We also leave behind a legacy. The reason Mary Anna came to StoryCorps was that she was attracted to the idea of leaving behind a record of her story for her grandchildren and great-grandchildren to hear. “We live in this world where we seem so little compared to everything that’s going on. After a couple of generations, no one even remembers who you are,” Mary Anna said. “So this is a way to leave something permanent behind.”
Death, as Mary Anna implied, poses a grave challenge to the ability to lead a meaningful life. If our lives will end anyway and we will soon be forgotten, what is the point of anything we do? This is the problem that led Will Durant to write that letter to his friends. In the absence of a definitive belief in an afterlife, the philosopher was in search of “a meaning that cannot be annulled by death.”
Is there one?
William Breitbart, the chairman of the Department of Psychiatry and Behavioral Sciences at New York’s Memorial Sloan Kettering Cancer Center, specializes in end-of-life care for terminally ill cancer patients. He has devoted the better part of his life to answering the challenge that death poses to meaning. His groundbreaking research shows that while the specter of death often leads people to conclude that their lives are meaningless, it can also be a catalyst for them to work out, as they have never done before, the meaning of their lives. Contemplating death can actually help us, if we have the proper mindset, to lead more meaningful lives and to be at peace when our final moment on earth arrives.
Meaning and death, Breitbart believes, are two sides of the same coin—the two fundamental problems of the human condition. How should a human being live a finite life? How can we face death with dignity and not despair? What redeems the fact that we will die? These questions roll around Breitbart’s mind every day as he works with patients facing life’s final challenge.
Breitbart was born in 1951 and grew up on the Lower East Side of Manhattan. His parents, Jews from eastern Poland, narrowly avoided Hitler’s death camps. During the war, they hid from the Nazis in the woods, and his father fought in the underground resistance movement. After the war ended, the two of them found themselves in a displaced-persons camp, and it was there that they got married. When they moved to America, they carried their memories of the war years with them. Breitbart’s childhood was steeped in that tragic past. Every morning, his mother would ask him at the breakfast table, “Why am I here?” Why, she wondered, did she live when so many others had died?
“I grew up with a sense of responsibility to justify my parents’ survival and to create something in the world that would be significant enough to make my life worthwhile. It’s no coincidence,” he laughed, “that I ended up at Sloan Kettering, where the people wear striped gowns and are facing death.”
Breitbart came to Sloan Kettering in 1984 because he wanted to live “at the edge of life and death.” It was the height of the AIDS epidemic, and young men Breitbart’s age were dying all around him. “They were constantly asking me to help them die,” he said. He was also working with terminal cancer patients. “When I walked in the room, they would say, ‘I only have three months to live. If that’s all I have, I see no value or purpose to living.’ This was not an atypical response. They said, ‘If you want to help me, kill me.’ ”
“Everybody said how important it is to have a positive attitude,” one woman, a former IBM executive who had been diagnosed with colon cancer, said. “But I’m not Lance Armstrong. I wanted to jump in the grave.” If death means nonexistence, Breitbart’s patients reasoned, then what meaning could life possibly have? And if life has no meaning, there’s no point of suffering through cancer.
By the nineties, physician-assisted suicide was a hot topic in Breitbart’s circles and beyond. Dr. Jack Kevorkian, known then as Dr. Death, had helped his first patient end her life in 1990. He claimed he helped another 130 patients end their lives over the next eight years. As the United States debated the ethics of assisted suicide, other countries were taking steps toward normalizing the practice. In 1996, the Northern Territory of Australia legalized assisted suicide, only to later rescind the law. Then, in 2000, the Netherlands became the first nation to make physician-assisted suicide legal. In 2006, the United States took a big step in that direction with the Supreme Court decision in Gonzales v. Oregon, which allowed states to make their own decisions on assisted suicide. Today, the practice is legal in California, Vermont, Montana, Washington, and Oregon. In 2014, the Journal of Medical Ethics released a report indicating the growth of “suicide tourism.” Between 2009 and 2012, the number of people who traveled to Zurich, Switzerland, where assisted suicide is legal, seeking to end their lives, doubled.
As Breitbart heard more and more stories of assisted suicide, he began to wonder what specifically was driving the terminally ill to give up on life. At the time, he was doing a series of research studies on pain and fatigue at the end of life, so he tacked onto those studies some questions that asked his subjects whether they felt a desire for a hastened death. What he discovered surprised him. The assumption had been that the ill chose to end their lives because they were in terrible pain. But Breitbart and his colleagues found that wasn’t always the case. Instead, those who desired a hastened death reported feelings of meaninglessness, depression, and hopelessness. They were living in an “existential vacuum.” When Breitbart asked patients why they wanted a prescription for assisted suicide, many said it was because they had lost meaning in life.
