THE AMERICAN JOURNAL OF PSYCHOANALYSIS 35:377-381 (1975)
BRIEF COMMUNICATIONS
The Blame of Dying Young He whom the gods love dies young Menander I do not know how exactly to define an early death, but surely it is one that occurs before age forty-five or fifty. No matter what number is chosen, everyone would agree that Carole Lombard, Mozart, and George Gershwin died young. In the world I grew up in we pitied Lombard - beautiful, talented, and the passive victim of a plane crash and wondered what Mozart would have written had illness not killed him. But even in Gershwin's time our attitudes had begun to change. What caused his death was not inoperable cancer of the brain, but seemingly incompetent physicians and a psychoanalyst who allegedly ignored the physical cause of constant headache. While Gershwin's early death was never blamed on him, faultfinding had begun to appear. In the past those who died young were pitied. Their wives and children were helped, and everyone felt sorry for them. Perhaps this represented a holdover from earlier times when medicine was not advanced and early death could not be prevented. The victims were seen as victims and could not be blamed. Their deaths were regarded with fear or perhaps with suspicion. For example, Mozart's rapid decline and demise lead people to whisper that he had been poisoned, and it was not until this century that rheumatic heart disease was identified as the most likely cause of his death. When a cause was suggested in the past it was more likely to be foul play, the gods, or fate than something self-induced. As medicine became more advanced and reached its present state of emphasis on prevention, those unlucky'enough to die young were ironically twice damned. Not only were their wives and children left alone, their own careers cut short, their aging parents forced to bury them, but in addition the specter of their death being their own fault arose. For surely if early death can be prevented by good work, diet, and health habits, then it could be assumed that those who die young have done something wrong. If a woman who religiously examines her own breasts for lumps learns that a friend of hers is dying of breast metastases, then she may feel that perhaps it is the poor woman's fault for not being more careful. The fact that a surgeon recently announced that breast self-examination is a failure in preventing death from this too-common misfortune and that physicians should once more assume responsibility for such examination is ,not known to the accusing friend.
Br/ef CommunicaUons does not include references or bibliographies. These may be secured by writing to the Amer/can ]ourna/ of Psychoano/ysis.
377
378
BRIEF C O M M U N I C A T I O N S
Some of the most unlucky men in the world are those who die of heart attacks between the ages of thirty-five and fifty. If the man is overweight everyone condemns him. While perhaps feeling sorry for the family, few seem to pity him. "He should have watched his diet; he didn't get enough exercise; he worked too hard; he was repressed and did not express his emotions; he was too amtitious," are some of the comments made. In "Type A Behavior and Your Heart" the primary cause of heart disease is alleged to be "a distinct behavior pattern, a particular complex of personality, life style, and attitude . . . . It is . . . 'hurry sickness' - aggressiveness and competitiveness, usually combined with a marked amount of free-floating hostility . . . common among hard-driving and successful businessmen and executives - but . . . just as likely to be found in factory workers, accountants, even housewives." Since Drs. Friedman and Rosenman believe half of all American males and a growing number of females are this way, if someone dies young of a heart attack it must have been his or her own fault. Blame for early death also occurs in cases other than heart attack. I recently heard Martin Luther King being condemned for wanting too many civil-rights changes; his critic said he therefore deserved to be assassinated. "He should have gone more slowly," he asserted, and he showed no pity for King's having been killed. An even more startling example of blame recently came to my attention. A young mother, walking home early one evening, was raped and killed. Everyone was enormously frightened that this might happen again. Rumors began to circulate among secretaries in one office that her husband either killed her or had her killed, since they had not been getting along and had been heard arguing. In the case of early heart attacks those of us who survive feel morally and psychiatrically superior to those who have died. We are alive because we watch our diet, our exercise, and our competitiveness and lead the good Greek life of a sound mind in a sound body. But we feel superior at the expense of the facts. Heart attacks before the age of forty do not seem to respect any pattern. Thin people apparently get them as often as fat ones. While weight does effect heart disease in older individuals, it does not seem to do so in the young. But even those men who are slim and in good condition are not immune from blame: "He obviously worked too hard; it must be too much ambition; too many business trips; late nights at the office; excessive worry or love of luxury." If the young victim was neither overworked nor overweight he still is not allowed to rest in peace. His other faults and excesses begin to be reviewed. He must have drunk too much, smoked too much, or taken too many drugs. Smoking and drinking have been linked to heart attacks, so surely these thoughts make sense. Yet once again the evidence is not conclusive that they are a cause of early heart attacks. Occasionally a young man dying of an early heart attack is found not to have been guilty of any excesses in eating, drinking, smoking, working, or drug ingestion. But the unofficial autopsy does not stop there. Like the medical doctor who has run out of possible physical causes, psychological ones are then turned to. Suicide is considered. Since heart attacks occur at random, only some happen in bed. if they take place in a car and are fatal and the vehicle is moving the result is liable to be a crash. Did the dead man commit suicide by crashing his car? The same is true when a fatal heart attack occurs when a man is swimming. Did he drown himself on purpose? Early heart attacks occur suddenly, often without warning, and can look mysterious to those
