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May 19, 2005

The Future of Death: The perspective of a 64 year old GP

Posted by Myles Harris

What is the future of death? Walking around an Irish cemetery, GP and writer Myles Harris considers how dramatically life expectancy has changed over the last 1000 years. Dr Harris argues that the medical breakthroughs now possible due to cell research make it probable that life expectancy will rise ever more rapidly. Future generation, argues Dr Harris, may well live until they are 150. But with this other dangers arise: "One threat is of a pandemic such as SARS. Large crowds of any species that are packed into one place frequently become diseased, be it chickens in a battery factory or 7 billion humans - many of them elderly - crowded on a tiny blue globe in space". All this will however come too late for a 64 year old GP to witness.

There is a small Protestant churchyard near my house in Ireland. It stands on the side of a hill overlooking the Atlantic. It is an ancient place. Here and there among the graves of English divines who came to convert the Irish after 1650 - and failed - are unmarked stumps of rock. These are tombstones that have been here so long - some over twelve hundred years - they have been worn away by the constant Atlantic gales.

I often walk in the churchyard. My ancestors - Catholics who exercised their right to be buried in Protestant ground by virtue of it being an ancient clan burial place - are buried there. At sixty four I have begun to dwell on the certain prospect of joining them. When you are young you think of death, but it is not until you are sixty that it becomes a presence, a stranger sitting in the corner of the room. Now and again the stranger stirs and you flinch, but then he is still again and you go on with your life.

Faced with death people either deny it or turn to religion. Those in the churchyard had no doubt they would rise again, but in our rational century nobody thinks that is literally true. The graves will not open and the dead appear, remembering things as they were, greeting old friends, being surprised at how much the world has changed. Everything we know about physiology suggests that life after death is impossible. Consciousness is inextricably linked to brain function. After death the body corrupts absolutely. Within seconds of death all its cells cease to work. When your brain stops, so do you. This is the principle of judicial execution by hanging or decapitation. Chop off the blood supply or smash the spinal cord and you, your personality, your memories, everything that makes up that which is you, is expunged forever. It is the basis upon which we make decisions to turn off the respirators of people we think to be brain dead. Belief in an after life has to remain just that, a belief.

It is unsatisfactory. Science has left our society in a philosophical limbo over the question of death. Our ancestors, the people lying in this graveyard, were sure of the resurrection, not merely amiably disposed toward it like modern attendees at a Church of England sermon. They knew that when they died they would rise again, that the body was, like a suit of clothes laid aside for the night, to be put on again on the morning of the Resurrection.

21st century man is not so sure. When asked if he believes in life after death he tends to fidget and look away. In the time of the Hubble telescope, Darwin, Big Bang and quantum theory, it is hard to believe in the literal truth of the sacred texts. And in a 100 years how will we think? Standing in the graveyard where I am now what will somebody from the 22nd century think of this ancient monument to the fragility of man? How long will people live in 2105? Will they believe in an afterlife? Will there be death at all?

It seems inconceivable but a closer examination of the graves reveals a powerful story. They are not a monument to the victory of death, but a record of its slow defeat. When the cemetery was first marked out, possibly three thousand years ago, life was pitifully short. Infant death rates could reach fifty per cent of all births, maternal mortality one in six of confinements. Adults would count themselves lucky to reach forty. War, pestilence and the unreliability of food supplies would keep the population small and death rates high. At intervals whole communities would be wiped out by visitations of disease or famine.

The first change to this state of affairs would have come around 500 AD. Soon after the Roman Empire collapsed missionaries fleeing the barbarians brought their books and ideas to Ireland. Their message was superficially Christian, but concealed in it were the powerful philosophical ideas of ancient Greece. Wrapped around this gift was the Christian theory of an afterlife and resurrection. In a world in which life was all too short this brought hope, and when that hope was linked to the virtues of hard work and a moral life, if you worked hard on earth you would see heaven, the clans gave up their warlike life for farming. In a more stable world literacy, technology and law established themselves.

Very slowly - almost imperceptibly - life expectancy began to increase. Taking into account interruptions caused by outbreaks of pestilence and war you can trace the added years of this relatively well off cohort by the dates on the tombstones. They follow a very slow but steady rise. Medieval society gave way to the Reformation, the Industrial Revolution came and even Ireland received steam engines and looms. Food supplies increased and housing improved (there would have been a dip due to the Irish famine but you will not find the Catholic poor in an expensive Protestant burial ground like this) but by the turn of the century expectancy was rising again. By the mid twentieth century people are living to their sixties. Then the curve takes off. By 1970 life expectancy reaches the middle seventies, by 2000 the tomb stones read 80 years or more. These figures will get higher. The number of pensioners in Western Europe is expected to double in the next fifteen years.

