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Alex Lickerman M.D.


Overcoming the Fear of Death

A physician confronts his own mortality.

Source: unsplash

In January of 2007, I developed a mild stomach ache and general feeling of being unwell while at a Sunday brunch. Initially, the pain sat in the center of my abdomen just above my belly button, but gradually over the course of the day inched its way down into my right lower quadrant, causing me to wonder briefly if I'd developed acute appendicitis. However, by evening the pain had actually begun to improve, so I dismissed the possibility; I'd never heard of case of appendicitis resolving on its own without surgery. But mindful of the adage that the physician who treats himself has a fool for a patient, I asked one of my physician friends to examine me the next day. When he did, he found a fullness he didn't like in my right lower quadrant and ordered CT scan. To our mutual surprise, it showed that I had, in fact, developed acute appendicitis.

I saw a surgeon later that afternoon who began me on antibiotics and scheduled an elective laparscopic appendectomy, which he performed two days later. The surgery went well and I was back at home that night with a bloated stomach but minimal discomfort.

At 3 a.m., however, I awoke with projectile vomiting and after a particular violent episode briefly lost consciousness. Panicked, my wife called 911 and an ambulance delivered me back to the hospital where I was found to be anemic. My surgeon diagnosed an intra-abdominal bleed and began following my red blood cell count every few hours, hoping the bleeding would stop on its own.

By late afternoon, however, it became clear that it wasn't, so I was taken back to the operating room where the surgeon found and evacuated approximately 1.5 liters of free-flowing blood from inside my abdomen. All told, I'd bled out half of my blood volume over the course of 16 hours. Over the next few days, however, my blood count stabilized and my strength returned, so I was sent home four days after I'd been admitted, slightly less bloated than I'd been after the first surgery but four units more full of a stranger's blood.

Three weeks later, my wife and I took a four hour flight to Mexico—a vacation we'd planned to take in Cabo San Lucas prior to my illness—spent three days on the beach, and then flew back home.

Two days later, I developed diarrhea. Because I'd only had bottled water while in Mexico, I thought I'd contracted a viral gastroenteritis that would resolve on its own within a few days. While driving home a few days later, however, I developed right-sided chest pain.

I called my physician friend, who asked me to return immediately to the hospital to have a chest CT, which in short order showed I'd thrown a large pulmonary embolism. I was taken immediately to the emergency room and placed on intravenous blood thinners to prevent another clot from traveling to my lung and possibly killing me. Luckily, this time my hospital stay was uneventful, and I was ultimately discharged on an oral anti-coagulant called Coumadin.

A week later, the diarrhea still hadn't resolved, however, so a stool culture was sent for clostridium difficile. It came back positive, undoubtedly as a result of the antibiotics I'd been given prior to my first surgery, so I was started on Vancomycin. Then I developed an allergic reaction to the Vancomycin, so I was switched to Flagyl. Within a week the diarrhea resolved, but then a week later it returned. Relapses are common with clostridium difficile colitis, so I tried Flagyl again, this time with a probiotic called Florastor. The diarrhea resolved and never came back.

A week later, however, the nausea did. It was absolutely crippling—as was the anxiety that accompanied it. What could possibly be wrong now? I longed for the blissful ignorance of a non-medical mind that had no knowledge of all the terrible diseases I now thought I might have.

I called my physician friend who suggested, after listening to my symptoms, that the nausea might be due to anxiety. I told him that idea hadn't occurred to me, that I'd supposed the anxiety was present as a result of the nausea, not as its cause, but that I was open to the possibility he was right. The next day I had a conversation with a psychiatrist who diagnosed me with mild Post-Traumatic Stress Disorder (PTSD).

Denial of Death

I'm always surprised by people who say they're not afraid to die. Most are usually quick to point out they are afraid to die painfully—but not of the idea of no longer being alive. I continue to be mystified not only by this answer but by the number of people who give it. Though I can imagine there are indeed people who, because of their age, character, or religious beliefs, truly do feel this way, I've always wondered if that answer hides a denial so deeply seated it cannot be faced by most.

Certainly, this has been the case with me. I love being here and don't want to leave. I've always spoken openly of my fear of death to anyone who's ever asked (not that many have—I suppose even the question is uncomfortable for most), but I've rarely experienced moments where I actually felt afraid.

Whenever I've tried wrapping my mind around the concept of my own demise—truly envisioned the world continuing on without me, the essence of what I am utterly gone forever—I've unearthed a fear so overwhelming my mind has been turned aside as if my imagination and the idea of my own end were two magnets of identical polarity, unwilling to meet no matter how hard I tried to make them.

