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16 World Health • 49th Year, No.5, September-October 1996

The meaning of life, suffering and death

Hubert Doucet

V

iews on the task of medicine differ from century to century and from culture to culture.

However, it seems that any health care must seek to mitigate suffering in order to help a sick person recover his or her integrity. Hippocrates, in the fourth century BC, said that the object of medicine was to get rid of the patient's suffering and reduce the violence of the disease, but abstain from intervening in cases that were beyond the powers of the art. Francis Bacon (1560-1626), on the other hand, said simply that medicine should reduce suffering and prolong

life as much as possible, and this has come to be the philosophy of today's medicine as well.

Modem medicine has evacuated death from its perspective, in which it exists only as a failure of the physician. Medicine does miracles in order to prolong life, but then leaves us with a major problem: how to manage the end of life, the dying process. For the last 20 years, pallia- tive care and a wide variety of ap- proaches have been tried in order to alleviate suffering and face death with dignity. But these do not solve the basic problem death faces us

We all hope to reach the end of our days with our dignity and integrity intact.

with, which is that we want to control something we no longer know how to relate to.

The cost of prolonging life

In the West, the prevailing assump- tion is that health and life are the most precious good we possess, and that everything must be done to fight illness and death. This helps to ex- plain the evolution of modem medi- cine. But the cost of attempts to save life where there is little or no hope of complete success can be extremely high, and is raising more and more questions. For instance, could our resources not sometimes be used better to meet other needs, such as primary care, family health, or help for underprivileged children? Since 1976 in the United States, there have been 84 court cases seeking the right to have treatment stopped. The public are turning to the law to pro- tect themselves against the power of medicine. Physicians for their part now use the expression "futility of treatment", referring to the many situations in which treatment should be stopped because it is unable to prolong human life with dignity.

Rather than prolonging life, it is prolonging the dying process.

The fact that medicine helps people to live longer explains why Alzheimer disease, for example, which seems to negate exactly what is human about a person, is now so prominently with us. In the case of the elderly, we spare no expense to make the patient survive when dis- ease becomes life-threatening, but then we seem unable to provide the kind of day-to-day care and human environment needed for a reasonably happy life. Since the family is not equipped to meet this need and the

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World Health • 49th Year, No.5, September-october 1996

state is not willing to invest in meet- ing it, the elderly are transferred to nursing homes to live out their last years. Such situations often raise the question: do we live longer to be- come sicker and lose more and more of our autonomy?

The cost of illness

Modem medicine has not only trans- formed death and dying, it has trans- formed the nature of illness. In the not very distant past, infections were the cause of most diseases and they seldom lasted for more than two months. If the body could not cure itself within that time the individual died. Today cancer, diabetes, degen- erative diseases of the nervous sys- tem, cardiac diseases, renal diseases and AIDS are common causes of death, and all of them are now chronic.

There are many examples of the problems we have created for our- selves. Severely disabled babies, who a few years ago would not have survived, now survive. Many will live on a respirator, artificially fed, and unable to develop mentally. At the other end of life, an 80 year-old man is demented, has arteriosclero- sis, hypertension and decubitus ulcers, and is artificially fed. In these ways acute care is creating the need for chronic institutional care. Once a technique for prolonging a person's life exists, we do not know if or when we should stop using it. For the individuals and families concerned, these situations are not just ethical dilemmas, they are tragedies. Within health care institutions, major ten- sions arise. On the grounds of respect due to the patient, for example, nurses in North America often op- pose decisions made by physicians.

In Western Europe too, nursing staff are increasingly anxious to find forums in which they can express their views on situations they feel are not being handled properly.

Palliative care

Some argue that palliative care makes it possible for patients to die with dignity. In fact, many specialists ' in palliative care oppose the legaliza- tion of euthanasia on the grounds that we are now able to control pain.

There is a movement in Switzerland and several other countries called Un hOpital sans douleur, which argues that much of the pain that now occurs in hospital is unjustifiable since the means of reducing it exist. However, it is not clear whether suffering, that basic dimension of any illness, is recognized for what it is. Modern medicine usually sees it as a physical matter which can be dealt with by technical means. This ignores the fact that some patients with incurable diseases, even when they receive effective palliative care, feel that they suffer in a way that is unworthy of a human being. Some request euthanasia for this reason, or because they feel too exhausted to go on fighting for life.

Palliative care thus teaches us two lessons. First, suffering is not only physical and psychological; it has spiritual and existential dimensions which are an inseparable part of it.

Patients can be helped in their search for meaning and for ways of corning to terms with what seems unaccept- able, but such help is usually difficult to give because suffering is a private experience that cannot be completely shared. Second, not all suffering can be treated or controlled. To suppose that medicine could deal with it entirely would be to make a major error, for suffering is a profoundly complex human experience in which the individual's whole identity is at stake.

It now seems to be agreed to be ethically acceptable to stop treatment when death is inevitable. There is in fact a consensus in medicine and ethics that some kinds of treatment aimed at relieving pain are accept- able even if they reduce the length of life. But when we have the technical means to prolong life, the real ques- tion is not "Is it acceptable to stop treatment at the end of life?" but "At

what point and how should we stop treatment in order to allow a person to have a good death?"

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There is probably no standard definition of "a good death"; it inevitably varies among individuals and cultures. One conclusion we may draw from these questions is that the experience of other cultural traditions is needed to help Western medicine recover its sense of the meaning of life, suffering and death.

Hubert Doucet is Professor of Ethics ot St Paul University, 223 Main Street, Ottawa KISIC4,Canada.

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