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    A Tunisian mosaic dating to the Roman era. Image: Dennis Jarvis/Flickr

    Scientifically, What Is the Worst Way to Die?

    Written by Alexandra Ossola

    We spend a lot of energy warding it off or putting it out of our heads, so I'm sorry to be the one to tell you: Death is inevitable. And even though it's been happening, either on purpose or by accident, since before humans were even human, there's been no real scientific consensus as to what kinds of deaths we should try the hardest to avoid.

    Those with a penchant for the morbid may have already thought about this question. Drowning could strike a particularly undesirable chord for you, or perhaps burning alive. We often think about these impersonally, as things that might only happen in our reality under strange circumstances, or happened back in the day before doctors had considered germs. If you talk about it at all, it’s over drinks with your friends—you all have a dark laugh and go about your life.

    But the deaths that haunt our nightmares have some common characteristics. And even though science is far from a consensus, we can piece together many different scientific perspectives, read between the lines, and get an answer to the question of “the worst way to die.”

    The answer I found is not an easy pill to swallow. You're not going to like it.

    Before we get to the nitty-gritty, it's helpful to characterize what "ways" to die actually means. When a person dies, a physician or medical examiner fills out a death certificate that indicates three things, according to Kevin Henderson, a coroner for Ontario County, New York: the cause, mechanism, and manner of death. While each of these elements can have cringe-worthy parts, I’m going to focus mostly on the cause of death.

    "The cause of death is the disease or injury that produces the physiological disruption inside the body resulting in death; for example, a gunshot wound to the chest," Henderson said. These causes are what populate our deepest fears. It’s the difference between being afraid of drowning versus being afraid of the oxygen deprivation, inhaled water, and contracted circulation that would actually kill you, or even the fact that you didn’t know how to swim.

    Eugène Delacroix. 1798-1863. Paris. La mort d'Ophélie. 1838. Munich Neue Pinakothek. Image: Jean Louis Mazieres/Flickr

    People are often distressed when thinking about a cause of death because of the particular brand of pain we assume we would get from them. Pain is generally defined as an “unpleasant feeling” in the body, but it's subjective, and can be improved or exacerbated by context.

    "Context is important when thinking about pain," according to Randy Curtis, the director of the University of Washington Palliative Care Center of Excellence in Seattle. "Childbirth is good example. It's pretty serious pain, but you know it’s temporary, you know why you're having it, and it's an exciting event. Women can tolerate much higher levels of pain in that context—as opposed to pain caused by cancer, which will shorten your life and might get worse."

    Even though pain is very subjective, it can be objectively categorized, which can help doctors determine how to treat it. They look at how long you have it: acute (short-term) or chronic (long-term). They can both be awful, Curtis said. But pain also feels different depending on its origin. Nociceptive or somatic pain is the sensation of nerves as a direct result of injury, whereas neuropathic pain has no discernable origin and can include pain from things like alcoholism, phantom limb syndrome, or multiple sclerosis.

    Few people understood the power of pain as profoundly as the early modern inquisitors who crafted what we usually refer to as "medieval" punishment. These gruesome punishments became relatively widespread starting around 1520, after the Reformation in Western Europe, according to Larissa Tracy, a professor of medieval literature at Longwood University in Farmville, Virginia.

    Decline is tough, so people fear losing more and more

    Tortuous punishment methods were used very infrequently, Tracy emphasized, and only on the worst criminals: traitors, heretics, and murderers. But their unifying characteristics were that they were very painful and took a long time to achieve their ultimate goal.

    Consider, for example, hanging, which was the most common form of capital punishment in the late Middle Ages. "This was not a sophisticated way of hanging—they would pull [the criminals] up so they would strangle, which could take six to ten minutes," Tracy said.

    Other gruesome methods included being hanged, drawn and quartered, reserved for the worst traitors in early modern England. A person would be hanged almost to the point of death, then cut down. Then he would be castrated and his intestines would be pulled out in front of him. Usually this was done with hooks or sharp tools. Finally, he would be beheaded and chopped into four pieces (some versions of this method used horses to pull a person apart, although Tracy said there’s little evidence that this worked well) and displayed prominently.

