16 World Health • 49th Year, No.5, September-October 1996 The meaning of life, suffering and death Hubert Doucet
iews on the task of medicine life as much as possible, and this has with, which is that we want to control differ from century to century come to be the philosophy of today's something we no longer know how Vand from culture to culture. medicine as well. to relate to. However, it seems that any health Modem medicine has evacuated care must seek to mitigate suffering death from its perspective, in which in order to help a sick person recover it exists only as a failure of the The cost of prolonging life his or her integrity. Hippocrates, in physician. Medicine does miracles the fourth century BC, said that the in order to prolong life, but then In the West, the prevailing assump object of medicine was to get rid of leaves us with a major problem: how tion is that health and life are the the patient's suffering and reduce the to manage the end of life, the dying most precious good we possess, and violence of the di sease, but abstain process. For the last 20 years, pallia that everything must be done to fight from intervening in cases that were tive care and a wide variety of ap illness and death. This helps to ex beyond the powers of the art. Francis proaches have been tried in order to plain the evolution of modem medi Bacon (1560-1626), on the other alleviate suffering and face death cine. But the cost of attempts to save hand, said simply that medicine with dignity. But these do not solve life where there is little or no hope of should reduce suffering and prolong the basic problem death faces us 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 We all hope to reach the end of our days with our dignity and integrity intact. equipped to meet this need and the World Health • 49th Year, No .5, September-october 1996 17 state is not willing to invest in meet what point and how should we stop ing it, the elderly are transferred to Palliative care treatment in order to allow a person nursing homes to live out their last to have a good death?" years. Such situations often raise the Some argue that palliative care There is probably no standard question: do we live longer to be makes it possible for patients to die definition of "a good death"; it come sicker and lose more and more with dignity. In fact, many specialists ' inevitably varies among individuals of our autonomy? in palliative care oppose the legaliza and cultures. One conclusion we tion of euthanasia on the grounds that may draw from these questions is we are now able to control pain. that the experience of other cultural The cost of illness There is a movement in Switzerland traditions is needed to help Western and several other countries called Un medicine recover its sense of the Modem medicine has not only trans hOpital sans douleur, which argues meaning of life, suffering and death. formed death and dying, it has trans that much of the pain that now occurs formed the nature of illness. In the in hospital is unjustifiable since the • not very distant past, infections were means of reducing it exist. However, the cause of most diseases and they it is not clear whether suffering, that seldom lasted for more than two basic dimension of any illness, is months. If the body could not cure recognized for what it is. Modern itself within that time the individual medicine usually sees it as a physical died. Today cancer, diabetes, degen matter which can be dealt with by Hubert Doucet is Professor of Ethics ot St Paul erative diseases of the nervous sys Un iversity, 223 Main Street, Ottawa technical means. This ignores the KISIC4,Canada. tem, cardiac diseases, renal diseases fact that some patients with incurable and AIDS are common causes of diseases, even when they receive death, and all of them are now effective palliative care, feel that chronic. they suffer in a way that is unworthy There are many examples of the of a human being. Some request problems we have created for our euthanasia for this reason, or because selves. Severely disabled babies, they feel too exhausted to go on who a few years ago would not have fighting for life. survived, now survive. Many will Palliative care thus teaches us two live on a respirator, artificially fed, lessons. First, suffering is not only and unable to develop mentally. At physical and psychological; it has the other end of life, an 80 year-old spiritual and existential dimensions man is demented, has arteriosclero which are an inseparable part of it. sis, hypertension and decubitus Patients can be helped in their search ulcers, and is artificially fed. In these for meaning and for ways of corning ways acute care is creating the need to terms with what seems unaccept for chronic institutional care. Once a able, but such help is usually difficult technique for prolonging a person's to give because suffering is a private life exists, we do not know if or when experience that cannot be completely we should stop using it. For the shared. Second, not all suffering can individuals and families concerned, be treated or controlled. To suppose these situations are not just ethical that medicine could deal with it dilemmas, they are tragedies. Within entirely would be to make a major health care institutions, major ten error, for suffering is a profoundly sions arise. On the grounds of respect complex human experience in which due to the patient, for example, the individual's whole identity is at nurses in North America often op stake. pose decisions made by physicians. It now seems to be agreed to be In Western Europe too, nursing staff ethically acceptable to stop treatment are increasingly anxious to find when death is inevitable. There is in forums in which they can express fact a consensus in medicine and their views on situations they feel are ethics that some kinds of treatment not being handled properly. 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 A premature baby in an incubator. New tion is not "Is it acceptable to stop technologies bring in new possibilities and new treatment at the end of life?" but "At ethical issues.