The Shattering of a Delusion

The true significance of my denial wasn't made clear to me, however, until I was diagnosed with PTSD. The anxiety that began to envelop me at that point was of an entirely different order than I'd ever experienced before. It began to interfere with my ability to function, which made plain to me that what my brush with death—twice—had taken from me was my ability to believe I would never die.

Knowing intellectually that death awaits us is quite clearly a different thing from believing it, much in the same way knowing intellectually gravity will make you fall is a different experience from actually swooning at the edge of a parapet at the top of tall building. Ultimately, being ill brought me to the realization, contrary to what I'd always believed in my heart, that there was nothing special about me at all. Like everyone else, I was only a piece of meat that would eventually spoil.

From that point forward, whenever I'd feel a minor twinge in my chest or develop a rash on my arms, or if my hand would shake for no reason, I would become paralyzed with anxiety. Even though I recognized intellectually that my reaction was overblown, every new random symptom I felt caused my doctor's brain to leap to horrifying conclusions, simply because I now knew—in a way I hadn't before—that bad things could actually happen to me.

I felt like one of my longtime patients, who, for as long as I've known him, has been consumed by an anxiety so great that he'd become like a child in his need for constant reassurance that he would be all right. His anxiety had made him inconsolable and his life became a joyless nightmare.

PTSD is often diagnosed in men (and now women) who return from the battlefield. It has been diagnosed in women who've been raped and people who witnessed the Twin Towers come down on 9/11. In short, PTSD has been diagnosed in anyone who either has an intense traumatic experience themselves or witnesses one occurring to someone else. In my view—completely unsubstantiated by any psychiatric literature, I should point out—PTSD results when a person has their deluded belief that they're going to live forever stripped away from them.

What to Do Next

I'd always considered the shattering of delusion in my life to be a good thing, something that's always brought me more happiness rather than less. And yet, here seemed to be an example that contradicted that rule, for around the time I was diagnosed with PTSD, I was surely suffering to a degree I never had. Frankly, I was happier before living in denial.

Over time, though, the crippling anxiety of PTSD resolved and I returned to my previous level of functioning. However, even minor injuries or transient symptoms that I would have ignored before now stir up vague feelings of worry. I remain acutely aware to this day that my ability to believe in my invulnerability has been irrevocably ruined.

I've decided, however, that this is a good thing: I've been given the opportunity to challenge my fear of death without actually having to be actively dying. Many others aren't so lucky. I began practicing Nichiren Buddhism 20 years ago because I was intrigued by the notion that enlightenment might actually be a real thing, attainable if only the correct path was followed. I've continued because I've had experiences with the practice that have convinced me it has real power to shatter delusions about life. But now more than an intellectual curiosity, my desire for enlightenment has become synonymous with my desire to relieve myself of delusions about death.

For me, three things are certain: First, my experiences with Buddhism so far have inclined me to think that enlightenment is a real thing, and that it might be the solution to my problem with fear of death. But, second, for me to become convinced that life is eternal ("there is no beginning called birth or ending called death"), I must have an experience that proves it to me beyond a shadow of a doubt. I need to know it the way I know gravity is real. I must confess I can't today even conceive of what that experience could be. Yet, I must remember that every time I've gained real wisdom from my Buddhist practice and become genuinely happier, it's always come as a result of having an experience I could never have predicted. And lastly, because I hope the establishment of indestructible happiness based on a belief in the eternity of life is possible, I must remain on guard against the seductive tendency to convince myself of it. Belief that arises from a desire to believe is usually, in my experience, too flimsy to withstand a genuine challenge. And I can think of no more genuine a challenge to a belief in life after death (whether through reincarnation or an ascension to Heaven or anything else) than the actual imminent approach of death itself.

I fully recognize that my current belief about death—that it is truly the final end of the self—is likely to be correct. Which makes me wonder if I wouldn't be better off throwing my energies into re-embracing denial and simply accepting that when it comes my time to die, if I'm given the chance to see it coming, I'll suffer however many moments, hours, days, or weeks of fear there are to suffer and then be granted a final release.

If only I could. Once a delusion has been shattered, I've found there's no going back. And even if there were, at some point I'm certain to be re-confronted with a denial-eradicating sickness or injury. Everyone will. Depending on your current life stage this might not seem like a pressing issue. But shouldn't it be? An experience like mine could become yours at any moment. And even more desirable than being able to die peacefully is being able to live fearlessly.

I've tried to resolve my fear of death intellectually and come to the conclusion that it can't be done, at least not by me. Some kind of practice that actually has the power to awaken me to a truth that frees my from my fear seems to be required. In my latest book, The Ten Worlds: The New Psychology of Happiness, I detail the research that suggests such an awakening is possible.


About the Author

Alex Lickerman, M.D., is a general internist and former Director of Primary Care at the University of Chicago and has been a practicing Buddhist since 1989.