    Another particularly nasty punishment was being broken on the wheel, reserved for the worst criminals in Europe and slaves trying to revolt in the United States. The criminal would be tied to a large wooden wheel and bludgeoned so that all of his bones broke. Some accounts indicate that victims could live for three days in this state. 

    Beheading was often reserved for nobility because it was fast and comparably painless. Image: Wikimedia

    Tracy said that today we use capital punishment much more liberally, and the "merciful" methods we use are far from it. Recent studies have shown that the chemical cocktail used in lethal injections may not have the anesthetic effect it’s supposed to. And that’s thought to be an improvement on the electric chair.

    "They run thousands of volts through a human body, their brains cook, flames burst through their skin in places," Tracy said, shuddering. "And they're alive through the whole process."

    Even though these methods are painful, they still (usually) only take a few minutes. The average American today is more likely to die from an illness that lasts much longer. The leading causes of death are heart disease and cancer, which together accounted for 63 percent of all deaths in the US in 2011. People with these and many other diseases often live longer than their ancestors, but those final increments of life are more drawn-out and painful.

    “People believe that they’ll know when they’re coming to their final days, weeks or months, but most of us come to the end of our lives very incrementally,” said Joanne Lynn, a physician and palliative care specialist. “We keep pretending that people will die of a heart attack overnight, but that’s not reality.”

    As the end gets closer day by day, many people must live out their fears about dying. “Decline is tough, so people fear losing more and more,” Lynn said. “They fear suffering, physical and emotional isolation. They fear losing control, becoming impoverished, not having access to food. And of course there’s the ultimate fear of nonexistence, of being dead.”

    It’s not uncommon to have to deal with all of these fears. For people who make it to 85 or 90, this ultimate fear is less jarring, because many of their friends have likely already passed away, so it’s often “distressing but not unexpected,” Lynn adds.

    So the bad news is that, if you’re alive today, your death will probably be drawn out and pretty scary. The good news is that we’re a lot better at managing pain than they were in the Middle Ages. Depending on the source of pain and how much it bothers you, doctors could treat you with anything from non-steroids like Tylenol to opioids like morphine. Here, again, the patient’s assessment of the pain is essential.

    “The first step before taking steps to treat pain is that we look at what is causing the pain to see if there is something we can do to get rid of the cause,” Washington’s Curtis said. For example, cancer that has metastasized to affect the bone can cause a particularly deep pain.

    “Some kinds of cancer are very responsive to radiation, so the pain can get a lot better," Curtis said. "But other kinds of cancer aren’t sensitive to radiation. If doctors do too much of it, it can cause problems—burns and injuries that can cause more pain.”

    This is where you're likely to die. Image: Dan Cox/Flickr

    Pain, Curtis noted, is one of many symptoms that can distress a patient near the end of life. “Nausea, vomiting, fatigue, depression, anxiety [and] shortness of breath can be really debilitating and scary,” Curtis said. This hints at something deeper, the mother of those other fears: the fear of people not understanding the pain one is going through and being forced to suffer alone.

    Doctors, because of what their work entails, are sometimes better at articulating this. “What I would be fearful of is severe pain and not having access to physicians who take it seriously and treat it effectively,” Curtis said.

    Lynn also fears inadequate care. “I want there to be a system I could count on that’s trustworthy, that everyone involved knew how to respond to my preferences and be honest about my prospects," she said.

    From speaking to these experts, it seems that the scientifically worst way to die is the way we’re all most likely to die: in a hospital room after protracted illness. You may or may not know it’s the end. And you may or may not have good doctors who can treat your pain, or family members who respect your wishes.

    But it’s not all quite so existential. Whether a person is a convicted criminal being eviscerated by a hot poker or an average citizen getting eviscerated by cancer, his psychological state can totally transform the meaning of “worst.” Researchers will surely develop more advanced ways to treat and understand pain, and maybe even death. But the psychological conditions are multi-faceted—and also much more under individuals’ control.

    Update 10/20: A previous version of this article noted that disembowelment was done with a hot poker. This was believed to have been the punishment only for King Edward II. It also omitted that heretics received early modern punishment in addition to traitors and murderers.