What’s my turn today
may be thine tomorrow.
Doctor Thomas Fuller
Disease and death are probabilistic herd functions that at random express themselves at an individual level. In any herd, at a given time, all can disease or die. Only some do. An understanding of disease and death can inspire humility and gratitude when one is alive and healthy, fortitude when one is diseased pr dying, and compassion when one is a witness to these.
And who that is alive is not facing death? The democratic operations of death make for each one of us, death here and now, an inescapable reality that spells, again for each one of us, life in its fullest, richest intensity - here and now. Our civilization’s ‘abdication of ecstasy’ is rooted in our ostrich-like disregard for the sandstorms of our inner, biological time that spell now and again, disease and death. Up to now we have been blind to the democracy of disease and death.
Dictates of the democracy of disease
- All - isms apart, one man’s disease - congenital, cancerous, vascular, metabolic, even infectious, and traumatic - is an expression of (bio)socialism, that is governed by a social contract. A Dictionary of Modern Thought defines socialism as a social system based on common ownership of the means of production and distribution. A herd, a society, by its corporate genotype owns and produces a birth defect, a stroke or a cancer and distributes it to some individuals at random, on an impartial and probabilistic basis. The dictionary further defines ‘social contract’ as the unwritten agreement between the members of a society to behave with reciprocal responsibility in their relationship, under the governance of the ‘State’ which, in social contract theory, is presupposed by the existence of that society.
"Your son has acute appendicitis, I’m afraid. We must discuss the fee for the operation. Can you afford twenty guineas?" That question from a surgeon, put to parents living near London in 1938, might well stand as the sole justification for the creation in Britain, ten years later, of a structure of medical care which strove to divorce the urgency of a patient’s need from his ability to pay for the treatment.’ This editorial comment in The Lancet of 1972 has undiminished relevance today, the world over. The fee-for-service principle breeds the twin anomalies of (a) service rendered, only if the patient’s purse is full, and (b) service rendered, often needlessly, just because the patient or the insurance company can pay. Both are antithetic to the socialism and social contract that govern disease and death in any society.
- Disease, as a personal event, is not to be treated with self-pity, for such a feeling has a tendency to expand out of all proportion. As diseasing is inherent to growing, a disease must be lived with, with life and business as usual. If there is disease, that is what ought to be treated.
- Paralyzing, corrosive pity for the diseased - a behavioral norm in modern society - is summarily unjustified: (a) the pitied may outlive the pitier; (b) the presence of disease is no prohibition against a good, creative, full life; (c) the pity stemming from a healthier-than-thou attitude can serve no useful purpose.
Cornelius Ryan, the author of best selling World War II trilogy, died of cancer. But before the cancer could kill hi, his friends almost did: ‘Well, we really can’t ask Ryan to do this article or count on him to finish this book, because the poor bastard’s got cancer.’ Modern society has been nurtured on the concept of disease as a product of faulty living, an id’ee fixe that is pregnant with the unmistakable ring of an accusation. Ryan, alientated from ordinary life, used to be greeted by the silence of his friends that made him feel as if he had committed ‘some unpardonable gaffe.’
- It cannot be overemphasized that, quite contrary to medical scare-mongering but much in conformity with the laws of the herd, a disease tends to remain silent for long, even right up to death, and the discomfort that it may produce does not necessarily mean death or even early death from that malady.
- The health and vigor of the young, in any herd or nation, is in direct proportion to the number of aged people it has. The West has been a self-evident example of this for a long time and East is catching up. While the expediencies of job scarcity force the message ‘65 and out’, the same has nothing to do with the right to full living, creativity, sex, and what is most important, respect. The doctors’ own lack of contact with the realities of ageing of a herd is sadly reflected in their talking of the elderly as ‘old crocks’, and in their penchant for making a fast buck from the problems of the aged.
