The one thing that appears the most in Marcus Aurelius, Seneca, and Epictetus is the importance of coming to terms with our mortality so we’re not defined by it. Most of us either deny our mortality or we are incredibly anxious about it. BJ Miller, one of the most well-respected and passionate doctors in the palliative care field whose TED Talk, “What Really Matters at the End of Life,” has been viewed more than 9 million times, and Shoshana Berger, the editorial director of the global design firm IDEO, joined forces to help put minds at ease about dying—and help people live fully until they do.
In their new book A Beginner’s Guide To The End, BJ and Shoshana draw on their personal experiences, which have made them each intimately familiar with death, to help us better understand and find meaning in this universal human experience. In our interview with BJ and Shoshana below, they explain those experiences that inspired the book, what BJ’s near-death accident taught him about living, why we should enter a relationship with the topic of death, the dangers of Silicon Valley’s obsession with prolonging (or ending) death, and much much more. Please enjoy our interview with Dr. BJ Miller and Shoshana Berger!
SHOSHANA: My father was a professor of engineering for 50 years and was basically a walking brain, so when he faded slowly and then very suddenly with dementia, it was harrowing to watch. As a caretaker, I was completely clueless about how to help him and give him the death he might have wanted. I had no idea how to deal with doctors, and hospitals, and insurance, and his new wife. When he died, I literally sat down at the computer and Googled “What do you do when someone dies?” I didn’t even know to call a funeral home! Why? Because it’s not exactly a popular topic here in America—no one talks about it unless it smacks them in the face. And because we live in a culture that treats death as optional—something we might avoid if we quit smoking and eat broccoli and walk 10k steps per day, most people end up like me, in an involuntarily crash course in illness and death and grief.
I met BJ in a hospice project at IDEO, the design firm where I work, when that wound was still fresh. His vision for how we might make a truce with death and reframe it as our most effective driver of meaning was catalytic. It made me think: People are afraid and bewildered and they need help with this, and not just essays about how broken our systems are, but a sense that they have agency in this—the Okay, now what? How do I actually prepare myself and the people I love so that the experience feels like an integrated part of life.
BJ: First, watching my mother go through life from a wheelchair, then as a disabled person myself, then as a physician, you come to see how much harder it is to live with illness and mortality than it needs to be. Especially from the clinical vantage point, you see how much insecurity and fear comes simply from a lack of fundamental, accessible information. So when Shoshana asked, it seemed right to try to help fill that basic gap. And right to try with Shoshana, precisely not a medical person, and whom I trusted and who brought myriad relevant skills and experiences to the table.
A Beginner’s Guide to the End might seem at first like an uninviting title for a book. You address it in the introduction, but could you share here what you hope readers take away from this book?
SHOSHANA: It’s so funny you ask that. I’ve been thinking a lot about the reactions the title causes in people. I showed the book to my accountant the other day and I thought he was going to pee his pants. The original title—don’t laugh—was How to Die. We didn’t want to hit people over the head with a polo mallet, but we also didn’t want to shy away from the fact that human life ends. Even if you believe life begins again or that we fly up to heaven or traipse around as spirits, the part that’s living in this body with these people is finite.
The fact of our finiteness is the vena cava of philosophy and poetry. “In my beginning is my end,” T.S. Eliot writes in Four Quartets. And Seneca’s essay On The Shortness Of Life, and how its end offers us a way to extract purpose and meaning, is required reading in my opinion. He urges readers to not waste their lives in the trivial pursuits of ego and material pleasure. I always have his words—that life is long if we know how to live it—in my ears.
There’s a beautiful, painful teleology to human life and to every story we tell. Every day thousands of our cells die off and others are born. We cannot begin without ending. So, for us to pay so much attention to how we bring new life into the world and completely ignore how we exit just seems odd. This book is designed to help us ignore it less. And what we hope people will take away is the feeling that they have a part to play in their lives right up until the end and that to lean in and think about, talk about, and prepare for death, is a way to honor and expand and enrich the lives we have to live.
BJ, you had a near-death death experience in college and have hundreds if not thousands of vicarious deathbed moments as a hospice and palliative care physician. What have years of observing death so closely taught you about living?
