Kennedy Institute of Ethics Journal

"I begin to discern the profile of my death." This sentence from Marguerite Yourcenar's novel Memoirs of Hadrian (1951) has stuck with me over the decades. In checking the quote, I learned that this sentence from an early draft caught the novelist's attention, and encouraged her to write the book from perspective of the dying Roman emperor. Something of this magic – finding, in one's earlier thoughts, a key that unlocks a story – is at work in F.M. Kamm's Almost Over, a book constructed as a series of rigorous conversations with her own work, that of fellow American philosophers over the past 50 years, and with public policy, aimed at bringing the profile of death into view, considering how mortality shapes the stages of life that lead up to it, and clarifying what humans should be able to do about the end.

Kamm's principal conversation partners (some of the chapters grew out of actual public conversations, described in the Introduction and notes) are philosophers Shelly Kagan and Thomas Nagel, bioethicist and physician Ezekiel Emanuel ("EE"), and surgeon and health care researcher and innovator Atul Gawande. All of these thinkers and practitioners are known for their "public-facing" work. Kagan teaches a popular "open" course on death. Nagel was one of the authors of the famous "Philosopher's Brief," published in the New York Review of Books in 1997, in anticipation of the U.S. Supreme Court's ruling on whether there was a Constitutional right to the practice of assisted suicide, now often called medical aid-in-dying (and for which there is no value-free term). Emanuel and Gawande frequently publish in nonacademic outlets – Gawande was a longtime staff writer for The New Yorker – and both have worked in government; Emanuel during the Obama Administration, where he designed the Affordable Care Act, Gawande in the Biden Administration, where he is a senior administrator [End Page E-1] of the U.S. Agency for International Development (USAID). Kamm is also a public philosopher, publishing in the Boston Review as well as scholarly journals. While some chapters of the book offer technical applications of philosophical logic, the tone is welcoming, an invitation to consider a series of arguments about death and the differing ways philosophers, applied ethicists such as medical ethicists, medical practitioners, and public policymakers have tried to make a "bad" – nonexistence – into something "good," which, as Kamm argues, is not so much a "good death" (we'll still be dead) as a good dying.

Kamm puts a recent tranche of public-facing work, including narratives embedded in public policy, widely read publications, and widely publicized "tools," up for philosophical and ethical scrutiny: what are the arguments, the normative premises, the nudges and biases? Chapters 3 and 4, which analyze Gawande's 2014 bestseller Being Mortal and a series of public policy documents informed by Gawande's research that aim to improve end-of-life conversations and care, should be required reading for every ethicist in the tools-making business. Kamm's rigor in identifying the premises and biases of familiar normative arguments about "good" and "bad" deaths (or rather, experiences of dying) keep us honest and remind us that not everyone will agree to the same story about how a life should end, or what constitutes "meaning," or "dignity," or "peace."

The "EE" debate is Kamm's extended consideration of aging in relation to death, although aging is also explored in an intriguing thought experiment based on the F. Scott Fitzgerald story "The Curious Case of Benjamin Button." Kamm's starting place is Emanuel's much-discussed essay, "Why I Hope to Die at 75," published in The Atlantic in 2014. The premise of Emanuel's argument was that he hoped his life would be over before his intellectual powers dimmed:

Doubtless, death is a loss. It deprives us of experiences and milestones, of time spent with our spouse and children. In short, it deprives us of all the things we value.

But … living too long is...