Fear of Near Death Thoughts

Sadly Hal Finney, who wrote many great posts here at OB, has ALS:

ALS … is only mostly fatal. When breathing begins to fail, ALS patients must make a choice. They have the option to either go onto invasive mechanical respiration, which involves a tracheotomy and breathing machine, or they can die in comfort. I was very surprised to learn that over 90% of ALS patients choose to die. And even among those who choose life, for the great majority this is an emergency decision made in the hospital during a medical respiratory crisis. …

Probably fewer than 1% of ALS patients arrange to go onto ventilation when they are still in relatively good health, even though this provides the best odds for a successful transition.  With mechanical respiration, survival with ALS can be indefinitely extended. And the great majority of people living on respirators say that their quality of life is good. …

There are a number of practical and financial obstacles to successfully surviving on a ventilator, foremost among them the great load on caregivers. No doubt this contributes to the high rates of choosing death. But it seems that much of the objection is philosophical. People are not happy about being kept alive by machines. … I hope that when the time comes, I will choose life. …. Stephen Hawking, the world’s longest surviving ALS patient at over 40 years since diagnosis, is said to be able to type at ten words per minute by twitching a cheek muscle.

Medicine and health are strange and distorted in large part because of the misnamed “fear of death.”  If we really feared death, we would think hard and critically about how to avoid death, and we would succeed a lot more.  Instead, however, we fear thinking about our own death, especially in near mode.  Near mode favors practical analytical reasoning, while far mode favors symbolic creative reasoning.  When we are forced to think about our death we run screaming into far mode, placing us at a further psychological distance, but hindering our ability to think practically.

My best idea for reforming medicine is for us to each put our medical decisions in the hands of someone with expert knowledge and a clear financial incentive to make good health vs. cost tradeoffs.  Unfortunately, this suggestion to put med choices in an expert hard-headed near-mode mind doesn’t hit the right symbolic chords in our far-mode avoiding-death-thoughts minds.

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  • John Maxwell IV


    The experience of trying not to think about something is very interesting. I’ve found that analyzing things I suspect I shouldn’t think about copiously has mostly turned out well. There is significant mental stress associated with trying not to think about something.

    Also, I’m starting to think maybe most of the people I’ve had really painful conversations with were doing far-mode thinking. Is improving one’s rationality really a study in doing more near-mode thinking?

  • I’d be interested in learning about what evidence supports the idea that medical/health behavior is distorted by the human fear of death.

    FWIW, the main example of this that springs to my mind is cryonics – but that involves a tiny minority.

  • jonathan

    Much of the fear of death is also rooted in superstitions about the after-life. Will I go to heaven? Will I go to purgatory or even hell? I know I did bad things in my life. Will I be confronted with them? I’m still waiting for the 1st actual report of life after death but think about how much time our society puts into these ideas.

    It wasn’t always thus. People have always clung to life as individuals but in some societies – ancient Rome, for example – how you conducted yourself as a man included how you faced death.

    Not speaking of ALS, I’m currently watching a number of friends and acquaintances deal with life-extending, very expensive treatments for very sick, very old people. I’m talking terminal illnesses. I’ve seen estimates of how much money is spent to keep a person alive for a few extra months. Is that worth it? Is some of that motivated by this fear of the afterlife and the judgement that implies?

  • I must admit that I find this post rather mystifying. Why is the finding that over 90% of ALS patients “choose to die” a sign of “far mode” thinking rather than “near mode” thinking? Sorry, but can someone please explain this?

    Next we have all these comments about the power of the fear of death. But does not this post indicate that the power of this fear, which is not obviously tied to “near mode” analytical reasoning, is not as strong as all these commenters are saying, when it gets down to it?

    Actually, there is evidence about life after death, although one can easily dismiss it because those who report arguably did not actually “die,” as they “came back.” I am talking about the large amount of data we have on “near death” experiences, some of which have involved people being “measurably clinically dead” for at least a period of time, after which, well, they stopped being clinically dead and came back to “clinical,” and even fully conscious and operational life. That data suggests that a strong majority of those having these experiences had very similar ones, ones that have become cliches and even jokes in literature in cinema, all that tunnel of light leading to a being of light and ecstatic feelings stuff, blah blah blah, hah hah hah. The being of light gets interpreted as being different beings depending on one’s background, and even atheists seem to get this being as well. In short, the best available evidence suggests that there is a “heaven after death,” and that most people get there. Not all that scary at all, and many of these people report having to make a conscious decision to return to the vicissitudes of the much less joyful actual life. I have even spoken with some (one of them a famous physicist involved in the Mahhatten Project, now fully dead).

    What is rarely reported is that there is a non-trivial minority, possibly more than 10%, who do not get there. Those who do not get there reportedly go into an isolated darkness that is described as truly awful. Hell, I guess. Some of those people report when they return that they know why they went there because of bad things they were doing, and then even reform themselves. Some also say that, but then just keep on doing it, whatever it is. However, the somewhat more disturbing datum is that not all of those going to such a state claim to have done anything terribly wrong. Perhaps the Calvinists are right, and it is simply by a mysterious “election” or grace that one gets “saved” and gets to have that nice tunnel of light rather than the awful darkness.

