LIVING, DYING

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The Dictates of the Nature of Disease and Death

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 or 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

  1. 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.

  2. 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 dis-ease, that is what
    ought to be treated.
  3. 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 him, 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 idée 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.'
  4. 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.
  5. 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 the
    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 predispositions
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 a
necessary salute from the spring of life to its inevitable autumn.

Dictates of the Democracy of Death

  1. 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.
  2. 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 off ignorance as knowledge.
  3. 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.
  4. 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.
  5. The climactic moment of death in its magnificence and
    munificence is beyond good and evil. Any natural death can be
    impartially and democratically a crowning glory.

     

Implications for Modern Medicine

  1. 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.

  2. 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 and death, nor alter their course should encourage
    medical personnel to regard no dis-ease, disease or even death as
    'uncareable', or 'incurable'.
    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.

  3. 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

  4. It is not for any small reason that most societies 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 regains this majesty for himself and
    the bliss for his dying patient.

  5. 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.

  6. 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
    dis-ease 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. The chief
    role of the physician is to palliate the dis-ease or vyadhi that may
    accompany gera. Vyadhi or dis-ease 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.

  7. 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.

  8. 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, so 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, (secundum) quieta non movere pleading that Don't fix
    it, if it ain's broken, meaning not treating those at ease with their
    diseases, and thirdly, 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.

  9. 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.

  10. A venerated general practitioner of Bandra, Mumbai, 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 spokes-
man for society. When death arrives, it is regarded as an
accident, a sign of helplessness or clumsiness that must
be put out of mind.
- Phillippe Ariés

The picture drawn by Ariés - 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.

  1. 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.'

  2. 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.

  3. 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, albeit , 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.'

  4. 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, seemingly even
    without any disease, much earlier than the patient can go a long
    way towards easing their sense of being victimized.
  5. 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 with his cancer for over 50 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.

  6. 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.

  7. 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.

  8. 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, so-called,
    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.

  9. The awareness of the proximity of death raises a question in the
    mind of a patient: do the life spent and the small ration of it now
    left have, or 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 are But a Moment's
    Sunlight.'

  10. 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 seemingly 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 are the
    humans he is handling.

  11. The dying patient and, more than he, the family, are ready to
    spend any amount of monies 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.

  12. 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.

  13. 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. Ariés 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 ignominious, 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.

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