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around the victim, especially those who do not know the facts very well. The newspaper reports heart attack, but is this just to protect the young children left behind from further pain? It is bad enough to lose a father at an early age without having to carry around the knowledge that it was suicide. People may assume that the possible suicide is being hushed up so the insurance company will pay. After all, the young widow and children need money now that the provider is dead. But if a happy young man dies in bed and clearly cannot be thought of as a suicide, then more subtle psychological thinking may be resorted to. Not only might he have been a heart-attack type, who did not express feelings of anger and sadness but kept them in, but also perhaps he only appeared to be happy. "Remember how angry he got when in traffic but absolutely nowhere else and how he was always in a hurry," people will say. I know of no early heart-attack victim who has survived this list of charges, no one who has remained pitied because he was the victim of a cruel whim of nature or of the unfortunate placing of an atherosclerotic plaque by an unknown disease process. Man is not thought of as frail and vulnerable, subject to cosmic forces and diseases beyond his control. He is believed to possess the power to triumph if not over death than at least over early death. Those who die young of a heart attack are invariably believed to have been at fault. After all, what man of forty who dies is so perfect that he cannot be accused of having eaten, drunk, smoked, worked, or taken drugs in excess? And if he is accused of none of these then he is accused of having been suicidal or of not having handled his emotions in a proper non-heart-attack-prone manner. In a way, this writing is a memorial to three psychiatrists I knew, all of whom died of heart attacks without warning between the ages of thirty-eight and forty-two. All left wives and children and frightened colleagues. The first was the youngest, a boyhood friend who died suddenly at the age of thirty-eight. There had been no previous warning. When his family called me they referred to how he saw patients until late in the evening. They believed this responsible for his early death. Without mentioning it to his relatives, my own alarmed thinking added that he had been fifteen pounds overweight, had smoked too many cigars, and had been caught by the Vietnam doctor's draft. The next was a teacher I had loved and respected in my second year of psychiatric residency, someone whose teachings have to this day left a profound impression on me. What did this excellent man do wrong? He smoked two packs of cigarettes a day, and he kept his feelings too much inside. The last was a psychiatrist who was brilliant but personally difficult. I scarcely knew him, but I was called by a colleague of his because, as circumstances had it, I had to be informed. The caller, a stranger to me, said that the doctor had died suddenly and without warning and had just been found dead in his home. He implied that suicide might have been the cause. I was surprised he would say this to me, someone who was a perfect stranger to him, not a member of his hospital's staff, and one who had scarcely known the deceased. The newspaper the next day reported the cause of his death as heart attack, but I continued to hear skepticism. Talk of suicide continued for months, with claims that it was being hushed up for the sake of the family. [ wish to remove the double damning these men have suffered. It is bad enough that their young widows and children have been left behind and that their brilliant careers have been snuffed out. It is bad enough that I have been deprived of their
380
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company and the chance to learn from them. I would like to make this attempt to relieve them of blame for their early deaths. Overwork, cigarettes,overweight, and suicide were probably not to Name. The facts as we know them are that early heart attack does not fit any set pattern but can happen to anyone at any time: fat or thin, smoker or nonsmoker, diligent or lazy. Then why does the blame occur? It makes those of us w h o live feel protected. Since we are not fat or alcoholic or work addicts or too excitable or flabby, but are thin, moderate in drink and work, emotionally balanced, and carefully exercised, then we are protected from early heart attack and perhaps from early death itself. We save ourselves by making the dead at fault. It is psychologically much more comfortable to blame the dead than to fear our own mortality. Their own actions are thought to have killed them so that we the living can believe that we control our lives from early loss. I learned of this blaming mechanism largely by observing it in myself and later in others. In the case of my