LIVING DYING

( By Dr Manu L Kothari and Dr Lopa A Mehta )

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The Democracy of Death

At the door stood Death. She said, ‘I smelled your
rooster and I came along to help you eat it.’
‘And why not?’ said the man. ‘Aren’t you one who treats
everyone alike?’
‘That is so,’ said Death. ‘I have no favorites. The poor,
the rich, the young, the old, the sick, the well - all look
alike to me.’
‘That is the reason you may come in and share my
food,’ said the man. Death entered and the two had a
grand feast.

Aurora Lucero White-Lea

Death’s inevitability is generally accepted; death’s impartiality as expressed in the story quoted above, has remained in the realm of the incomprehensible. Death as a function of time and as the integral, climactic part of the normal, physiological development of man remains indifferent to the considerations of age, sex, nationality, Gross National Product, presence of disease, treatment or no treatment, good prognosis or bad. In death’s democracy lies the explanation for the paradox of the diseased, the hedonistic and the devil-may-care outliving the healthy, the ascetic and the disciplined. The human body as a machine constantly acts counter to expectations; sometimes with every organ diseased, it still manages to drag along. This oddity lies neither in the human body nor in death, but in the erroneous assumptions of the lay, and more so, of the learned. A new ‘Death View’ - Todesanschauung - is in order: in the immutable democracy of death, all have equal rights, and all are treated impartially.

Death is merciful - to man

The perceptible upswing in the graph of world population started around the beginning of the 15th century A.D. It has continued unabated, and today man has become the cancer of his own planet. The four billion plus human population of today will double itself in the next 33 years. Hasn’t death been kind to man?

Today’s man, under advice from modern medicine, fears death because of his much-voiced susceptibility to demonized diseases: heart attack, cancer, diabetes and so on, are all presented as all-consuming killers. Were these diseases as effectively lethal as paranoically portrayed, would man have turned into the cancer of the planet Earth? Isn’t it that death’s kindness is matched only by man’s unkindness to man? In an age ruled by speed, terror and weapon, death by man-made violence stalks its quarry at every step, and since the year 1945, our species has acquired the diabolic power to annihilate itself. Isn’t death then in the words of Francois Mauriac the ’one grace vouchsafed mankind?’

Death stands undisturbed

‘Think of what has happened since 1950 ... Progress in medicine has virtually eliminated many dread diseases. Most recent discoveries foretell the same fete for many others in the relatively near future.’ This technological optimism expressed in an encyclopaedia is ill-founded. ‘We might,’ Comfort, the gerontologist, observes, ‘in theory except that removal of successive causes of death would increase the expectation of life of the old as well as the young. It is interesting to notice that there is so far very little evidence of such an effect from the general advances of medicine in the last century.’ The presumed payoff from the inventions of immunization and antibiotics is being seriously doubted, the greater part (that is, ninety per cent) of the improvement in death rates from infections having already occurred prior to the introduction of immunization and antibiotics. In 1802, a committee of Scottish physicians wrote a memorandum declaring that the gains of medicine against breast cancer were a cipher; in the 1970s, other researchers reiterated the statement, adding that if at all, the mortality rate had increased. For example, at the Johns Hopkins Hospital, the impact of radionuclide scanning for brain tumors was assessed from 1962 to 1972. The number of brain scans increased ten-fold in that decade, and for patients with tumors the average interval between the onset of symptoms and operation fell from four years to less than one. Yet there was no favorable change in survival after operation.

The widely acclaimed increase in human life-expectancy, the world over, is an outcome of some unflattering phenomena. Semmelweis, Lister and good obstetrics meant more babies survived, thus widening the base of the human population pyramid, the widening effect seen throughout, from base to apex. Now, more people live into old age just because there are more people. This demographic upsurge long presaged medical advances which, however, took the credit as these advances arrived pari passu with a peak in the exponentially expanding human population. Death per se, however, has serenely defied the march of modern medicine.

Death prevails, because, as Tagore says, Death belongs to life as birth does. Balancing the ‘will-to-live’ natural to every organism there is the ‘will-to-leave.’ Each human being, as an animal, is born with a built-in death wish, or death programme together with an intrinsic mechanism for fulfilling the same, somewhere in his or her body. The will-to-leave, may reside in the brain cells of an Isaacs, the discoverer of interferon, in the pancreas of a Dr. Knowles, lately the President of the Rockefeller Foundation, or in the blood vessels of a Nietzsche, a Nehru, or a Brezhnev.

