JOURNAL OF PALLIATIVE MEDICINE Volume 15, Number 7, 2012 Mary Ann Liebert, Inc. DOI: 10.1089/jpm.2012.

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Heroism and the Fear of Death

Simon Wein, M.D.

Heroism is rst and foremost a reex of the fear of death. Ernest Becker1

Dear Editor: Zilboorg stated that the fear of death is always present in our mental functioning (and) it must be properly repressed to keep us living with any modicum of comfort.2 The evidence for this is that fear is so quickly evoked by ordinary events such as a loud noise in the dark, a small lump in the breast, a large hairy spider, or a near accident while driving. Since we are symbolic animals the fear of death is not just of physical annihilation; there are also the human fears we experience each day: fear of loneliness, fear of public speaking, or fear of a lack of achievements to ward off insignicance. Fear of death is clearly a good thing in that it keeps us alive; however, too much fear paralyzes with anxiety, and too little fear may kill by neglect. In oncology, with death shadowing our every move, intense conscious and unconscious efforts are made to repress the fear of death. Psychological defenses are complex and varied, and often mask painful emotions. These defense mechanisms, from both sides of the bed, include denial, black humor, cynicism, and aggression. One less well known defense is heroism. Becker considered heroism an essential psychological element of character: Heroism is rst and foremost a reex of the fear of death.1 That is, in response to the fear of death one automatically adopts an heroic posture. If the fear of death is everywhere, then also might be heroism, since heroism represses fear. According to Becker: It doesnt matter whether the cultural hero-system is magical, religious and primitive; or secular, scientic and civilized. [It provides a] feeling of primary value, of cosmic specialness, of ultimate usefulness to creation, of unshakable meaning.1 If I can show my colleagues or adoring home crowd that I went out into the cold, hard world and against the odds conquered the enemy (war or cancer), or opponent (politics or sport), then I will be hoisted onto their grateful shoulders as a hero. It is not by accident that war is frequently used as a metaphor for the battle against cancer. War is the traditional theatre for dening heroism. The hero, shrouded in a protective cloak of uniqueness, pictures himself even if only symbolically, as an exception to the usual end of man. In society at large one can be a hero in endeavors such as culture, sport, war, morality, and adventure. Upon careful

analysis each of these heroic endeavors has the two essential elements of heroism: an exception to the rule, and prevailing in the face of death. Public embarrassment, shame, and humiliation can be as difcult as facing physical death. Consider people who commit suicide rather than face their demons. Furthermore, people who practice hero-worship are swept away along with the hero, and are thus able to repress their own fear of death. It is unclear who needs whom more: the hero or the adoring fans. Both feed off of each other in order to experience the sense of specialness that protects them from a sense of insignicance, which is itself a sliver of death. The Secret Life of Walter Mitty is a short story by James Thurber.3 Mitty, the hen-pecked protagonist, imagines himself in series of ve daydreams as a hero in life-or-death situations. In one of the stories he is a world-famous surgeon brought in at the last moment to help sort out a case of Obstreosis of the ductal tract. Tertiary, in a personal friend of Roosevelts. In another he is a fearless death-defying war pilot: Its forty kilometers through hell, sir, said the sergeant. Mitty nished one last brandy. After all, he said softly, what isnt? The daily reveries in which we all indulge are not so different from those of Walter Mitty. The gist of these daydreamsyours, his, and mineis to picture oneself in a scenario as someone special who succeeds against the odds, to imagine oneself as a hero. Who among us in the intimacy of our silent reveries has not dreamt of being published in a major medical journal or delivering a plenary lecture at the annual meeting? The reveries are a soothing, stabilizing, comforting elixir. Upon further reection, however, there is something amiss when one applies the heroism model to medical practice, since medicine is not the same as winning gold medals at the Olympics, or getting into the Guinness Book of World Records. Doctors should not treat the disease as an object that can be manipulated at will, unattached to the subject. Medicine should not be the malignant kidney in room 18 or the liver, second on the list. Nevertheless, sometimes the patient benets if the doctor, consumed by a sense of personal heroism, struggles above

Institute of Oncology, Davidoff Center, Rabin Medical Center, Petach Tikvah, Israel.

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732 and beyond the call of duty to save a life and succeeds. On other occasions, since the heroic posture is essentially a narcissistic mechanism to protect ones ego from the terror of extinction, the patient may receive inappropriate therapies in the service of the doctors personal needs. The call for resuscitation, emergency surgery, and prescribing a new chemotherapy protocol in the hope of beating the odds, are examples of when heroism might be a motive for the doctor to be medically active. At the end of the day, notwithstanding personal foibles and fantasies, there is another human being for whom the doctor has responsibility. One cannot indulge in heroics for the sake of self-esteem, if in the process one compromises the patients well-being. This responsibility trumps a doctors personal needs. So how can we tell where the line is between heroism and zealotry? Pellegrino wrote an article about the putative loss of professionalism in medicine.4 He noted that the claim of doctors to be professionals is based less in their expertise than in their dedication to something other than self-interest, while providing their services. That something else, is a certain degree of altruism, or suppression of self-interest when the welfare of those they serve requires it.4 Humility can be characterized as embedding oneself in a thing other than self, and is another way to describe the core ethic of professionalism, as Pellegrino suggests. This is not to say that professionals should live as ascetics or shed any and all vestiges of self-pride. Going home after work and congratulating oneself on a successful day, and feeling good and a little heroic.well, there is nothing wrong with that. A careful reading of the last line of the quote from Pellegrino reveals that strictly speaking, self-interest need only be suppressed in relation to the practice of the profession, when there is a potential conict of interest between the needs of the doctor and those of the patient. Like everyone else, doctors have many motives which are not necessarily mutually exclusive. It is not that heroism as a psychological defense does not work; it does. And very often the heroic efforts of surgeons or reghters save lives. The point is that it is not always the most appropriate defense to use in clinical medicine. The daily

LETTERS TO THE EDITOR ups and downs of mistakes and near-misses conrm clinical medicine as a humbling experience. This reinforces Pellegrinos suggestion that humility is a virtue in medical practice. The more mature paradigm is that of the professional as described by Pellegrino. It sounds a little old fashioned and is a commentary about the role of money in medicine today. When we look back at the heroes of modern medicineOsler, Jenner, Harrison, and Pasteur, among many othersand read their biographies we note a common theme of seless dedication to the profession and to society. It is important to distinguish between a true hero who is committed and humble, and the hero whose defense is a psychological mechanism born out of need. The challenge in medicine is to combine humility with heroism in a professional embrace, while restraining the heroic impulse. In this way the value of professionalism is preserved, along with the universal need to overcome the fear of death. References
1. Becker E: The Denial of Death. New York: Basic Books, 1972. 2. Zilboorg G: Fear of death. Psychoanalytic Quarterly 1943;12:465475. 3. Thurber J: The Secret Life of Walter Mitty. In: My WorldAnd Welcome to It. Boston: Harcourt, Brace and Company, 1942. The full text is available free at: www.all-story.com/issues .cgi?action = show_story&story_id = 100 (Last accessed January 3, 2011). 4. Pellegrino ED: Professionalism, profession and the virtues of the good physician. Mt Sinai J Med 2002;69:378384.

Address correspondence to: Simon Wein, M.D. Institute of Oncology Davidoff Center Rabin Medical Center 39 Jabotinsky Road Petach Tikvah Israel 46100 E-mail: simonwe@clalit.org.il

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