Breitbart knew he could treat depression—there were medicines and well-developed psychotherapies for that—but he was stumped when it came to treating meaninglessness. Then, in 1995, he began to see a way forward. He was invited to join the Project on Death in America, which aimed to improve the experience of dying. Breitbart and his colleagues on the project—who included philosophers, a monk, and other physicians—had long conversations about death and the meaning of life, “peppered with references to people like Nietzsche and Kierkegaard and Schopenhauer,” Breitbart said.
“What I suddenly discovered,” Breitbart explained, “was the importance of meaning—the search for meaning, the need to create meaning, the ability to experience meaning—was a basic motivating force of human behavior. We were not taught this stuff at medical school!” Breitbart became convinced that if he could help patients build meaning, he could decrease their suicidal thoughts and urges, protect them from depression, improve their quality of life, and make them more hopeful about the future. In short, he believed he could make their lives worth living even to the very end.
He developed an eight-session group therapy program where six to eight cancer patients come together in a counseling workshop. Each session, in one way or another, helps build a meaning mindset. In the first session they are asked to reflect on “one or two experiences or moments when life has felt particularly meaningful to you—whether it sounds powerful or mundane.”
The second session deals with identity “BC and AD”—that is, with who the individuals were before the cancer diagnosis and who they are after the diagnosis. They are encouraged to respond to the question “Who am I?” to tap into the identities that give them the most meaning. One woman responded saying, “I am a daughter, a mother, a grandmother, a sister, a friend and a neighbor….I’m somebody who can be very private and not always share all my needs and concerns. I also have been working on accepting love and affection and other gifts from other people.” She reflected on how the illness was changing who she was: “I don’t like to receive care, but I’m beginning to,…actually…this may be the one thing that my illness has caused me to mull over. That I’m more accepting of people wanting to do things.”
In the third and fourth sessions, they share the story of their life with the group. “When you look back on your life and upbringing,” they are asked, “what are the most significant memories, relationships, traditions, and so on, that have made the greatest impact on who you are today?” They also discuss their accomplishments and points of pride, and what they still have lef
t to do. They think about lessons that they want to pass along to others. For homework, they are asked to share their story with a loved one.
Session five is one of the most difficult. Here, they confront life’s limitations—the greatest limitation of all being death. They talk to each other about what they consider a “good” death: whether they want to die at home or in the hospital, what their funeral will look like, how they hope their families will adapt in the aftermath, and how they want to be remembered by those who love them.
In the next two sessions, they dwell on their “creative” and “experiential” sources of meaning—the people, places, projects, and ideas that helped them express their most important values and “connect to life.” They discuss their responsibilities and any “unfinished business” they have and what’s preventing them from accomplishing those goals. They’re also asked to think about the role that love, beauty, and humor played in their lives. Many people mention their families here. Others discuss work, or hobbies like keeping a garden. The former IBM executive mentioned seeing the statue of winged victory, the Nike of Samothrace, at the Louvre in Paris when she was a young woman.
In the final session, the patients consider their hopes for the future and their legacy, the part of them that will go on living even after they are dead. They present a “legacy project” to the group, which is generally something they do or create that represents how they want to be remembered. One man brought in a woodcut of a heart sculpted into a Celtic Trinity. “This is what I will teach my children,” he said, “that there is eternal love and that I will be there for them, far beyond my passing.”
Breitbart performed three randomized controlled experiments on the meaning-centered psychotherapy, giving it to several hundred patients. When he analyzed the results with his colleagues, Breitbart saw the therapy had been transformative. By the end of the eight sessions, the patients’ attitudes toward life and death had changed. They were less hopeless and anxious about the prospect of death. They no longer wanted to die. Their spiritual well-being improved. They reported a higher quality of life. And, of course, they found life to be more meaningful. These effects not only persisted over time—they actually got stronger. When Breitbart followed up with one group of patients two months later, he found that their reports of meaning and spiritual well-being had increased, while their feelings of anxiety, hopelessness, and desire for death had decreased. The time between diagnosis and death, as Breitbart saw, presents an opportunity for “extraordinary growth.” The former IBM executive, for example, was initially devastated by her diagnosis—but after enrolling in the therapy program, she realized, “I didn’t have to work so hard to find the meaning of life. It was being handed to me everywhere I looked.”
Breitbart’s ideas are catching on. Doctors in Italy, Canada, Germany, Denmark, and beyond are using his therapeutic methods to infuse the lives of their otherwise hopeless and despairing patients with meaning. “The reaction in the field was explosive,” Breitbart said. “They hadn’t paid attention to it before, but now everyone and their cousins have suddenly started discovering meaning.”
Breitbart developed his meaning-centered psychotherapy for the terminally ill, but the lessons gleaned from his research can help anyone live a better life. No matter how near or far off death may be in each of our individual cases, thinking about death forces us to evaluate our lives as they are and to consider what we would change about them to make them more meaningful. Psychologists call this “the deathbed test.” Imagine that you’re at the end of your life. Perhaps a freak accident or diagnosis of disease has suddenly shortened your life, or maybe you have lived a long and healthy life, and are now in your eighties or nineties. Sitting on your deathbed, with only days ahead of you to live, reflecting on the way you have led your life and what you have done and not done, are you satisfied with what you see? Did you live a good and fulfilling life? Is it a life you are glad that you led? If you could live your life over again, what would you do differently?
