician to accept that medicine has no power. "He has studied to heal and considers death a personal failure". "A palliative care unit encompasses clinical competence and understanding of pain, the emotions of the sufferer. Therein patients are no longer numbers but persons". "We must not humour family members and friends. They think that the patient will be not able to tolerate the truth. They fail to recognize that the patients know the truth and carry its weight in solitude" [79].

Sex and the origins of death

W.R. Clark in Sex and the origin of death, 1996, provocatively discussed the limits of DNA transmission for men and women, and the risks connected with this transmission and attached them to the hope that humankind might be able to ponder on that. "We want so desperately to be more than just a vehicle for DNA, and at least transiently we are. Yet somatic cells will die at the end of each generation, whether they are part of an insect wing or a human brain. We may come to understand death, but we cannot change this single, simple fact: In the larger scheme of things, it matters not a whit that some of these somatic cells contain all that we hold most dear about ourselves; our ability to think, to feel, to love – to write and read these very words. In terms of the basic process of life itself, which is the transmission of DNA from one generation to the next, all of this is so much sound and fury, signifying certainly very little, and quite possibly nothing" [80].

Acknowledgements

I express heartfelt thanks to Reg Green, Nicholas Green Foundation, a man who knows death, for his friendly reading, questioning and improving the English language of this paper.

Thanks are also due to Carmela Bisaccia who prepared Table 1, on Montaigne's sources on Death and edited the section on references and cancelled duplicated sentences. It is a privilege to thank Giusy De Rosa and Rosa Maria De Santo who provided strong comments and suggestions about appropriate readings. I am finally indebted to Aldo Masullo for disclosing his view on Leopardi's small works.

Conflict of interest statement

There are no potential conflicts of interest or any financial or personal relationships with other people or organizations that could inappropriately bias conduct and findings of this study.

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Submitted on invitation
Accepted on 27 June 2014

Address for correspondence:
Natale Gaspare De Santo,
Policlinico, Nefrologia SUN, Via S. Pansini 5, Pad 17, 80131
Naples, Italy.
E-mail: nataleg.desanto@unina2.it.