Honesty is the best medicine
DOCTORS learn a lot of things in medical school, but death is not one of them. Dissection of dead bodies teaches us human anatomy. Medical textbooks have almost nothing on aging or dying. How the process of death unfolds, how people experience the end of their lives and how the near and dear ones around them are affected are never taught. The purpose of medical study is to save lives, not how to help them die when it is inevitable. To make the medical study more humane and well-rounded, students are taught physical examination etiquette, effect of socioeconomics and race on health. At other times students contemplate helplessly the suffering of the patient as he lies ill, worsening moment to moment from some unnamed, untreatable disease. No one can agree on a diagnosis and remedies they give him accomplish nothing. He suffers pain and torture helplessly.
There is a certain degree of deception which for some reason they all accept, that he is not dying but is simply ill. He has flashes of hope of getting well but he grows weaker everyday. He lives with fear of death. But his doctors, friends and family cannot accept death which causes him profound pain. The failure of those around him to offer comfort or to acknowledge what is happening is a failure of our character and culture.
Knowing fully well the patient has no cure and probably has months to live, doctors often push for all sorts of interventions and procedures which are inherently dangerous and even potentially life-threatening and force him to accept them. What is most striking is not how bad the patient's decisions are but how much the doctors in our country avoid talking honestly about the choice before him. Doctors should have no difficulty explaining the specific dangers of various treatment options, but never touch on the reality of the disease. They all have seen him for months of treatment for a problem that they knew could not be cured. They can not discuss the larger truth about the condition or ultimate limits of their capabilities, let alone what might matter most to him as he neared the end of his life. If the patient was pursuing a delusion, so were the doctors. The chances that he could return to anything like the life he had even a few weeks earlier were zero. But doctors seldom offer comfort or guidance. They just offer another treatment with the false hope that something good would result.
Modern science has profoundly altered the course of human life. People live longer and better than any other time in history. But scientific advances have turned the processes of aging and dying into medical experiences, matters to be managed by health care professionals. But the profession has proved alarmingly unprepared for it.
There is no escape from the tragedy of life – we are all aging from the day we are born. One should come to understand and accept this fact. But that is not the same as coping with what can not be mended. Doctors succeed if they are able to fix. But if it is not fixable? The fact that we have had no adequate answers to this question is troubling and has caused callousness, inhumanity and immense suffering.
We don't have to spend much time with the elderly or those with terminal illness to see how often medicine fails the people it is supposed to help. The final days of our lives are given over to treatments that torment our brains and sap our bodies. They are spent in institutions, nursing homes and intensive care units where regimented, anonymous routines cut us off from all the things that matter to us in life. Medical profession's reluctance to honestly examine the experience of aging and dying has increased the harm we inflict on people and deny them the basic comforts they most need. Absence of a clear view of how people might live successfully all the way to their very end has allowed our fates to be controlled by the imperatives of medicine, technology and strangers.
Being mortal is the struggle to cope with the constraints of our biology, with the limits set by genes and cells and flesh and bones. Medical science has given us immense power to push against these limits. But we have to admit this power is finite and always will be.
We have been wrong about what our job is in medicine. We have been taught our job is to ensure health and survival. But it is larger than that. It is to enable well-being. Well-being is the reason one wishes to be alive. Those reasons matter all the way in life – in health and sickness. The vital questions are the same whether one is sick bodily or mentally.
The field of palliative care emerged over the recent decades to bring this kind of thinking to the care of dying patients. It is encouraging that the specialty is advancing, bringing the same approach to other seriously ill patients, whether dying or not. But it will only bring significant change when all clinicians apply such thinking to every person they touch. It should not be a separate specialty.
To be human is to be limited. The role of caring professions ought to be aiding people in their struggle with those limits. Sometimes we can provide cures, sometimes only symptomatic relief, sometimes not even that. Whatever we can offer, our interventions, are justified only if they serve the larger aims of a person's life. If we forget that, the suffering we inflict can be barbaric. If we remember that, the good we do can be overwhelming. The most meaningful experience a doctor as a human being can get, would come from helping others deal with what medicine can do as well as what it cannot.
The writer is a former Director of Medical Service of Bangladesh Army.
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