thirty-eight-year-old boyhood friend, all my thoughts were efforts to make him different from me, so that my fright that I too might die would be relieved. I do not see patients until eleven o'clock at night. I am not fifteen pounds overweight and gave up smoking fifteen years ago. I was fortunate not to have been drafted, to not have had to endure all the strain of moving, terminating, and rebuilding my practice, leaving my friends, colleagues, students, and research. I am different from my beloved teacher because I do not smoke two packs of cigarettes daily and because I am not an inhibited man who has difficulty feeling or expressing sadness or love. And I am unlike the mean, successful psychoanalyst who worked over seventy hours a week doing research, taught full time, and wrote more than seventy papers by the time he was forty. I had to succeed, through my psychological defenses, in distinguishing myself from these men so that I could feel I would not die. What amazed me was seeing other psychiatrists, social workers, and psychologists doing exactly the same thing. These sophisticated, psychoanalyzed people were thinking just like the ignorant man who thought Martin Luther King got what he deserved. They were distinguishing themselves from the dead psychiatrists; they were in fact blaming them for not handling their emotions properly (even for being inadequately psychoanalyzed) and for being too hard-working and ambitious. And they were doing so without realizing it. In one case, speculation about possible suicide was so freely indulged in that I became convinced it was psychologically motivated. After all, if the man had killed himself, then the living do not have to fear their own vulnerability. Life and death are under control. The desire for control of life and death can go so far as to influence thinking about the young mother who was raped and killed on the street. Other women would not have to fear the existence of a maniac if they could decide that her husband killed her. This would make it a unique marital dispute and not a danger that could effect others. It is a product of the same reasoning that blames youthful death on the victim. Those who die young are truly tragic and unlucky victims. Too often their affairs are not in order. There is not enough life insurance and too much debt. The will is not written or not up to date. All the bank accounts cannot be found. In addition, we know from studies of the stages of grief that their loved ones will feel angry with them for having deserted them. Their young children will be scarred for life. But at
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381
least the rest of us do not have to blame them. We are lucky. Let us recognize and bear the fear and anxiety that we too are vulnerable, that cosmic forces and unknown diseases can snuff us out at any time. But surely we are strong enough to bear this grim reality without blaming the unfortunate early dead. William S. Appleton, M.D. Reprint requests to 51 Brattle Street, Cambridge, Massachusetts 021 38
BRIEF COMMUNICATIONS
The Blame of Dying Young He whom the gods love dies young Menander I do not know how exactly to define an early death, but surely it is one that occurs before age forty-five or fifty. No matter what number is chosen, everyone would agree that Carole Lombard, Mozart, and George Gershwin died young. In the world I grew up in we pitied Lombard - beautiful, talented, and the passive victim of a plane crash and wondered what Mozart would have written had illness not killed him. But even in Gershwin's time our attitudes had begun to change. What caused his death was not inoperable cancer of the brain, but seemingly incompetent physicians and a psychoanalyst who allegedly ignored the physical cause of constant headache. While Gershwin's early death was never blamed on him, faultfinding had begun to appear. In the past those who died young were pitied. Their wives and children were helped, and everyone felt sorry for them. Perhaps this represented a holdover from earlier times when medicine was not advanced and early death could not be prevented. The victims were seen as victims and could not be blamed. Their deaths were regarded with fear or perhaps with suspicion. For example, Mozart's rapid decline and demise lead people to whisper that he had been poisoned, and it was not until this century that rheumatic heart disease was identified as the most likely cause of his death. When a cause was suggested in the past it was more likely to be foul play, the gods, or fate than something self-induced. As medicine became more advanced and reached its present state of emphasis on prevention, those unlucky'enough to die young were ironically twice damned. Not only were their wives and children left alone, their own careers cut short, their aging parents forced to bury them, but in addition the specter of their death being their own fault arose. For surely if early death can be prevented by good work, diet, and health habits, then it could be assumed that those who die young have done something wrong. If a woman who religiously examines her own breasts for lumps learns that a friend of hers is dying of breast metastases, then she may feel that perhaps it is the poor woman's fault for not being more careful. The fact that a surgeon recently announced that breast self-examination is a failure in preventing death from this too-common misfortune and that physicians should once more assume responsibility for such examination is ,not known to the accusing friend.
Br/ef CommunicaUons does not include references or bibliographies. These may be secured by writing to the Amer/can ]ourna/ of Psychoano/ysis.
