The fatal blow to President Biden’s reelection bid came during the debate when he appeared to have a stroke. The insult of being “too old” haunted and hounded him ever since. How quickly did Biden need to end his campaign to save face?

Dignity grants the certainty of whether three seconds, three minutes, three hours, three days, three weeks, or three months is reasonable to pull the plug on sustainability and longevity.

The undying strength to stand up and “fight, fight, fight” is determination. The moral courage to stand down and rest in peace is dignity. Dignity arises from seeing the light, and this “enlightenment” ends suffering.

Following his near-death debate in the POTUS race, President Biden might question, “Should I stay or should I go? I don’t know” … raises uncertainty and diminishes dignity. Three days might be enough time to agonize in insults before coming to terms with the inevitability of age, cognitive impairment, loss of control, and even death.

As an emergency physician, I see the loss of dignity from those who suffer from serious illness, incapacitating injuries, and cognitive impairment. Each has roughly three hours to choose between fighting the odds by staying at the hospital and accepting the inevitable by returning home. Patients mostly think they’re damned if they do and damned if they don’t follow through with sustaining longevity and defying mortality. Their dignity seemingly leans toward denying the obvious rather than realizing acceptance.

Could Biden anticipate his decline at the end of last year before running for re-election? At what point might he recognize the beginning of the end? Personal dignity is at stake when deciding between continuing the course and changing direction with age and serious illness. Age 80 is a great milestone and finish line to acknowledge the beginning of the end of life expectancy and reasonability.

We as a society appreciate that young adults don’t have the brain capacity to make autonomous decisions until age 18. The frontal cortex is not fully developed until age 25. Since the brain begins to atrophy or shrink at age 70, a caregiver might need to approve any life decision ten years later that might harm self and others, like driving a car or running for public office.

The key practice of emergency medicine is managing patients’ expectations. If patients are demanding and have high expectations, self-determination will sabotage personal dignity. The insults will continue until the person finds the moral courage, radical acceptance, wondrous humility, and sweet surrender inherent to dignity.

Dignity is inversely proportional to morbidity. The longer one suffers, the less personal dignity. Enlightenment serves to end suffering and restore dignity. Once patients see the light in the emergency room and decide to return home, their demeanor changes. I witness the stress being lifted and a smile emerging. Their dignity was lost, but now is found.

If Biden searched the “Soul of America,” he’d discover America’s need to beat the odds and win at all costs. This hubris, if unchecked, leads to violence against self and others. We value a system of checks and balances that could give humility and nonviolence equal footing.

Humility is often seen as a weakness. While humility is chosen for oneself, dignity is witnessed by others. What does it mean to die with dignity? It means making the right decision at the right time to end suffering without regret or shame.

The adage “There’s no time like the present” serves dignity. Family members often focus on a loved one’s past achievements and future hopes instead of being present to the life-limiting/emergency situation. The choice to save a life or spare dignity is ever-present. Few are prepared to make the ultimate sacrifice.

Advance directives have proven useless in emergencies because most illnesses and injuries are obliged to be treated to save lives. A suitable replacement for an advance directive would be my “Dignity Decree.” This proclaims:

In the event of certain and imminent death, disfiguration, or permanent incapacitation, WITHHOLD medical treatment and provide comfort measures.

AND if within three days of certain and imminent death, disfiguration, or permanent incapacitation, WITHDRAW medical treatment and provide comfort measures.

Imagine if Biden signed my Dignity Decree before taking the oath of office. Would there be cause to run for reelection after an upending debate? Would he understand why family, friends, and donors might withhold support in deference to his Dignity Decree?

Dignity, like democracy, works from the principle of self-governance. The biggest regret of patients is the loss of control (dignity) with admission to ICUs and extended-care facilities. Could they anticipate this endpoint and change direction before compromising their dignity?

Political figures and patients are scapegoats for broken political and health care systems. There’s no dignity in being a patient or president who becomes a scapegoat for all the ills of society.

Biden’s focus on saving the “Soul of America” distracted him from the heart of humility that upholds personal dignity. Like so many others, his legacy depended on the time lag between insult and dignity. We might all learn from his dithering about how to shorten this time lag to save face.

Kevin Haselhorst is an emergency physician and author of Wishes To Die For: Expanding Upon Doing Less in Advance Care Directives.