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A good death, or a good life?

Sonny Inbaraj Krishnan / Khmer Times Share:
Do the aged have to be confined to nursing homes? Reuters

Sonny Inbaraj Krishnan on ageing, nursing homes and death. Is medical science ignoring personal suffering of the aged by prolonging their life?

Being Mortal: Illness, Medicine and What Matters in the End
Atul Gawande
Wellcome Collection/Profile Books Ltd (UK)

This is really a thought-provoking scenario. Or is it the current reality as we experience ageing as part of the human process? Medical science can alter the course of human life, and I can personally testify to that.

For several decades, I have been trying to have a baby but to no avail due to my low sperm mobility – as a good friend once told me, I was shooting blanks! Then in-vitro fertilisation (IVF) came about and my current partner and I decided to give it a shot. Nine months later, Rumi was born – perfect, cute and hyper-intelligent. Embryo profiling, test-tube baby, going against the laws of nature – call it whatever you want. But a baby was brought into this world, defying nature, to continue the lineage. At the age of 59, I became a father to a healthy baby boy, thanks to modern science.

Now coming to Atul Gawande’s “Being Mortal – Illness, Medicine and What Matters in the End”, Gawande points out that people now live longer and better than at any time in history. But he also states that scientific advances have also turned the processes of ageing and dying into medical experiences, “matters to be managed by health care professionals. And we in the medical world have proved alarmingly unprepared for it.”

Gawande, as a medical student in the US, was emotionally moved when his class had to discuss mortality as depicted in Tolstoy’s classic “The Death of Ivan Ilyich”. In the Tolstoy classic, Ivan Ilyich is dying and lives in mounting anguish, and fear of death. As Tolstoy puts it, it was the failure of the doctors around Ivan Ilyich to offer him comfort.

“No one pitied him as he wished to be pitied,” Gawande quotes Tolstoy.

Gawande goes further: “We paid our medical tuition to learn about the inner process of the body, the intricate mechanisms of its pathologies, and the vast trove of discoveries and technologies that have accumulated to stop them. We didn’t imagine we needed to think about much else. So we put Ivan Ilyich out of our heads.”

Doctors and patients alike are forced to confront the realities of physical decline as a result of ageing and mortality.

As medical progress extends our lives, Gwande points out that humankind undergoes what is called the “rectangularisation” of survival. It is simply put this way: throughout most of human history, a society’s population formed a sort of pyramid – young children at the base, and each older group successfully forming a smaller and smaller group right through the apex. But what we could be seeing in about 30 years’ time is that there are as many people over the age of eighty as there are under five.

Few societies are coming to grips with the new demographics. Japan’s life expectancy has increased steadily over the past century, and currently stands as the highest in the world at almost eighty-four years. It is reckoned that Singapore in 20 years’ time will have the same demographic profile as Japan has today.

Atul Gawande is a surgeon, writer, and public health leader. He is CEO of the non-profit-seeking health care venture formed by Amazon, Berkshire Hathaway, and JPMorgan Chase to deliver better outcomes, satisfaction, and cost efficiency in healthcare.

Photo: Sonny Inbaraj Krishnan

The beauty of “Being Mortal” is that Gawande does not hold back in describing the death of his hundred and ten-year-old grandfather, Sitaram. It happened in India after Sitaram, still active and in full control of his faculties, hit his head falling off a bus as he was going to the courthouse in a nearby town on business. He developed a subdural hematoma – bleeding inside his skull – and over a couple of days faded away.

“He got to live the way he wished with his family around him right to the end,” writes Gwande.

Gwande brings up an important point following the death of his grandfather. For most of human history, for those few people who actually survived to old age, his grandfather’s experience was the norm. Elders were cared for in multigenerational systems, often with three generations living under one roof. The elderly were not left to cope with their infirmities on their own.

But now, the obvious stares in our face. There is a strong possibility that we could die alone in our old age. By contrast, old age and infirmity, writes Gwande, have gone from a shared, multigenerational responsibility to a more or less private state – something experienced largely alone or with the aid of doctors and institutions.

Do we, as we get to our 80s, have to face the harrowing prospect of being expected to be confined in a nursing home with square meals, professional health services, physical therapy and bingo? Doesn’t it seem frightening, desolate and even odious to spend the last phase of one’s life that way? Gwande writes, “We need and desire something more.”

“How did we wind up in a world where the only choice for the very old seem to be either going down with the volcano or yielding all control over our lives?” asks Gwande.

Maybe we have ourselves to blame – and I confess I am also at fault with both my parents who are in their 80s.

To paraphrase Gwande: “We didn’t look around and say to ourselves, ‘You know there’s this phase of people’s lives in which they can’t really cope on their own, and we ought to find a way to make it manageable’. Instead we said, ‘This is a medical problem. Let’s put these people in the hospital’.” The modern nursing home thus developed by accident.

“Being Mortal” is about the human struggle to cope with the constraints of our biology with the limits set by our bodies. But medical science has given us remarkable power to push against these limits.

Yet there are no answers. Neil Young in ‘Hey, Hey, My, My’ sings: “It’s better to burn out than to rust away”. Is that the way to end suffering?

“Whatever we can offer, our interventions, and the risks and sacrifices they entail are justified only if they serve the larger aims of the person’s life. When we forget that, the suffering we inflict can be barbaric,” Gwande concludes.


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