The cult of youth is ignorant of the time dimension, of the fact that the old can and do outlive and outperform younger people, and that the greater number of the elderly only reflects a much greater number heading for that oldness. The pathetic lack of awareness of this truth has fostered prejudices and predis- positions against old age. This irreverence toward the old -ageism - can only be changed by substantial doses of reality. It is time to revive the Eastern and the Navajo tradition of revering the aged. It is necessary salute to the autumn of human life.
Dictates of democracy of death
- Death belongs to life as birth does. It is a natural function, physiological in its working, and governed by the herd, being as egalitarian as disease. It is a herd function that finds expression at the level of an individual.
- Death is essentially transcausal, transpathological. The medical obsession with the cause of death apparent only in hindsight, is an illusion that has been kept alive posthumously by modern medicine’s success in passing ignorance off as knowledge.
- Death is pantrajectorial for any species. As a herd function, the time of death is distributed over a wide range - from a very short to a very long life. The longer-lived owe a debt to the shorter- lived, as a part of their reciprocal responsibility. There is more than meets the eye in John Donne’s ‘Any man’s death diminishes me.’ Ontolysis i.e., one’s own death, is but a gradual herd-lysis.
- Death’s dominance as a pantrajectorial force makes it an ever present, and immediate reality, for the healthy as for the diseased, for the young as for the old. Death comes without warning and exercises its task peremptorily. This is reflected in an anonymous saying: ‘Don’t hope to repent at the eleventh hour; you may die at ten thirty.’ Camus has put tellingly in The Fall: ‘Don’t wait for the last Judgment. It takes place every day.’ In Uttar Ramcharit, an Indian Epic, the plea is pithy: What you would want to do at the last moment, do it now.
There is a positive side to the above, If death is here and now,so is life. Therefore any God-given moment is the right moment for the joy of living, the joy of loving and the joy of being.
- The climactic moment of death in its magnificence and munificence is beyond good and evil. Any natural death can be impartially and democractically a crowning glory.
Implications for Modern Medicine
- Thomas Jefferson inspired us with the adage that all men are created equal: they are endowed by their creator with certain ‘unmedicable’ rights; amongst these are developing, diseasing, and dying.
- The serene nonchalance with which disease and death have treated modern medicine urges the medical technocrat all the more to be a compassionate friend. The fact that doctors cannot get to the cause of disease or death, nor alter their course should encourage medical personnel to regard no dis-ease, disease or even death as ‘uncareable’.
The fact that causation of a disease in an individual is a herd function proscribes medical men from hurling an accusation at a patient for the latter’s cancer or coronary, hypertension or hyperacidity, diabetes or deformity.
- Because most cultures fear dying, one way to combat that dread is to look around for a scapegoat. Doctors see disease as the enemy and wreak vengeance on it. No wonder, the patient, the human being, is so easily lost sight of. The disease charts its adamant course; death keeps its own time. The treatment treats the doctor: a stage comes in many a terminal illness when the doctor treats himself by administering chemotherapy, radiation, a bypass, or a transplant to the patient. If only modern medicine were to care more, and ‘cure’ less!
Thou shalt not kill
But need’st not strive Officiously
To keep alive.
Arthur Hugh Clough
- It is not for any small reason that most society that function with less sophistication than the affluent West have better insight into the needs of the dying and their family. ‘In the picture known to most physicians, the kindly, bearded humanitarian sits quietly by the bedside waiting for his little patient to die or recover: the decision is not his. There is hidden ignorance and sentimentality in the picture, but there is paradoxically great strength, beauty and spiritual dignity implicit in the situation portrayed. Much of this is denied today to members of the healing profession.’ It is high time the medical man regain this majesty for himself and the bliss for his dying patient.