377
378
BRIEF C O M M U N I C A T I O N S
Some of the most unlucky men in the world are those who die of heart attacks between the ages of thirty-five and fifty. If the man is overweight everyone condemns him. While perhaps feeling sorry for the family, few seem to pity him. "He should have watched his diet; he didn't get enough exercise; he worked too hard; he was repressed and did not express his emotions; he was too amtitious," are some of the comments made. In "Type A Behavior and Your Heart" the primary cause of heart disease is alleged to be "a distinct behavior pattern, a particular complex of personality, life style, and attitude . . . . It is . . . 'hurry sickness' - aggressiveness and competitiveness, usually combined with a marked amount of free-floating hostility . . . common among hard-driving and successful businessmen and executives - but . . . just as likely to be found in factory workers, accountants, even housewives." Since Drs. Friedman and Rosenman believe half of all American males and a growing number of females are this way, if someone dies young of a heart attack it must have been his or her own fault. Blame for early death also occurs in cases other than heart attack. I recently heard Martin Luther King being condemned for wanting too many civil-rights changes; his critic said he therefore deserved to be assassinated. "He should have gone more slowly," he asserted, and he showed no pity for King's having been killed. An even more startling example of blame recently came to my attention. A young mother, walking home early one evening, was raped and killed. Everyone was enormously frightened that this might happen again. Rumors began to circulate among secretaries in one office that her husband either killed her or had her killed, since they had not been getting along and had been heard arguing. In the case of early heart attacks those of us who survive feel morally and psychiatrically superior to those who have died. We are alive because we watch our diet, our exercise, and our competitiveness and lead the good Greek life of a sound mind in a sound body. But we feel superior at the expense of the facts. Heart attacks before the age of forty do not seem to respect any pattern. Thin people apparently get them as often as fat ones. While weight does effect heart disease in older individuals, it does not seem to do so in the young. But even those men who are slim and in good condition are not immune from blame: "He obviously worked too hard; it must be too much ambition; too many business trips; late nights at the office; excessive worry or love of luxury." If the young victim was neither overworked nor overweight he still is not allowed to rest in peace. His other faults and excesses begin to be reviewed. He must have drunk too much, smoked too much, or taken too many drugs. Smoking and drinking have been linked to heart attacks, so surely these thoughts make sense. Yet once again the evidence is not conclusive that they are a cause of early heart attacks. Occasionally a young man dying of an early heart attack is found not to have been guilty of any excesses in eating, drinking, smoking, working, or drug ingestion. But the unofficial autopsy does not stop there. Like the medical doctor who has run out of possible physical causes, psychological ones are then turned to. Suicide is considered. Since heart attacks occur at random, only some happen in bed. if they take place in a car and are fatal and the vehicle is moving the result is liable to be a crash. Did the dead man commit suicide by crashing his car? The same is true when a fatal heart attack occurs when a man is swimming. Did he drown himself on purpose? Early heart attacks occur suddenly, often without warning, and can look mysterious to those
BRIEF COMMUNICATIONS
379
around the victim, especially those who do not know the facts very well. The newspaper reports heart attack, but is this just to protect the young children left behind from further pain? It is bad enough to lose a father at an early age without having to carry around the knowledge that it was suicide. People may assume that the possible suicide is being hushed up so the insurance company will pay. After all, the young widow and children need money now that the provider is dead. But if a happy young man dies in bed and clearly cannot be thought of as a suicide, then more subtle psychological thinking may be resorted to. Not only might he have been a heart-attack type, who did not express feelings of anger and sadness but kept them in, but also perhaps he only appeared to be happy. "Remember how angry he got when in traffic but absolutely nowhere else and how he was always in a hurry," people will say. I know of no early heart-attack victim who has survived this list of charges, no one who has remained pitied because he was the victim of a cruel whim of nature or of the unfortunate placing of an atherosclerotic plaque by an unknown disease process. Man is not thought of as frail and vulnerable, subject to cosmic forces and diseases beyond his control. He is believed to possess the power to triumph if not over death than at least over early death. Those who die young of a heart attack are invariably believed to have been at fault. After all, what man of forty who dies is so perfect that he cannot be accused of having eaten, drunk, smoked, worked, or taken drugs in excess? And if he is accused of none of these then he is accused of having been suicidal or of not having handled his emotions in a proper non-heart-attack-prone manner. In a way, this writing is a memorial to three psychiatrists I knew, all of whom died of heart attacks without warning between the ages of thirty-eight and forty-two. All left wives and children and frightened colleagues. The first was the youngest, a boyhood friend who died suddenly