‘The aim of all life is death’ - with this aphorism, Freud formulated, in 1920, his concept of a death instinct or death wish. According to Konrad Lorenz, Freud’s theory of the death wish is a destructive principle which exists as an antithesis to all instincts of self-preservation, and is therefore both unnecessary and false. It must be made clear that the will-to-leave, as proposed above, has a fundamental protoplasmic or cellular quality that is independent of the Freudian psyche or the Lorenzian lore. It simply is, wherever life is, served by a built-in death programme.

Death: A herd function

Death, like disease, is a herd function. It treats a given human herd in 3 distinct, sequential phases - herd trimming, herd stability, and herd lysis. Herd trimming ensures herd quality control to eliminate the defective concepti, fetuses and newborns. Herd trimming starts from the stage of conception, whence it is at its peak, and in a diminuendo fashion, operates till about the age of five years. This explains ‘fetal wastage’ in the form of spontaneous, unpreventable abortions, infant mortality which is the highest in the first day of life, leukemia having its most lethal effect in the first year of life whatever the treatment, the greater incidence of cancer in the first five years of life than during either of the two ensuing quinquennia, and the rather fixed incidence of major birth defects. This may seem a wasteful and cruel method, but no living species can escape this relentless force of natural selection. The same acausal and uncontrollable factors as govern diseases and death in the adult human subserve herd trimming. Herd trimming paves the way for the phase of herd stability.

During the phase of herd stability, disease and death are at their lowest ebb, well-nigh close to the baseline. No wonder that the incidence of and the mortality from cancer, for example, reaches an all-time low. Starting at 6 and extending up to about the age of 16, this most generous phase of human survival allows 97% of the herd who escaped herd trimming to reach the state of reproductive fitness. And then starts the gradual, but relentless crescendo phase of herd lysis.

The phase of herd lysis may be defined as the Age-Dependent Obligatory Herd Mortality that begins around the age of 15-16, very low in intensity to start with, and doubling every 8 years. Graunt in 1662 and Gompertz in 1825, both from England, were the pioneers in the presentation and prediction of such programmed herd mortality, often known as the Gompertz function which cuts across all species barriers - e.g., the mortality’ in rats, closely parallel, mutatis mutandis, to that in man, doubles every 3- days. The gentle beginnings of herd lysis allow most people to get into their forties, whereafter only the lethal impact of Gompertz function starts being felt. Gompertz function is an integral group function that is remarkably impartial, and highly democratic. Its inexorable sway explains the failure of modern medicine to add even one year to the human life span. The Vedic blessing of 100 years and the Biblical blessing of three score and ten are no modern inventions.

The increase in vulnerability with age is an all-round and non- specific process. For example, even the age distribution of pedestrian death in road accidents is similar in contour to the general distribution of human deaths from all causes. This is but an illuminating reflection of herd vigour, in its biological sense,for it represents a combination of sensory acuity, speed of avoidance, and power of recovery when hit. Needless to say, the function of herd mortality is not cause-crazy. It achieves a common end through seemingly diverse diseases. One would never have thought of any similarity among chronic lymphatic leukemia, disseminated breast cancer, cirrhosis of liver, and heart attack. But the similarity is very close in the way each disease takes its toll of mankind. The epidemiologists, who detected the similarity, found it surprising that the above diseases resembled each other very closely in the relationship between their mortality rate and the duration of disease. Furthermore, the nature of this relationship in all these diseases was quite unexpected: the basic death rate remained constant during the entire course of the disease. Prognosis was neither better nor worse for the patient late in the disease than for the patient early in the disease; the patients neither ‘got over’ the disease nor did they develop cumulative damage that progressively increased their death rate. And the similarity was unaffected even when a variety of standard treatments or no treatment at all was employed for the different diseases. This also meant that even within a single group, say of chronic lymphatic leukemia, treatment made no difference to the overall survival or mortality.

Memento mori:
Death here and now

And had you watched Ahab’s face that night, you
would have thought that in him also two different
things were warring. While his one live leg made lively
echoes along the deck, every stroke of his dead limb
sounded like a coffin-tap. On life and death this old
man walked.

Herman Melville

All of us, newborn to nonagenarian, walk on life and death. The common lament that the young never consider the prospect of their death is rooted in death’s mild, almost imperceptible sway on this side of 40. Yet no year of human lifespan is exempt from death, here and now. Mortality tables on heart attack, stroke, cancer and infections bear a telling testimony to the above. That the young are not used to thinking of the hour of their death is trite; it is this habit carried into old age that underlies many human problems.