- A good doctor may be defined as one ‘who knows that he knows not.’ In all humility, he ought to admit all the aspects of this not knowing as well as knowing to his patients, erasing thereby the needless dividing lines between the treater and the treated. Rutstein wrote in 1967 that, ‘The public has been oversold. Even the most staid and accurate newspapers carry front-page reports on breakthroughs in the control of major illness at regular intervals. Thus, responsible publications cure cancer almost every week.’ The iatrogenic illusion of the power to cure all makes people hope against hope to believe that death, not the doctor, would be the one to make an error. It is for the doctor to protect his patients from falling prey to such blind optimism.
- Indian scriptures have classified the problems that the human frame is prone to, into two broad groups - (a) gera (akin to GK. geras = old age) or time-governed senescence, and (b) vyadhi or disease because of , or independent of, the former. Gera or ageing is built into one’s developmental programme, being innate, inevitable, and a mere function of the temporal flow. Vyadhi or disease when independent of gera is something one invites, a situation wrought upon oneself as a result of intemperance, irregularity, an indifference towards the body’s dharma. Gera and death are inevitable; vyadhi is not. Many a person carries on through a long life without any disease or vyadhi.
The doctor is not capable of making an iota of difference in the working of gera; the doctor may be able to mitigate vyadhi. Gera as a function of time is as unfathomable as time itself. The summary failure of modern medicine to understand the cause, course, or the ‘cure; of all age-related processes provides a scientific vindication of the scriptural insights.
- Medical men have an incurable penchant for holding meetings, seminars, conferences, workshops and congresses on a regional, national, continental, and global basis more than once in 365 days. The astutely advertised proceedings of such meetings create, in minds medical and lay, an illusion of medicine’s relentless progress that reaches the public as decorously printed Modern Trends, Recent Advances, Clinical Progress and so on. The rich payoff has been a matter of envy even for Madison Avenue: patients get seduced into the medical whirlpool: governments and international funding agencies enthusiastically pour more money in the pious belief that the more you spend, the better everyone feels. The incomparable cost spiral exhibited by the ‘health industry’ in developing countries is a direct outcome of medicine’s inability to see, speak, and communicate the realities that surround human diseasing and death.
- A global survey of the medical scene reveals that 9 out of 10 pills, potions, or procedures that are prescribed to patients are unnecessary, if not harmful. As often as patients get well because of the doctors, or worse for the same reason, do they get better despite the doctor. This chastizing data drives home two guiding lessons for medical men - firstly, of the wisdom of omission epitomised in the Hippocratic primum non nocere which means above all (do) no harm, and secondly, of the humility that must govern every act of commission, best stated over 400 years ago by Ambroise Pare, the father of French surgery: Je le pensay, et Dieu le guarit, which means I dressed him, and God healed him.
- The above must make it clear that the essential relationship between a physician and his patient is one of faith - the former thinks he can cure, the latter feels he can be cured. Down-to- earth humanism demands, that, at least in matters of health and disease, dying and death, faith is a phenomenon that should not be exploited by the ‘powerful’ medical men, makers of drugs / instruments, hospitals and research institutes at the inevitable expense of the ‘powerless’ patients.
- A venerated general practitioner of Bandra, Bombay, has left a laudable legacy for medical men: Dr. Vaidya urged that any system of medicine - allopathy, homeopathy, naturopathy, etc. - is good for the patients provided it is mixed with adequate doses of sympathy and empathy.
Thanatognosis: Doctors and the dying
It has been noted that the doctor is less mysterious and less absolute in the home than he is in the hospital. This is because in the hospital he is part of a bureaucracy whose power depends on discipline, organization, and anonymity. These hospital conditions have given rise to a new model of medicalized death.
Death has ceased to be accepted as a natural, necessary phenomenon. Death is a failure, a business lost. This is the attitude of the doctor, who claims the control of death as his mission in life. But the doctor is merely a spokesman for society. When death arrives, it is regarded as an accident, a sign of helplessness or clumsiness that must be put out of mind.
The picture drawn by Ari’es - all too common in the hospital and in the home in the developed countries, and becoming common in developing countries such as India - is a paralyzing side-effect of medical treatment that is too trustful of technique, too ignorant of death and the realities of disease and dying.