    • fenn

      I must admit that I find this post rather mystifying. Why is the finding that over 90% of ALS patients “choose to die” a sign of “far mode” thinking rather than “near mode” thinking? Sorry, but can someone please explain this?

      Analytical/near mode: people on respirators tend to report being relatively happy and find life worth living. Best results occur the sooner this step is taken.

      Far mode: Gus McCrae romanticism.
      Woodrow Call: What do you want legs for anyway? You don’t like to do nothing but sit on the porch and drink whiskey!
      Gus McCrae: I like to kick a pig every once in a while. How would I do that? (so I guess I’d rather die).

      • Of course this is a biased sample, the small percentage who chose respirators. We do not know the mental processes of those who chose not to have respirators, and it may indeed be that they were making analytical calculations relating to the problems for the would-be caregivers, whose interests they were taking into account.

        Oxygen deprivation may well be the source for all of these experiences, which may be purely subjective and have no “objective” reality. It may be that once people are “really dead,” there simply is no existence, and these experiences are what someone experiences “on the way out,” maybe, some of the time, probably a lot of the time, given their ubiquity, and the high degree of commonality of the two apparently most likely outcomes.

    • In order to understand what Dr. Hanson means by near/far mode look at his earlier posts on the topic:

      Far Thoughts Fit Ideals

      Regarding near-death experiences – it is entirely possible that your claims about what people typically experience during near-death experiences is entirely correct. However, people’s sincere descriptions of, say, a tunnel of light should not be interpreted literally as evidence for a tunnel of light. Rather, interpret the data as evidence of SOME cause or explanation for the pattern of sincere descriptions. For example, the events that people describe as “near-death” may all have some common biological features, such as oxygen deprivation, which may cause the experiences that people relate.

    • Allan Crossman

      So, not only are you suggesting there’s some immaterial soul that leaves the brain and experiences the afterlife, but you’re also suggesting that it can be pulled back to the brain, where it proceeds to execute a write command to the brain’s physical memory – presumably violating the conservation of energy in the process – so that the person can remember all of this.


    • Doug S.

      Astronauts in centrifuges, training to deal with the high G-forces experienced during rocket launches, sometimes pass out, and they report exactly the same kinds of things that people with “near death experiences” report. In other words, a “near death experience” is what it feels like to have the brain shut itself down due to extreme conditions (loss of oxygen, etc.).

    • gwern

      I think you’re focusing on the wrong factoid. The 90% may or may not be a sign of irrationality caused by near/far thinking – though it wouldn’t be hard to argue that it is.

      The real kicker is :

      > “And even among those who choose life, for the great majority this is an emergency decision made in the hospital during a medical respiratory crisis.”

      Now, there are 2 explanations for why this is true of most of the surviving 10%: either they simply put off & postponed what they *knew* was an inevitable choice (die or intubate), or they had decided to die, but then at the actual event changed their minds.

      The first one is obviously irrational; they are already spending hundreds of hours suffering and learning about ALS and dealing with it, could they really not take a few minutes to investigate life while intubated and make a considered choice? I mean, this is a majorly important decision: it decides literally decades worth of life. To not even make a decision is really really terrible.

      The second possibility is also bad: they came to a decision, but then at the last minute, despite the fact that nothing has changed, they have learned nothing knew, etc., they reverse it. This too is irrational, though perhaps predictable due to hyperbolic discounting (death doesn’t look *too* bad from a distance of months, maybe).

  • Unnamed

    Robin, are you familiar with Terror Management Theory (e.g., pdf, or just google it).

  • Vince


    OT but I guess a possible upcoming post could be about how the Nobel Peace Prize isn’t actually about “Peace.”

  • Would it be fair to summarize this as, “People aren’t afraid of death. If we really feared death, we would think hard and critically about how to avoid death, and we would succeed a lot more. People are afraid of thinking about death.” — Robin Hanson

    • We don’t mind so much thinking about death in far mode. What we fear is thinking about our death in near mode – where it feels way way too close for comfort.

  • Eric Falkenstein

    First, my sympathies to Hal, as this is tragic news. I wish him all the best. He seems to have had a good life.

    I think the works of the stoics are most useful in facing death. Epictetus, Marcus Aurelius. Accept fate, and recognize that death is as natural as life. One doesn’t have to do anything more if we are dealt a bad hand, do not feel obligated to maximize one’s lifespan. We can’t know what happens next to our consciousness, but a human’s unique ability to be anxious about his own death isn’t a feature, it’s a bug. I don’t begrudge people for hanging on to life as long as they can, but I do think the cost/benefit ratio isn’t as most think.

  • Are we (most of us) even capable of contemplating our deaths in near mode? Just like I cannot think about, say, Robin’s house in near mode because I’m not even positive he has one, I cannot think about my death in near mode because I’ve never had grievous injuries or a near death experience.

  • Thanatos Savehn
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