We are born and the fight begins. The slugfest that is life brings miracles and nightmares, and sometimes they are one and the same. The narrative medicine article in this issue of the journal, “In The Ring”, is a true story of a patient’s father’s near-death experience of Hell and the history of its follow up impact on the patient and her doctor.

Regardless of your beliefs of an afterlife, what do we know about near death experiences (NDEs) and their distressing variants? Although NDEs are reported occurring up to 15%1,2 of cardiac arrest survivors, visions of Hell are not as common as near-death experiences of visions of a glorious, comforting Heaven. Positive experiences include feelings of lightness, peace, unity, and tranquility. There is a sense of welcoming from loved ones within a warm glow or tunnel. Often there is a sense of floating pleasantly and leaving the body (autoscopy). A sense of significant time distortion is also frequently part of NDEs.1,2 But frightening experiences do happen, reported as low as 1% and as high as 15% of NDEs in multiple series.1,3–7 Distressing NDEs have been organized by researchers into 3 categories.3 The first type of experience is simply negative, often starting as peaceful and degenerating into a very intolerable emotional state. The second category is a Hell of isolation, darkness, loneliness, nonexistence, and eternal void, matching the narrative medicine story in this journal issue. The third type matches a more classic terrifying vision of Hell with entrapment in landscapes of torment, frequently with “malevolent beings”. A proposed fourth type involves “a life review in which [the individual] feels negatively judged by a higher power being”.7

What is the medical perspective on NDEs? How are NDEs different from other altered mental states? What about deep anesthesia recollections? How do the NDEs compare to psychedelic experiences and the new psylocibin treatments for psychiatric conditions? How are they different from our usual dreams and nightmares? What is the line between our imagination, dreams, and our conscious state? What determines that line? What does science now understand about consciousness itself? What is the difference between computer artificial intelligence (AI) and sentience? Can there be “machine consciousness”?8 A deep dive into these existential and highly relevant questions is beyond the scope of this manuscript, but here is an attempt to succinctly address some of these questions in relation to this journal’s narrative medicine story of Hell, “In The Ring”.

Four centuries ago, Descartes, often called the Father of Philosophy, said, “cogito ergo sum”, translated as “I think therefore I am”.9 This philosophic axiom of sentience has been accepted for centuries, but science now understands that it is not so clear and even within the human condition, one person’s sentience might never match anyone else’s.8,10,11

Scientists are trying to objectify frameworks for the conscious state. We can no longer define consciousness by knowledge, deductive reasoning, or creativity. These are all now reproduced by computer AI. Although daunting, and beyond the reach of our current technology, work goes on to explore creating machine consciousness. Consciousness, that is, human consciousness, is best defined by self-awareness, self-perception, reflection, sense of presence within a timeline, and reactivity or emotional response to input.8 Self-perception, the I-vs-not I, would be best simulated in a humanoid robot format with multiple surface, visual, and auditory inputs. Self-awareness could theoretically be accomplished in a computer by looping intrusive messages stating awareness in reaction to input concomitantly triggering computer reflection and reorganization of previous input to plan new directions for further input. Awareness as such is illusory, self-awareness by going through the motions of self-awareness. The recent development of agentic AI, where the computer resynthesizes its input, and makes its own new actions and tasks, seems closer to this self-awareness activity. Thus, to an outside observer of the machine, the machine appears self-aware, matching Alan Turing’s definition of whether a machine is intelligence.12 Turing proposed the Turing Test, also called the Imitation Game, deciding that a machine is intelligent if a human investigator cannot tell if he is talking to a computer or a human being, that is, exhibiting behavior indistinguishable from a person. We are beginning to understand that our own consciousness may be similarly illusory.10,11

Reinforcing this illusion of self-awareness is our sense of ourselves within a timeline. Although there is an intrinsic ability to sense time in infants, a growing child must learn the nuances of time; how long is a second, how long is a minute, an hour, a day.13–17 Only with experience do we understand our own present tense within our life’s timeline. And even then, it is subjective and subject to emotional state. An elderly patient will reflect on how short life has been, and a child waiting for school to be out for summer vacation feels like classroom time is interminable. Not surprisingly, a sense of time within an NDE can be vastly distorted.

Children under two are amnestic, losing all cognitive memory of the events of their nascent years, seemingly wiping RAM clear without saving on their hard drive. Although those years are vital for brain development and learning, the consciousness of those years essentially never happened. By age four, those memories are more codified into distinct episodic memories. Thus, consciousness requires memory of consciousness.16–19

This structural framework of consciousness sets the stage for understanding alternative states of sentience, those of other living creatures inhabiting our planet, and those other states within ourselves, that of dreams, hallucinations, drug-altered states, the growing brain of children, the declining brain of aging, as well as to our subject of the day, the state of near-death experiences.

