Reality TV: from public autopsies to what?

In November, a German physician performed the first public autopsy in Britain since the practice had been outlawed in 1832. "Performance" is literally the word, since Dr. Gunther von Hagen's dissection was conducted before an audience that had paid $19 a head to attend and, even more significantly, was televised on a commercial station. Von Hagen had already attracted a huge audience in London for his exhibit of preserved human cadavers ("plastinated," as he calls it) in various poses of running, swimming, and fencing. The subject for the televised dissection was a German businessman who had died in March and, according to von Hagen, had consented to this public display of his cadaver.

British television has already led the way for U.S. programming in "reality" shows such as Big Brother and Survivor. Will televised dissections also cross the Atlantic--perhaps as an alternative offered to contestants who fail to survive? Our closest domestic variation thus far was the 1998 60 Minutes telecast of Jack Kevorkian administering a lethal injection to a man suffering from ALS, Lou Gehrig's disease. Kevorkian is now serving a prison sentence in Michigan for this performance; and it is clear that the public nature of his action, rather than the act itself, was the basis for his conviction.

According to an extensive empirical investigation published in the New England Journal of Medicine in 1998, some 5 percent of American physicians have performed euthanasia on at least one patient and 3 percent have prescribed lethal medication, but these acts had been concealed from public view and no criminal convictions followed. For many years, U.S. prosecutors ignored such physician conduct--an unacknowledged policy of "don't ask, don't tell." Kevorkian insisted again and again on "telling" and his public taunt forced prosecutors into retaliatory action.

Von Hagen's professed motive for his violation of British law was less portentous than Kevorkian's avowed goal of publicizing the need for repealing laws against euthanasia or physician-assisted suicide. Von Hagen claimed to "stand for democracy"--presumably based on the public's right to know something about dissected corpses or the process of dissection. Kevorkian's goal would transform medical practice (physician-assisted suicide is now legal only in Oregon, the Netherlands, and Belgium). But it is not clear that the public would learn anything more from von Hagen's autopsy than could already be found in textbooks or computer simulations--just as von Hagen's plasticized cadavers seem little different from Madam Tussaud's waxwork displays, except for their unadorned nudity.

There is, however, a different kind of knowledge that von Hagen's autopsy offers--a knowledge that has a deep connection with Kevorkian's public display. The audience knows that von Hagen was cutting into a real corpse, not a simulation, just as Kevorkian's patient was really dying, not just acting as if he were dying. The simulated enactment in both cases might look the same on television; but somehow it doesn't feel the same. There is a pervasive public appetite today for seeing the "real thing" rather than viewing something that "looks real" in every way--except that it isn't. And this appetite has special attraction these days regarding death.

Looking away from the reality of death--the so-called culture of denying death--first took hold in the United States regarding capital punishment. Until the early nineteenth century, public executions carried out before large crowds in a carnival-like atmosphere were common practice. Beginning in 1834, legislatures in one state after another hid executions behind prison walls, and a few states even outlawed newspaper announcements; the last officially administered public execution occurred in Kentucky in 1936, witnessed by some twenty thousand people. By 1958, the ethos of concealment had become so strong that the simulation of an execution in the movie I Want to Live! was widely seen as a daring breach of a social taboo. (Susan Hayward won an Oscar for her portrayal of the condemned prisoner.)

The century-long retreat from public executions to hidden infliction behind prison walls became part of a more encompassing change of attitudes and practices surrounding death. After the Civil War, death was generally transferred from the custody of clergy and family into the hands of physicians and, by the mid-twentieth century, from a home-based to a hospital-based event. Part of this transference was driven by the newfound capacity of physicians and the increased role of hospitals in averting death. But even when all curative efforts had failed, most patients remained in the hospital to die rather than revert to the old pattern of dying at home. The first significant breach in this practice came in 1967 with the founding of the hospice movement in England; the first hospice in the United States was opened in 1972.

Since the 1970s, the claim that we should definitively end American culture's "denial of death" has become a virtual mantra in public discourse. A primary impetus for this claim was the loss of public trust in the unambiguous goodness of scientific technology and the good will of practicing scientists. Physicians were especially hard hit by this new skepticism; in 1966, 73 percent of public opinion poll respondents expressed "great confidence" in physicians; in 1973, this number dropped to 44 percent, and by 1993, it had plummeted to 22 percent--one percentage point below public regard for lawyers! Physicians were especially blamed for the indignities inflicted on dying patients--their hospitalized isolation from family and friends, and their entanglement with high-technology that provided no benefits but only imposed suffering during their last days or even months of life. The cure for these indignities, according to the contemporary mantra, is to shift authority over death from physicians to the dying patients themselves and to bring death from the shadows of hospital corridors into public visibility. Von Hagen's public autopsy, like Kevorkian's public displays of physician-administered death, is riding the wave of this impulse to strip away the legal and social inhibitions on the visibility of death.

Yet the "in-your-face" quality of von Hagen's televised autopsy and Kevorkian's videotaped deaths actually inspires intense discomfort. Trading on two conflicting messages, they both shock and shame the viewer. They shock because most lay people feel some uneasiness, even revulsion, when looking at a carved-up human body or watching a person really die; and these images shame by implying that this instinctive discomfort cannot be rationally justified, and therefore is somehow a moral failing. "Death is a natural part of life, death should be faced with calm resolve, not fear or aversion"--so goes the contemporary agenda for public acceptance and visibility regarding death.

If, however, we set von Hagen's display into historical context, it is not clear that his televised dissection of a corpse should be counted as moral progress. Did the public executions of the nineteenth century reflect a wholesome realism toward death--or did this social practice promote a casual hardheartedness, even sadistic pleasure, regarding suffering and death? Did such public spectacles encourage calm acceptance of one's own mortality--or did they feed the fantasy of the spectator's invulnerability ("He is dying and I am not, because he deserves to die and I do not")?

It is true that the modern denial of death, the ethos of invisibility, is implicated in callousness and the infliction of considerable suffering on dying people. Still, it is not clear that calm, rational (one might say, bloodless) confrontation with the reality of death is an adequate or even a possible antidote to the callous infliction of suffering. It is important to recall that the ethos of death's invisibility itself arose regarding capital punishment as part of an effort to combat proclivities toward the infliction of suffering. From this perspective, the discomfort aroused by von Hagen's televised display can be understood as a protective acknowledgment of ambivalence, of respect for a sense of mystery and even contamination surrounding death, rather than being viewed as a soft-headed, outdated prejudice that should be coolly and rationally repressed.

From the same perspective, we can see Kevorkian's ministrations not simply as he would claim--as a compassionate response to terminate terrible suffering. A different kind of suffering can readily arise from Kevorkian's invitation to accept death with cool detachment whereby the "right to die" of, say, an elderly woman in a nursing home becomes understood by her and by us as her "duty to die."

The new ethos of openness toward death can bring many good things to all of us as we approach the inevitability that each of us must die, but we must see the risks as well as the potential benefits before we wholeheartedly embrace it. Notwithstanding their single-minded espousal of the new ethos, Doctors von Hagen and Kevorkian have performed an unwitting public service by alerting us to the risks by the very weirdness of their public performances. They want us to ignore any instinctive discomfort aroused by their flagrant displays. Thereby we would repress awareness of the disturbances inevitably provoked by death itself. We should decline their invitation.

Robert A. Burt, professor of law at Yale University, is author of Death Is That Man Taking Names: Intersections of American Medicine, Law, and Culture (University of California Press).