Yet this dramatic progress was not due to any fundamental insights into the ultimate nature of the cell. Rises in life expectancy in the 20th century were due to advances in sanitation, better food, an understanding of germ theory, safe surgery and the chance discovery of antibiotics. But these are crude insights into the basic mechanics of the body, they do not represent major intellectual leaps in our understanding of fundamental biology. Until the discovery of DNA doctors were in the position of car mechanics who could only change a car's tyres, wash its windscreen, hoover its carpets, bash out dents and keep it filled with petrol. If it really broke down it was the scrap heap. Nobody had the factory drawings. Now they have. DNA has taken them under the hood.

Since 1960 subtle and far reaching discoveries about cell chemistry, DNA and gene regulation have been made. We have moved from simple descriptions of the cell to an understanding of it as a marvellously complex digital information engine. Like exceedingly clever apes confronted with a computer we are beginning to dimly understand exactly how we can subvert it to our own purposes. Interest has particularly focused on stem cells. These cells, few in number in the body, contain master plans of how we are built. When stimulated they can grow organs or replacement tissue. Researchers have tried to find out what stimulates them into activity and how they can be induced to grow cells or organs to order.

There has been a recent success in this field. Using stem cells surgeons at a hospital in East Grinstead, England, have found a way of restoring the sight of people some of whom have been blind for years.

The patients they chose had had the cornea - the transparent 'window' in front of the pupil - destroyed by acids, alkalis, boiling metals or burns. The surgeons grew lines of donor corneal stem cells and laid sheets of them over the damaged area. They expected the new cells to create the new graft, but to their surprise the victim's own cells copied the master instructions and 'pushing aside' the stem cells completely repaired the damaged eye with the patients' own native cells. A perfect transplant was achieved.

A 65 year old man described catching a glimpse of blue on a nurse's uniform:

It was the most emotional moment ..... I couldn't believe it. For ten years all I had seen were shades of black and grey, then after I had the operation the nurse came by and I saw a flash of blue from her uniform. I went home and when I took the patch off my eye, I had my vision back. It is only when you lose something like sight that you realise how precious it is.
Another patient described how after the operation she saw her child, who had been born after she became blind, for the first time.

The corollary of this astonishing discovery is that it may be possible to repair any organ in the body using the same technique. The Times reported:

A consultant surgeon at St Mary's Hospital, London, said that it was likely that such action could be mimicked in other organs, thus reducing the need for organ transplants........The hope is that stem cells will one day be used to generate large quantities of cells and tissues and possibly entire organs damaged by disease and is a dream.

Another arm of the work on cells is research into ageing. To answer the question why our bodies get old we have to answer the question why the cells that make them up get old. Particularly vulnerable is the cell's delicate and vulnerable motor, an object called a mitochondrium, which as time progresses burns out in its own exhaust products even at ordinary 'speeds'. Efforts are being made to develop chemicals to protect this vital engine.

In another striking discovery, scientists have discovered that human cells, contain a tiny chemical 'hourglass' called a telomere filled with tiny strips of DNA 'sand'. Each time one of our cells replaces itself with a perfect copy, which all of them do at regular intervals, the hourglass in the cell sheds a grain of sand. When the last drop of chemical sand has fallen the cell stops repairing itself and begins to age. This and the failing mitochondrial motors in our cells combine to bring us down. Our faces wither, our arteries corrode, our livers shrink and we begin to die.

To many to even contemplate interfering with ageing is profoundly upsetting. It undermines the social order, kicks away cherished beliefs and takes God from his heaven. They insist that it will never happen, that it is too complicated, that we don't know enough and we never will. William Harvey who discovered the circulation of the blood in 1616 endured the same chorus of frightened dissent. John Aubrey, who met Harvey in 1642, recounts in his Brief Lives:

I have heard him [Harvey] say, that after his Booke of the Circulation of the Blood came-out, that he fell mightily in his Practize, and that t'was believed by the vulgar that he was crackbrained; and all the Physitians were against his Opinion, and envyed him: many wrote against him. With much adoe at last it was received in all the Universities in the world..

It is true that Harvey's discovery had no immediate effect. Physicians continued to bleed their patients, taste their urine and sniff their stools until the middle of the nineteenth century. It was only then that rapid communications, the railways and fast printing began to allow physicians to share information. Today sitting at my desk I can summon almost any medical journal in the world onto my screen. If a doctor wants to show a patient to an expert on the other side of the world, she has only to turn on a video camera. Ideas are like genes, combine them and you get new organisms.

