Although death is at the heart of our lives, in many societies people are reluctant to seriously engage in a conversation about death, and the value of death as a fundamental human experience is often lost. The inevitable dissolution of death and its human values blurs our understanding of health and life.
The Lancet Death Value Report[1] emphasizes that the dying process of the 21st century is a paradoxical story. Advances in technology, science, medicine, artificial intelligence, and pharmacy are saving lives, but they are also complicating death in highly resourced health systems. Today, many people die undergoing a lot of treatment that is often "ineffective care." This over-medical treatment in hospitals occurs mainly in high socio-economic settings, in stark contrast to the huge global gap in medical resources. [2] For residents of countries that lack adequate health resources, the end-of-life process is often linked to large inequalities in basic care and basic support. Globally, 61 million people experience severe pain and suffering caused by health-related factors that could have been avoided, and many are still dying from preventable diseases. [3] Countries where the world's poorest 50% of the population are located have access to morphine, an essential drug for pain relief, 1% of the world's total. [4]
For countries where the challenge is to balance dying and death in poverty and inequity, can the Lancet Death Value Significant Report provide a reference? In countries where universal health coverage has not been achieved, death and the dying process have multiple determinants, including the lack of services, resources, professional training, and medicines; the cost of access to treatment; health workers who are reluctant to tell bad news because of cultural, social, and time-critical factors; high-priced interventions that do not deliver on care; and barriers to access to suitable or safe places of death due to isolated sanitation services or the lack of basic supplies such as bed sheets, mattresses, sanitation, and running water. All of the above factors can actually be dealt with. Unlike other global health priorities, the biggest obstacle countries face to properly delivering care for their deaths is not unaffordable prices, but the failure to properly recognize the value of the dying.
The dying process has become one of the most expensive health care events. Spending in the last year of life is surprisingly high as a share of total health spending in high-income countries, and the global gap in services and treatment doesn't mean that people in low-income countries spend little on the death and end-of-life process – rather, underinvestment in effective palliative care contributes to intergenerational poverty, with children forced to drop out of school and school savings used for health care. [5]
The report argues that rebalancing our relationship with death and rebalancing our relationship with the planet should go hand in hand. The climate crisis, the paralysis of ecosystems, and the loss of biodiversity are not only leading to the unfortunate deaths of people, but also to the deaths of entire planets. The direct and indirect impacts of climate on health have brought adverse health conditions closer to death, and as pressure on the health sector has increased, it has itself begun to exacerbate the climate crisis. [6] Is this broken relationship between man and nature related to the alienation of death? And is it related to society's wishful thinking that nature and death can manipulate, domesticate and manage?
By creating "death systems," the report explores the complex makeup of care received by the dying and the deceased — which embraces and excludes whom, where care takes place, and the dynamic shift in "ownership" of death. The report makes 30 recommendations for radically changing the death system, acknowledging that the death system shaped by culture, history, religious beliefs and resources is an extremely unique existence in society. However, what about death for those who are blatantly opposed to the state, members of minority communities persecuted by the regime, and where mass deaths have led to the collapse of the death system (such as in Yemen, Syria, and the increasingly serious situation in Afghanistan)? [7-9] The 21st century is expected to be a century of mass migration, with refugees, internally displaced persons, trafficked women and children, and persecuted communities all maintaining a fragile balance between life and death, and their lessons to be learned, but the experiences and importance of this group do not occupy much space in the report. Will the value of death be different in the context of political oppression or immigration? What about entrenched racism, xenophobia, and even misogynistic tendencies that have reached the point of murdering women? February 1, 2022, the first anniversary of the military coup d'état in Myanmar, is a stark reminder of the violence and death of health workers who have been targeted by the military regime. [10,11] Rohingya communities in Cox's Bazar, Bangladesh, and refugees across the Mediterranean have had to develop ways of moving outside the norms of the surrounding social structures in the face of death, caring for the dead and the dying. [12,13] In these scenarios, it would be difficult to "rebalance" life and death, as the report proposes.
As highlighted in the report, conflicts, accidents, natural disasters, pandemics, violence, suicide, negligence or disease are all factors that can lead to death. The World Economic Forum's Global Risk Report 2022 identifies the ten most serious risks for the next decade, including livelihood and debt crises, severe climate, infectious diseases, environmental damage and geoeconomic conflicts, where it is almost impossible for a single cause of death to be caused by a single cause. [14] Perhaps the greatest challenge facing societies in re-installing death systems is the need to abandon a single factor and move toward interrelated factors.
In many societies, we lose confidence in the ability to deal with death and neglect it. The medicalization of death and the ability of health systems to manage it have begun to determine how people treat it. The report argues that only by re-establishing the value of death can we reinvent health systems. The Value of Death Major Report paints a new picture of the death and dying system, underpinned by five principles – addressing the social determinants of death, dying, and mourning; accepting that dying is not just a process of physical change, but also a process of interpersonal and spiritual change; empowering formal and informal care networks; gradually daily sharing of stories about death, dying, and mourning; and death being understood as having its value. This architecture gives a global approach to improving the death and dying experience. Achieving the report's vision requires an acknowledgement, based on a renewed common conception of humanity, that we are born equal but suffer from gross inequalities, and that death is inevitable, although unshakable, but that society can transform the environment to avoid a senseless death and provide the time, space, comfort and compassion needed to die. END
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