By Zubeida Mustafa
SPEAKING at a seminar, a medical professional once described the changing relationship between patients and physicians. He recalled the time when for centuries, physicians had the upper hand by virtue of their superior knowledge and their ethical standards.
Then the parties achieved a balance in their relationship as public awareness about health issues grew and patients could question the physician’s diagnosis and treatment. They also got more space to decide on the options for treatment available to them.
The time has now come for patients (or their attendants if the patient is not in a position to be consulted) to decide between life and death. Should the patient be sustained on a ventilator, even when in pain and with indignity, just to prolong the dying process? Or should he be allowed to go in peace when no remedy is available?
The fact is that this difficult choice arises not just in the final moments of life. Given the growing power of the pharmaceutical industry, the miracles of medical science and research and the wonders of diagnostic technology, the time to choose between perishing quietly sooner or struggling for survival for a few more years in pain and indignity often comes at a younger age. The terminal stage of an illness can be quite a long-drawn process as life expectancy has grown. In Pakistan, it was 37 years in 1950. Today, it has doubled to 76.
A healthy discourse is needed on aging, illness and death.
It is not the medical profession that alone faces this choice. Conscientious physicians and surgeons continuing to struggle to save human lives at all cost have often come under criticism. I remember the extremely wise words of a German surgeon, “Our aim should not be to add years to life but add life to years.”
The final word must be the patient’s himself who is required to take this difficult decision. The commercialisation of healthcare has increased the pressures on patients because attractive offers and fake promises of magic cures by men with vested interests make it difficult for a layman to take such vital decisions objectively.
The choice between ‘to live or to die’ is really a personal decision except when such a patient is being treated in a government hospital or is sent abroad at state expense. It is then that taxpayers have the right to raise questions about the feasibility of the treatment and its appropriate use.
Culturally our society shies away from discussing the issue of death — as a fact of life — although our religion is replete with references to death. Doctors tend to be very discreet about it as many of them say the relatives do not want the physician to bring up this issue before the patient. Many patients who would want to talk about the subject especially with regards to themselves are hushed up by their next of kin. As such, the issues surrounding death are brushed under the carpet, and people just grope around in the dark at such crucial moments.
A major factor that has added to this confusion is the increase in lifespan. It means that people are living longer and productively for many years after retirement. Though retirement ages have been raised from time to time, the population growth rate has not dropped as it has in other societies. The ageing of society has not taken place in Pakistan. As such we are facing a youth bulge with 64 percent of the population being under 30 years.
With no effective social welfare system for the old and not enough jobs for the young, who is to provide for those who are no longer productive? Even healthcare is not tailored for the aged. How many geriatricians do you have in Pakistan? The health problems of the aged are not even recognised and are left in the hands of specialists of all variety except geriatricians. People end up with long, unhealthy and unhappy lives.
So what needs to be done? First of all we need to introduce a healthy discourse on aging, illness and death. I find many senior citizens in a happy frame of mind and contented with their lives. They have created groups for themselves and are engaged in pleasant activities. But these are just a handful. One generally finds them disgruntled, as a result suffering from chronic illnesses and in the grip of dementia that creates problems of its own. And when they fall seriously ill, no stone is left unturned to provide them with life-saving therapy that doesn’t restore their health but certainly drags on their misery.It is time to talk. People in good health should not be afraid to say, ‘If this happens … if that happens … I would like to cling or go’ This approach would also open a discourse on deceased organ donation, a taboo subject in Pakistan.