In the eighties it was this rapidity of information transfer which enabled us to confront a novel and deadly disease, AIDS, caused by an organism that so deeply embedded itself in the cell it seemed impossible to get at it. But researchers were able to describe it, discover its weaknesses and tailor make drugs to kill it, all in the space of a decade.

What will the consequences be of success in the fields of ageing? Initially progress will be slow and costly, but any form of cell manipulation has the potential for mass application. Biological cures, like biological weapons, are easy to mass produce and are cheap. Just as a syringe of measles vaccine - a product of cell chemistry - costs around 3 while treating a complicated case of measles in hospital costs 3500, so a stem cell refurbishment of the heart might cost 2000 against 60,000 for a traditional transplant.

We live in an unstable, overcrowded world, created by a multitude of discoveries we eagerly accept and then are quite unable to control. Life extension will add to that instability. One threat is of a pandemic such as SARS. Large crowds of any species that are packed into one place frequently become diseased, be it chickens in a battery factory or 7 billion humans - many of them elderly - crowded on a tiny blue globe in space.

We are lucky that AIDS is spread by sexual intercourse - a very slow way of spreading a contagion - and not by coughing. If it was spread by coughing we would be looking at a world population about one tenth of what it is now. Most pandemics might kill millions but they would not decimate the world's population. The Spanish flu in 1919, killed 'only' 30 40 million. But the flu killed more than the Great War. Many at the time thought that the terrible psychological effects of the epidemic were a major cause of the social and political disruption that followed leading to the next war. This was in a disciplined population inured to privation and loss. How would our society, which sees life as a right, and has no sense of death or limitation, cope?

If we are to have an epidemic, let us hope we will be left with a slightly smaller chastened, world population which, if it is fortunate, may be able to take advantage of the discoveries that indirectly brought about the epidemic rather than falling upon itself. Much will be a matter of chance. As Clint Eastwood said, "Do you feel lucky?"

I am not a utopianist. My instinct tells me that if there is a pandemic it will not be the most enlightened members of society who will rule the world after it has passed. But there is a chance we will somehow see things through to a successful conclusion. Just as mankind has, surprisingly, so far escaped destruction by his nuclear weapons, there is a chance that there will no pandemic, or social disruption, that mankind might survive the Pandora's box of cell chemistry he is about to open uninjured. He may even extract a necklace.

Unless some huge and simple discovery is made in the next five years I am not going to see any of this. It disappoints me. I would love to know how things will stand in 2105 and what 22nd century man will make of this ancient burial ground. If I am right the world's population will by then be much smaller, but life expectancy will be hugely increased, perhaps to 150 years. It is highly speculative, but by then insights into the nature of mind and quantum computing may offer us a way out of our bodies we cannot even conceive of now. We will rise again but in a way that nobody, especially our priests, predicted. Ours will be a type of religious victory, a victory of knowledge, the word, over the flesh.

Myles Harris is a doctor and a journalist. He has worked in England, Australia, Papua New Guinea, Canada and Africa. He has written for The Spectator, Daily Telegraph, The Independent, Evening Standard and Daily Mail. He is the author of Breakfast in Hell (Simon & Schuster New York, Picador London), an account of his work as a doctor in a relief camp during the Ethiopian famine of 1984.

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What a wonderful contrast to the poorly thought essay on creationism by William D. Rubinstein.

Thank you.

Posted by: Dr. Gary Hurd at May 19, 2005 09:34 PM

This is an extremely interesting article, but there's one point where the author seems to me just plain wrong.

It simply isn't correct to say that no one believes in the literal, bodily resurrection any more. Sure, it's a difficult doctrine to accept. There's nothing new about its difficulty. Augustine, for example, found it challenging. The miraculous is hard to believe - that's the whole point of the miraculous. Still, that doesn't stop some of us, even here in the relatively pagan and under-evangelised West, from seeking the gift of faith, including faith that in this flesh we shall see God.

Or to put it another way, please don't assume that the dogmas of secularist liberalism are going to have quite the staying-power of those espoused by the Christians who, all those centuries ago, first interred their dead in that graveyard by the sea, evoked so powerfully at the start of your article.

Posted by: Bunny Smedley at May 20, 2005 12:08 PM

An interesting piece - but I must say I am not convinced by Dr Harris's argument that increased population will lead to outbreaks of pandemics. Would not medical advances mean that we are better able to deal with future pandemics? Also the circumstances in the rich countries of the West are very different today from 1918. Housing, sanitation, nutrition is much improved, making it less likely that pandemics will break out.

Posted by: Dr David Halton at May 24, 2005 12:07 PM
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