It is for the medical man to redress this imbalance. The doctor, for whatever reasons, has turned into the most important intermediary between a patient’s disease and his dissolution, the final arbiter of how the patient, and his dear ones will conduct themselves when death seems near. The doctor must teach the art of ‘learning to die’ - the final lesson, that few doctors know how to impart, by preaching or by precept. Towards this imperative, set below are some helpful and practicable generalizations for the medical art of thanatognosis.
- The physicianly art of knowing about a patient’s ‘death in prospect’ and acting accordingly for the welfare of the patient and his family can be called thanatognosis, comparable etymologically and professionally, to diagnosis. If the ‘gnostic’ part of diagnosis and prognosis guides a doctor in the management of a patient’s illness, the ‘gnostic’ part of the art of thanatognosis helps the doctor, and through him the patient and the family, to face death realistically, courageously, and in good cheer.
Strange as it may seem, the readiness of the doctor to learn and exercise the thanatognostic art can be soothing treatment for the doctor himself by freeing him from the guilt and the anxiety often associated with his inability to prolong his patient’s life. The doctor could take consolation from Murchie’s version of the Sixth Commandment: ‘Thou shalt not kill - neither shalt thou obstruct a healthy or needful death.’
- Along the course of a patient’s illness, the doctor should - at an appropriate time determined by the nature of illness and its response to various therapies - realize that there is ‘nothing else to be done.’ At this stage, the physician stops treating the disease and starts guiding the patient and his relations towards a more enlightened outlook on death.
- The patient and the people around should be taken into confidence and be made to participate in accepting the nearness of death. Compassionate discussions can make the patient and the family consider death as a real possibility, a meaningful desensitization that is achieved gradually and to begin with, painfully. The discussions should not have an aura of sorrow. As Kubler -Ross, pioneer thanatologist has stated, ‘ It might be helpful if more people would talk about death and dying as an intrinsic part of life just as they do not hesitate to mention when someone is expecting a new baby.’
- Predicting exactly the time of death is impossible. Death will come sooner or later. Driving home to a patient and the family that another ‘normal’ human being may die of the same disease much earlier than the patient can go a long way towards easing their sense of being victimized.
- The dissociation between the presumed ‘lethal’ or ‘terminal’ illness and resultant death must be spelled out through personally known examples, through lay or medical literature, and through the realization that death by itself is a pristine physiological function that uses health and disease alike to suit its purpose. The patient must therefore be told that any disease can be comfortably and creatively lived with. Freud lived for 17 years with his cancer, Pasteur with his stroke for 27 years, and Solzhenitsyn has already lived with his cancer for over 25 years. The seemingly grim reality of ‘death-here-and-now’ the patient must be taught, is as much for those in full health, as for those beset with disease. The motto therefore ought to be while we are living, let us live, here and now to our fullest.
- The patient and the family should be led into appreciating that dying with dignity is an honourable duty which, when well- performed, can permit the one who dies and those who survive him to tell death to "be not proud." Dying with dignity is dying victorious over death.
- Thanatognosis should not be reserved only for the moribund patients. Patients ‘terminally ill’ and fit for thanatognosis should mean those for whom nothing further is to be done therapeutically, but who are otherwise fully alive to their surroundings, to the people around them and to their own self. (While administering specific therapies to the patient, the therapist should not compromise with this right to be alive). Thanatognostic advice from a doctor is something that the patient should comprehend, and accept, while in full possession of his senses.
- Kubler-Ross once wrote, ‘Guilt is perhaps the most painful companion of death.’ Therapeutic crusaders and preventionists, with their ‘do-gooder’ tirade against the killers of men, breed remorse and guilt to a pernicious degree in patients and their relations. The guilt centers around having smoked, having neglected the symptoms, not having taken the right kind of treatment, not having sufficiently suckled one’s children thus ending up with, say, breast cancer, and so on. The art of thanatognosis must strive at freedom from this burden of guilt. The doctor should explain that there are innumerable patients suffering from cancer, heart disease and diabetes despite their ascetic and temperate lives, that early treatment can mean early death, that neglect of symptoms does not unfavourably alter the course of the disease, and so on.