Time :
Death’s sole weapon

Given any of the so-called killer diseases - heart attack, cancer, diabetes, etc. - modern medicine has been unable to say which patient would die from the disease, and when. Take the example of acute heart attack: the outcome of a heart attack, in a given person is unpredictable. On the one hand, this is because of the constant threat of sudden unexpected death, even for persons convalescing favourable, and on the other hand because of the possibility of long survival even for persons critically ill. In November 1972, Dr. B. , aged 58 years, a leading physician and cardiologist in Bombay, went to see a heart patient in an Intensive Coronary Care Unit (ICCU); Dr. B developed chest pains while seeing the patient, and died soon after, in the ICCU. Notwithstanding the absence of a correlation between the severity of a disease and death, what has been predictably observed is the unswerving nature of age-dependent herd mortality that obeys the age of a human herd. And as yet, the only infallible way to measure a herd’s age is time. Time, then, is the sole weapon that death wields, with severe disregard for doctors’ diagnoses and prognoses. For each one of us, ‘the end is at hand; and ‘the measure full,’ when ‘our time is up’ - at the herd level always a certainty: at the individual level, a blissfully unpredictable probability.

The cause of death:
So-called

The realization that time is the only ally death has, drives home that the cause of death, a long-cherished medical, epidemiological or public institution, is an a posteriori assessment in all natural (non-accidental) deaths, a situation that allows us to paraphrase Pascal: death has its own reasons which are quite unknown to the doctor.

One of the ‘more popular’ teaching-exercises in medical schools is the clinicopathological conference, where the gross and microscopic postmortem findings are correlated a posteriori with the clinical features so as to arrive at the diagnosis and the cause of death. Over the years, such conferences have been a theater for defensive gamesmanship, display of pedantic erudition and, despite all these intellectual acrobatics, they have served no epistemological purpose in medicine. No wonder such retrospective exercises are now held as obsolete by discriminating thinkers in medicine.

Consider some typical obituary announcements for both sexes: Death from heart attack at 48, 61, 77, 81, from cancer at 40, 42, 69 and no cause - old age? at 88 and 108. Why fatal heart attack at 48 at one end and 81 at the other, giving the fallacious but favourite average age of fatal heart attack as 65? What turns out more influential , the age or the attack? Take cancer: if cancer itself does not kill by and large, and if treatment reputedly prepones death, what or who was responsible for death in lung cancer cases, one at 42, the other at 69? The American hotel magnate Conrad Hilton died of pneumonia at 91. Why did Mr. Hilton not get the same pneumonia at 89? And what if he had not had the pneumonia? It is a general autopsic observation that people dying in advanced age show their bodies to be a veritable museum of various pathologies, each as terminal and as lethal as the other. Usually one amongst these emerges - or so it is assumed, to be labelled as the cause of death. Hence the question remains as to what was more important - the host of pathologies that Mr. Hilton must have had for decades, or the fact that he was 91? Death, the climax of an inner developmental process, occurs when the timer from within rings to say that ‘the time is up’. Diseases are pointers to the proximity of death, not causal; and isn’t life the most incurable disease?

The democracy of death

Death has been called the great leveller. The appellation need be no different when it is probable death, for it fully satisfies Mahatma Gandhi’s idea of a democracy in which the weakest enjoy the same opportunities as the strongest. In an age stepped in the Darwinian concept of survival of the fittest, Gandhi’s invocation appears impracticable, out of place. That isn’t so. As Arthur Kestrel pointed out in his book Janus: A Summing Up, ‘Once upon a time, it all looked so simple. Nature rewarded the fit with the carrot of survival and punished the unfit with the stick of extinction. The trouble only started when it came to defining "fitness" ... What exactly are the criteria of "fitness"? The first answer that comes to mind is: the fittest are obviously those who survive the longest.’ Those who survive the longest may have satisfied neither the Darwinian decree of reproductive fitness nor the medical criteria of physical fitness. Death, in its impeccable impartiality, is above all this. Death does not spare the young; the old do outlive them. When in a memoir to his son, who in his teens died of a brain tumor, John Gunther cried "Death Be Not Proud,’ he could as well have said, "Death Be Not So Damned Just.’ In the Rape of Lucretia, Lucretia’s father cries: ‘If children predecease progenitors, we are their offsprings, and they none of ours.’ The fact that not many parents have to lament like Lucretia’s father, does not mean that death fails to be democratic. It is just that its mathematics work in a lower key at a younger age, in animals and men.

