In different ways, this image seems both realistic and unrealistic. The man, the wheelchair, and the sign are depicted is realistic ways. In this respect, our chapter four image is unlike the flower image for chapter two, which was clearly symbolic, or the windows image for chapter three, which was both spatially and temporally ambiguous. On the other hand, I am pretty sure that none of us has every seen someone really doing what this man is doing, whereas we have seen flowers and neighbors in windows. He appears to be straining upward like a healthy man calling for a taxi. He looks alert. Yet he is unambiguously signaling his desire to be taken to a hospital. What is going on here?
Dr. Dugdale says this man “provides a visual representation of the many people who grow increasingly dependent on the mechanisms of health-care institutions” (page 226). That reliance, she says, “is partly responsible for the fact that only a minority of people die at home, contradicting their own strongly expressed wishes” (page 226). This man doesn’t appear to be dying (though appearances can deceive). Perhaps his present desire to go to the hospital will lead to his dying there later in life. Or perhaps the eager desire expressed by his body is a symbol of the inward desires of those who suffer terminal illness.
These observations make me think about the meanings of works like wish and want. Dr. Dugdale refers to people’s “strongly expressed wishes” to die at home. Like the man in this image, however, people who die in hospitals in some sense wanted to be there. Otherwise they wouldn’t have gone. This disconnect between what people want and what actually happens seems to come down, at lease in part, to the difference between what they previously wished and what they want when the time comes. That previous wish might just be a general, all-things-being-equal kind of desire. When decisions really have to be made, all things are not equal and there are often practical challenges that make dying at home less desirable.
I find in this disconnect, between what people want in a general way and what they want when confronted by the particular circumstances of dying, similar difficulties to those that pertain to making advance directives. (Here is an article I wrote about that.) In both cases, desires people have about their futures are more or less uninformed. We can’t fully anticipate the circumstances of our future illnesses, whether those circumstances have to do with where we will die or whether we will choose this or that treatment option. To an extent, however, we can anticipate. We can consider many possibilities ahead of time so that our wishes are less general and more informed, less like daydreamy fantasies and more like practical wants that inspire real preparation.
Perhaps we can draw two conclusions about this disparity between wishes and reality. First, that this disparity should be expected. Because we aren’t comparing apples to apples, but apples to oranges. People’s general wishes to die at home are not contradicted by their later decisions to go to or stay in a hospital, nursing home, or hospice. It is not as though they were performing the same activity in contradictory ways, like donating money to the Democratic candidate one day and to her Republican opponent the next day. Wishing and deciding are, in the sense in which we are considering them, two very different activities. As a second conclusion, we might say that our general advanced wishes would be more similar to our specific in-the-moment decisions if we considered beforehand the practical circumstances of our future dying.
People’s “strongly expressed wishes” to die at home are often at odds with the kind of desire that is expressed in this image. Advanced consideration about practical possibilities could have the desirable effect of partially bridging that divide. Dr. Dugdale is clearly interested in that. But I think she is more interested in the effects that could result from advanced consideration of cultural, existential, and personal aspects of human death and dying. I think she will attend more to those subjects in the remaining chapters of this book.