at the age of thirty-eight. There had been no previous warning. When his family called me they referred to how he saw patients until late in the evening. They believed this responsible for his early death. Without mentioning it to his relatives, my own alarmed thinking added that he had been fifteen pounds overweight, had smoked too many cigars, and had been caught by the Vietnam doctor's draft. The next was a teacher I had loved and respected in my second year of psychiatric residency, someone whose teachings have to this day left a profound impression on me. What did this excellent man do wrong? He smoked two packs of cigarettes a day, and he kept his feelings too much inside. The last was a psychiatrist who was brilliant but personally difficult. I scarcely knew him, but I was called by a colleague of his because, as circumstances had it, I had to be informed. The caller, a stranger to me, said that the doctor had died suddenly and without warning and had just been found dead in his home. He implied that suicide might have been the cause. I was surprised he would say this to me, someone who was a perfect stranger to him, not a member of his hospital's staff, and one who had scarcely known the deceased. The newspaper the next day reported the cause of his death as heart attack, but I continued to hear skepticism. Talk of suicide continued for months, with claims that it was being hushed up for the sake of the family. [ wish to remove the double damning these men have suffered. It is bad enough that their young widows and children have been left behind and that their brilliant careers have been snuffed out. It is bad enough that I have been deprived of their
380
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company and the chance to learn from them. I would like to make this attempt to relieve them of blame for their early deaths. Overwork, cigarettes,overweight, and suicide were probably not to Name. The facts as we know them are that early heart attack does not fit any set pattern but can happen to anyone at any time: fat or thin, smoker or nonsmoker, diligent or lazy. Then why does the blame occur? It makes those of us w h o live feel protected. Since we are not fat or alcoholic or work addicts or too excitable or flabby, but are thin, moderate in drink and work, emotionally balanced, and carefully exercised, then we are protected from early heart attack and perhaps from early death itself. We save ourselves by making the dead at fault. It is psychologically much more comfortable to blame the dead than to fear our own mortality. Their own actions are thought to have killed them so that we the living can believe that we control our lives from early loss. I learned of this blaming mechanism largely by observing it in myself and later in others. In the case of my thirty-eight-year-old boyhood friend, all my thoughts were efforts to make him different from me, so that my fright that I too might die would be relieved. I do not see patients until eleven o'clock at night. I am not fifteen pounds overweight and gave up smoking fifteen years ago. I was fortunate not to have been drafted, to not have had to endure all the strain of moving, terminating, and rebuilding my practice, leaving my friends, colleagues, students, and research. I am different from my beloved teacher because I do not smoke two packs of cigarettes daily and because I am not an inhibited man who has difficulty feeling or expressing sadness or love. And I am unlike the mean, successful psychoanalyst who worked over seventy hours a week doing research, taught full time, and wrote more than seventy papers by the time he was forty. I had to succeed, through my psychological defenses, in distinguishing myself from these men so that I could feel I would not die. What amazed me was seeing other psychiatrists, social workers, and psychologists doing exactly the same thing. These sophisticated, psychoanalyzed people were thinking just like the ignorant man who thought Martin Luther King got what he deserved. They were distinguishing themselves from the dead psychiatrists; they were in fact blaming them for not handling their emotions properly (even for being inadequately psychoanalyzed) and for being too hard-working and ambitious. And they were doing so without realizing it. In one case, speculation about possible suicide was so freely indulged in that I became convinced it was psychologically motivated. After all, if the man had killed himself, then the living do not have to fear their own vulnerability. Life and death are under control. The desire for control of life and death can go so far as to influence thinking about the young mother who was raped and killed on the street. Other women would not have to fear the existence of a maniac if they could decide that her husband killed her. This would make it a unique marital dispute and not a danger that could effect others. It is a product of the same reasoning that blames youthful death on the victim. Those who die young are truly tragic and unlucky victims. Too often their affairs are not in order. There is not enough life insurance and too much debt. The will is not written or not up to date. All the bank accounts cannot be found. In addition, we know from studies of the stages of grief that their loved ones will feel angry with them for having deserted them. Their young children will be scarred for life. But at
BRIEF COMMUNICATIONS
381
least the rest of us do not have to blame them. We are lucky. Let us recognize and bear the fear and anxiety that we too are vulnerable, that cosmic forces and unknown diseases can snuff us out at any time. But surely we are strong enough to bear this grim reality without blaming the unfortunate early dead. William S. Appleton, M.D. Reprint requests to 51 Brattle Street, Cambridge, Massachusetts 021 38