Many people on their actual deathbeds fear that the lives they led were not meaningful enough. Bronnie Ware, a former palliative-care worker, found that at the end of her patients’ lives, their regrets fell into the same basic categories. Their principal regrets included not following their true aspirations and purposes, giving too much of themselves to their careers rather than spending more time with their children and spouses, and not keeping in better touch with their friends. They wish they had spent more time during their lives building the pillars of meaning.
Breitbart has thought a great deal about the challenge death posed to another group of individuals—the victims and survivors of the Holocaust. After Breitbart joined the Project on Death in America, he read the book Man’s Search for Meaning by Holocaust survivor Viktor Frankl about his experiences in the concentration camps. The book made a powerful impression on Breitbart, as it has on millions of people, and he developed his meaning-centered therapy after reading it. He gives each of the patients who receives his therapy a copy of Frankl’s book to read, hoping that though their circumstances may differ, they may find in one man’s struggle with suffering a source of wisdom and consolation.
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In September 1942, Frankl, a Jewish psychiatrist and neurologist in Vienna, was arrested and transported to a Nazi concentration camp with his wife and parents. Three years later, when his camp was liberated, most of his family, including his wife, had perished—but he, prisoner number 119,104, had lived.
In Man’s Search for Meaning, Frankl describes the importance of finding meaning in suffering. The prisoners in the camps lost everything—their families, their liberty, their former identities, and their possessions. Many, as a result, concluded that they had nothing more to live for and abandoned hope. But some continued to believe their lives were meaningful. Frankl saw that the prisoners who found or maintained a sense of meaning, even in the most horrendous circumstances, were far more resilient to suffering than those who did not. Those who had a reason to live, he argued, were even more “apt to survive” in the face of starvation, sickness, exhaustion, and the general degradation of camp life.
Frankl worked as a therapist in the camps, and in his book he tells the story of two suicidal inmates he counseled there. Like many of the people around them, these two men believed that they had nothing left to live for. “In both cases,” Frankl writes, “it was a question of getting them to realize that life was still expecting something from them; something in the future was expected of them.” For one man, it was his young child, who was still alive. For the other, a scientist, it was a series of books that he hoped to finish writing. As Frankl observed more and more inmates, he saw that those men and women who knew the “why” for their existence, as Nietzsche put it, could withstand almost any “how.”
He was also struck by how some people were able to maintain their dignity despite the dehumanizing conditions by choosing how to respond to the suffering they faced and saw others endure. “We who lived in concentration camps,” he wrote, “can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms—to choose one’s attitude in any given set of circumstances, to choose one’s own way.”
Before his arrest, Frankl had established himself as one of the leading psychiatrists in Vienna. His interest in psychology and meaning had been intense and precocious. When he was about thirteen years old, one of his science teachers declared to the class, “Life is nothing more than a combustion process, a process of oxidation.” But Frankl would have none of it. “Sir, if this is so,” he cried, jumping out of his chair, “then what can be the meaning of life?” A couple of years later, he struck up a correspondence with Sigmund Freud and sent Freud a paper he had written. Freud, impressed by Frankl’s talent, sent the paper to the International Journal of Psychoanalysis for publication. (“I h
ope you have no objection,” Freud wrote the teenager.)
During and after medical school, Frankl distinguished himself even further. Not only did he establish suicide-prevention centers for teenagers—a precursor to his work in the camps—but he also developed his signature contribution to the field of psychology: logotherapy. Frankl believed that people have a “will to meaning,” and that this drive to find meaning in life is the “primary motivational force in man.” The purpose of logotherapy, then, was to treat the distress and suffering of his patients by helping them find meaning in their lives. By 1941, Frankl’s theories had received international attention, and he was working as the chief of neurology at Vienna’s Rothschild Hospital, where he risked his life and career by making false diagnoses of mentally ill patients to keep them from being killed by the Nazis.
That same year, Frankl faced a decision that changed his life. With both a rising career and the threat of the Nazis looming over him, Frankl had applied for and was granted a visa to America. By that time, the Nazis had already started taking Jews away to concentration camps, focusing on the elderly first. Frankl knew that it was only a matter of time before the Nazis came to take his parents away. He also knew that once they did, he had a responsibility to be there with them to help them. Still, he was tempted to leave for America, where he would find both safety and professional success.
Frankl was at a loss for what to do, so he set out for St. Stephen’s Cathedral in Vienna to clear his head. Listening to the organ music, he repeatedly asked himself, “Should I leave my parents behind?…Should I say goodbye and leave them to their fate?” Where did his responsibility lie? He was looking for a “hint from heaven.”
The Power of Meaning Page 21