I was impressed with the article by Meier and colleagues [1], who present a thoughtful perspective on a troublesome and increasingly recognized problem. I was concerned, however, by the general thrust of this article (and many others), which compartmentalized dying as a "medical" process and separated it from the cycle of human life in the setting of families, communities, and society as a whole. Even the laudable and necessary hospice movement, in effect, declares that this portion of life-the end of it-is of necessity a "pathologic state" requiring medical expertise.

The general belief of the U.S. public that dying is mainly a medical event, rather than a social event, is testified to by the oft-cited statistic that "80% of Americans die in hospital" and by the authors' allusion to studies that suggest that "most family members have never witnessed death and are uncomfortable with the prospect." Certainly, families and others will probably always be uncomfortable with the prospect of death, but this is not necessarily a reason for denying them the experience, and they are furthered in their inexperience with it by its sequestration into hospitals and even hospice.

Dying may certainly be accompanied by pain, anxiety, dyspnea, nausea, vomiting, and other forms of symptomatic distress that can be relieved by palliative care. Certainly the identification of dying with the unpleasantness of all of the signs and symptoms constantly cited in the palliative care literature tends to frighten people. Most physicians have seen many persons die in coma, with metabolic encephalopathy, in extreme old age, with sepsis, or in only mild distress, and I wonder what proportion of deaths in the United States, if the patients were not hospitalized or medically treated, would be peaceful. Should we not consider the reintegration of some categories of death into the social milieu, with broad education of the public about what medicine can do and what they-society, communities, and families-can do to make dying at home less anathematized and less frightening? To suggest that we must always appoint medical personnel to oversee it implies that death is a disease, and this may have led to a situation wherein people would sooner be dead that be medically treated for dying.