BJ: That they are entirely entwined. That you can’t have one without the other. The cosmic package deal. The fact of this statement often becomes obvious by the end of a life. And with that, you are off the hook; there is in fact no shame in dying; you cannot fail at it. Sometimes, you can see this by the peace on a dying person’s face, and the anguish on those who have to keep living. In the end, death doesn’t seem to be much of an enemy. And, the sooner you reconcile the relationship between life and death, the clearer life’s challenges and opportunities become and the less there will be to regret when death finally comes. People who really know they will die also know that life goes on without them, and so just maybe they will invest themselves in the world outside themselves.
The one thing that appears the most in Marcus Aurelius, Seneca, and Epictetus is the importance of coming to terms with our mortality so we’re not defined by it. Most of us either deny our mortality or we are incredibly anxious about it. Through your experiences, have you found ways that best help people manage and overcome either denial of or anxiousness about death?
BJ: One way or another, people need to enter a relationship with death. It will impose itself if you don’t find some way to relate. In other words, mortal fear or angst signals the need to come closer rather than run away. For many of us, with some pondering, death becomes knowable in small bites as we mature and age; every loss is a little death, and an opportunity to become slightly more familiar with being gone.
And it’s often instructive to parse fear of dying from fear of being dead. The first is easier. For starters, from what I’ve seen, dying is worse in people’s imaginations than in person. And second, so much can be done to treat whatever discomfort arises, especially with hospice involved.
As for the fear of being dead, that has much to do with your faith or belief system, but I like Seneca’s reminder that we are dead long before we are alive, not just after, and it wasn’t so bad then. Whether judgment day is a concern for you, or you believe life entirely ends with death, the ultimatum is the same: live your life the best you can.
It’s remarkable how constant death is as a theme in the ancient world compared to today when we just don’t talk about it. If we do talk about death, it’s mostly in how to avoid and prevent it. Which of these attitudes is better in your eyes? What does the Stoic approach have to teach us?
BJ: I think it is best to open the subject up for discussion. To pull it out of the closet. We shrink our lives to make them more manageable. I’d rather instead that we managed our lives by expanding definitions of ‘normal’ and grow our capacity to handle fuller notions of reality.
That’s in-general, as a societal goal. As for each of us within the confines of our respective lives, I would not impose any judgment. The only question for any one of us is, does my view of death serve me and those I love well?
And if it’s control or personal agency you seek, focus your efforts on how you respond to reality rather than trying to bend what is real. Enter humor, enter grace, equanimity, forgiveness, kindness, love, etc.
What do you think of the sort of Silicon Valley obsession now with either indefinitely prolonging death or ending death?
SHOSHANA: SV is drunk on longevity. Investors are pouring millions in startups like Google’s Calico and Juvenescence, which is using AI to test magic “healthspan” pills and get them to market quicker. People are popping Metformin, a commonly prescribed diabetes drug, doing periodic fasting and my personal opinion is that this is a classic case of wanting to extend power as much as life—hubris that Greek myth and philosophy has long cautioned us against.
It’s not just them. Our obsession with immortality is—forgive me—ageless. From the Epic of Gilgamesh to the myth of Tithonus, and we’ve seen this movie before, it never ends well. What are the dangers of prolonging life indefinitely or even by 50 years? Here are a few: This is only for the 1%. Overpopulation will strain our ability to provide food and infrastructure and may be the earth’s final blow. There are unforeseen mental health effects (if you think we suffer from ennui and meaninglessness now, just wait). And what if the type of people who should not live a long time (Stalin, Mao, Hitler) start to live longer? What about creative turnover? There’s this great quote by Steve Jobs, one of Silicon Valley’s heroes, that I wish they’d pay more attention to: “Death is the most wonderful invention of life. It purges the system of these old models that are obsolete.”
Could you leave the Daily Stoic community with one message or piece of advice? It could be a question to journal on, a philosophical practice to try, or just something to think about as they go about their day.
SHOSHANA: The Buddhists suggest that we think about death five times a day in order to live well. There’s even an app called “We Croak” that delivers you five death quotes as notifications. I tried it for a while and it drove me nuts. Instead, maybe try putting down your phone and looking the person you love in the eye when you’re saying goodbye. Be there. Participate. Love.
BJ: We are freer than we think we are. (And that freedom owes much to death.)
P.S. Check out BJ and Shoshana’s new book A Beginner’s Guide To The End. As they write, “Our ultimate purpose isn’t so much to help you die as it is to free up as much life as possible until you do.”