As to gender, death is democratic, with a slight difference - women live longer than men, a fact that forms an outstanding contradiction to the Darwinian dogma of reproductive fitness as necessary for survival: the human female happens to be the only mammal divested of her reproductive function when she is hardly half-way through her natural lifespan. Darwinism has fostered the concept of the survival of the fittest rated according to the ability to reproduce. If we were therefore to believe that the loss of the ability to reproduce is tantamount to the loss of the capacity to survive, we cannot but conclude that menopause, inevitable as it is in every human female by about the age of 45-47 years, is not merely a change of life but the loss of life-sustaining selection pressure. On the other hand, although function of the testes does tend to decline slowly with advancing age, the evidence is clear that there is no male menopause or climacteric similar to that occurring in women. Naturally, the perennially potent and fertile man, ever ready to contribute ‘to the gene pool of the succeeding generation’, should possess an outright and consistent advantage in survival capacity over the human female. But, alas, in reality exactly the opposite prevails. From birth onwards, in every age group life is shorter for males than for females, the death rates for males consistently exceeding those for females in the average ratio of about 1:5:1 for all age groups. This has been the case over the centuries the world over. However, death’s favour to the fair sex ends at that. The mathematics of herd trimming and herd lysis in the female operate in the same way as in the male. The curves of mortality in both the sexes remain closely parallel and the incidence of cancer and of stroke remains equal. Prior to menopause, coronary artery disease affects women less; but thereafter, almost in a hurry, it catches up with the incidence in men, so that the end result - that is, the number of heart attacks per 100 deaths - comes out to be the same in both the sexes.

Now some factors remain - presence of disease, administration of treatment, or when a doctor himself is the patient - that bear testimony to death’s democracy. The affliction of a major disease is no bar to living long. Louis Pasteur had a nearly lethal stroke at 47, and lived most creatively till the age of 74. A man found to have Hodgkin’s disease at the age of 29 developed 11 different cancers, one after another, during the next 27 years. One Mrs. R., known personally to the authors, lived to be a vigorous 99, having nursed an untreated bladder cancer for her last 32 years. The treated exhibit no survival advantage over the non-treated, even in the medically most advanced countries, where sophistication borders on the Utopian. In a study by Cregan and others, of the 150 patients treated with Paulingian megadoses of vitamin C, the only long-term survivor for 63 weeks and more against the average 7 weeks was a patient with massive liver-jaundice, and a widespread cancer that had refused to show any response to many attempts at chemotherapy; and as a ‘control’ this very case had been denied vitamin C. Doctors are no exception to death’s democracy. Bernard Shaw preached this through The Doctor’s Dilemma: ‘Make it compulsory for a doctor using a brass plate to have inscribed on it, in addition to the letters indicating his qualifications, the words "Remember that I too am mortal." ‘The Koran implores medical men to treat the diseased, and the dying, with extreme humility - a gentle, inner submission that ‘it could have been me.’

Democracy of dying

Death, devoid of its presumed dependence on a disease for achieving its aim, assumes the role of a physiological process. The innate wisdom of the human body sees to it that the climactic event of death actuates physiological mechanisms that facilitate the function of giving up one’s mortal frame. The discovery of encephalin, recently honoured with a Nobel prize, the body’s own morphine, a potent, ever ready antidote to any pain, points to the possibility that there are other substances, indigenous to our body and released at the time of death, that smooth the passage through the door of death.

The common fear that dying is a painful process fails to be vindicated by what is known about dying. There is no denying that certain illnesses are painful, but death itself tends not only to be not painful, but also brings relief from pain. All competent observers agree that except in the imagination, there is no such thing as death agony. In fact, if one were to summarize the recent reliable reports from persons who, once declared dead came back, it would be - ‘Death is the final delight.’

Death, delightful and friendly; but for whom? And how? For us, all of us provided we have realized well in advance the inevitability of the final moment and its impartial luminescence. What has hitherto been considered apocryphal, or at best anecdotal, has been shown to be a fairly common, illuminating death experience, bordering on the divine or the supernatural. Regardless of the age, sex, past illness, past deeds, learnedness or otherwise, the act of dying bestows on an individual beatific blissful experience, devoid of any sense of fear, with unseen loving guides close enough not to allow the dying person to feel lonely. Before breathing their last, dying persons move away from their corporeal self to serve as witness - autoscopy - to the event. Dying persons who returned to life ‘from the embrace of eternity’ stress the need in this life of cultivating love for others as the prime necessity of existence.

If we are wonderfully made, and as wonderfully maintained, is there less reason to assume that the same spirit sitting within us sees to it that we are no less wonderfully unmade! If the sheer beauty and complexity of ontogeny (formation of one’s self) is everybody’s privilege, the same must hold true for the glory and the grandeur of ontolysis (dissolution of one’s self) - the climactic moment of merger with the infinite.

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