- The awareness of the proximity of death raises a question in the mind of patient: do the life spent and the small ration of it now left have, have they ever had, any meaning? Mustering all his compassion and competence, it is for the doctor to assure the patient that what was, what is, and what shall be is right. Putting it in the terminology of Victor Frankl, it is for the doctor to administer to the patient a dose, and an adequate one at that, of the meaningfulness of the patient’s life, and of the patient’s dying and death. Intensity of life and the fullness of being are not functions of temporal duration, for ‘we all are but a moment’s sunlight.’
- The worst complex gnawing at a patient with a statistically determined disease such as cancer or heart attack is, of course the resentful ‘why me?’ A patient who had committed a cancerogenic blunder may guiltily reconcile himself to his having cancer, but what about the many who not having made any such incriminatable slip, develop cancer? ‘Don’t come and tell me this is God’s will for me,’ is a cry which typifies the desperate indignation of a dying person which can only be assuaged by making people at large understand that this is the will of God for one and all, and that staggered mortality is planned herd-lysis, with some dying of something at 9 years and some at 19 or 90 of the same thing or something else. The resolving of such questions as ‘Why me?’ or ‘why my dear one?’ may be the most difficult task for the doctor, and his success would greatly depend on how enlightened and how realistic about death the humans he is handling are.
- The dying patient and, more than he, the family, are ready to spend any amount to get the ‘right’ treatment or cure for the patient. This explains many of the international safaris undertaken in search of more modern treatment. The customer’s readiness to spend is inordinately boosted by the medically floated myth that, with the right amount of money and the right equipment, any disease can be successfully combatted. It is the duty of the doctor exercising thanatognosis to put an end to such illusions so that those who survive the dead are not reduced to penury and debt.
- While thanatognosing, the most important pill, potion or procedure to be administered to the patient is the doctor’s time; a relaxed and unhurried interest evinced in a patient can beget an interaction that eases the patient and educates the physician. If the patient is in any mental and / or physical distress, all palliative measures should be judiciously employed towards easing the discomfort of the patient.
- Put briefly, the art of thanatognosing aims at making the patient live until he dies, well and with dignity. It also means guarding the patient against censure by family, society, and other medical men.
The payoff from thanatognosis, as an important branch of medical practice, can be quite satisfying for the doctor, quite blissful for the patient, and quite consoling for the patients’s family. If dying is the final act that the (really) living must perform, then the act ought to be an artistic one.
Talking in theatrical terms, if the final act is a piece of art, the patient dies an artist; if the act is a dragging flop, he dies a failure, an outcast. Which patient-artist and which doctor-director would abjure this golden opportunity of making the final bow an artistic one? The Indian scriptures have it that an average person comes to know three days in advance the time of his death. Ari’es has described how, in Europe, until the advent of the medicalization of death, a timely premonition of one’s death was every man’s prerogative - a timely warning that was greeted naturally and spontaneously. The trustworthy wisdom of ordinary people had it that no death , even from an accident or following too great an emotional shock, was or could be sudden. And if it did come suddenly, that is without the advance warning, it was called mors repentina, being ignominous, shameful, and an act of God’s wrath.
The more death was medicalized, the more people grew insensitive to the act of dying and started seeing death as, at worst, an avoidable evil. Present times could be described as the age of mors repentina for almost every one. Medical men ought to rekindle in themselves and their patients the innate ability in every human being to know of one’s death in advance, and to accord it a spontaneous welcome, as was done in the past. That achieved, the thanatognostic task of the doctor would be eased tremendously. In fact, the onus and the honour of exercising it would shift onto the patient - the ultimate in self-care.