The conscious distinction between dreaming and the awake state is best understood through the lens of child neurologic development. “Cognitively, young children often have difficulty distinguishing dreams from reality. Research indicates that the understanding that dreams are internally generated and not real develops progressively, being a late acquisition in childhood. Children under age seven may not reliably recognize that dreaming is different from waking experience, and their ability to reflect on their own mental states (metacognition) improves with age”.20

Thus, the mind’s ability to know conscious reality from dreaming and other altered states is learned, experiential. The line that separates sane reality awareness in the brain is not intrinsic to human consciousness. It is simply learned. Using this insight, hallucinations are a suspension of this learned skill by disruption of our cognitive architecture. Autoscopy, the sense of leaving the body and viewing the body surroundings from outside, as is frequently reported in NDEs, is also a well-established psychiatric form of hallucination as part of mental illness.21 Hallucinogens like psilocybin also disrupt our reality skill set, and the psychiatric guide in its therapeutic use sessions helps the patient learn how to control the unreality of the cognitive alteration and allow it to be transformative rather than demoralizing.

In terms of the aging brain, memory dwindles in neurodegenerative aging and consciousness becomes decreasingly recognizable. The sense of self-awareness in a timeline is lost. The executive function for self-reflection cannot be sustained.

Applying these constructs to an additional NDE, the author of this Editors’ Note is aware of an additional case of a distressing NDE of the second kind, the void experience.

The patient was 10 years old at the time of the NDE, an ordinary innocent child of a stable marriage in an upper middle class suburban neighborhood. One day, he went to see the dentist for a routine wisdom tooth extraction procedure under anesthesia. There were never any medical issues during the procedure. No cardiac arrest, no hemorrhage, no hypoxia. But under anesthesia, the patient had an awakening within the void.

He found himself in the very same dental chair quietly drifting in an endless black space. Gradually, he became alarmingly aware that all his memories were not real. There was no family, no best friends, no school, no home, no dentist visit, no Earth. He had always just been floating in space alone and he would always float alone there forever. It was a profoundly and devastatingly lonely experience that went on for a crushingly infinite time. And then he woke up back in the dental office doing just fine.

That child was too young to be an evil sinner deserving Hell. He was too young to have self-criticism or guilt, and he was not suicidal. Although distressing NDEs are more common after suicidal events, this child’s event was not part of some underlying psychiatric condition, a presumption that most researchers of distressing NDEs have discounted.7,22 NDEs have a propensity to occur in patients with either dissociative tendencies or strong spiritual beliefs before the event.6 Neither applied to this 10-year-old child. In the end, it seems the patient’s NDE was just random rather than meaningful, emphasized by its occurrence under ordinary anesthesia. Of note, NDEs under routine anesthesia have been well-documented, and can exactly mimic cardiac arrest NDE’s.23–25

Survivors of hellish NDEs often report lasting psychological effects, as seemingly occurred to the patient from the narrative, “In The Ring”. This is somewhat contingent upon beliefs of the individuals with the NDEs. Individuals with theistic beliefs are most likely to have NDEs the nontheistic persons and these NDEs are more likely to be experienced as spiritual events.21,26 Within the overall NDE group, many individuals find new purpose, appreciation of nature, less fear of death, more tolerance, and some experience a spiritual awakening.27,28 But distressing NDEs are more likely to have negative psychological effects.7 Three potential responses to distressing NDEs have been described; “(1) the negative event may be perceived as a warning about unwise behaviors, [leading] to a self-analysis and ultimately to a ‘turn around’ in one’s life, (2) the NDE survivor may treat the event as if it did not matter; and (3) the frightening event may result in a difficulty [integrating] the experience and in the development of a sense of stigma”.7 Overall, at least in one study, NDEs did not create a different result on quality-of-life assessment one year after the event.6

The 10-year-old patient’s distressing NDE did NOT have a profound impact on his life. It took about a month, but gradually he became reassured that his quiet American family life was real and not an illusion. He was a child, so separating dreams and imagination and NDE’s from reality was expected to be a slow process, and just part of normal growing up, except perhaps that no other child he knew had an NDE.

Miracles and nightmares. This is the life of physicians and the stories of our journal. The author would like to see the journal readership send letters to the editor of your reactions to these 2 NDE cases, or of your own experiences with NDEs, or any narrative medicine stories of your own professional miracles and nightmares.