trabajo 558
The doctor's attitude to death
(Reflections of an oncologist)
Dr. Adrián Pablo Huñis
Professor of Internal Medicine (UBA)
Director of the Medical Specialist in Oncology’s Dregree (UBA)
Master teacher of Oncology(U. Maimónides)
Director and Head of Oncology of the Buenos Aires Oncology Center
(Institution Affiliated to the Faculty of Medicine UBA)
Introduction
This work is guided by two premises: the first, that the contemporary western man, except in exceptional cases of personality or being affected by some psychopathology, is afraid of death. The second is that doctors, for the most part, want to cure the sick, they want to fight against their death and for that they resort to the tools provided by scientific knowledge.
The attitude of men towards death varies, according to conditions of time and space. In the same society we can find different attitudes towards death in different times and, at the same time, different attitudes are found in different societies. That happens nowadays in the world, where we can find radically different positions that coexist in the four cardinal points.
Taking into account the existence of this diversity, we decided to cut the scope of reflection to western contemporary society in whose reality we live and in which we exercise our profession on a daily basis.
Thus, we speak of the man considered mentally healthy, who is aware of what represents the end of his life, leaving aside the cases in which the person does not distinguish the difference for not having the full enjoyment of his mental faculties. In the same way, the relationship with the death of any type of suicide is not addressed either.
It does not escape our studies the fact that there are doctors who are interested in getting the most economic benefit possible from the health / disease relationship, but for the purposes of these reflections that line of work will be left out.
In order to deal with these issues, it is first necessary to address the concept of culture and dwell on what death currently represents for Western society in general and for medical professionals in particular.
What is culture?
In many social circles you can still find the concept of culture emerged in France, Germany and England in the eighteenth century. This was a concept very close to that of civilization and so ambiguous with it. In this context, culture was refinement, advance in knowledge, assimilation of the values and behavior of the rising bourgeoisie. To be educated was to acquire the aesthetic tastes and ethical values of the classes that occupied higher places on the social scale. In short, to be cultured was to be civilized, a climax on an evolutionary scale that began with savagery and barbarism (1)
Within this framework arises the dichotomy between erudite culture and popular culture that still prevails in the field of arts, especially in music. For many, the word culture is immediately associated with theater, ballet and lectures, while "educated" people are those who attend such shows.
However, at the end of the 19th century, a definition of culture arose which is still associated with civilization but which is already a precursor to the conceptual expansion of which it will be the object. "The culture or civilization in a broad ethnographic sense, is that complex whole that includes knowledge, beliefs, art, morals, law, customs and any other habits and capabilities acquired by man as a member of society" (Tylor, 1871)
At the beginning of the 20th century, anthropological theory introduced more variables to the concept, enriching it on the one hand and destabilizing it on the other. Those responsible for this change were the anthropologists who investigated the marginalized cultures of the western civilizing process, such as the inhabitants of Polynesia, Africa and various islands. These anthropologists were often sponsored by governments, notably by the British, who understood that it was necessary to know the way of living, being and thinking of their colonized to better perform their colonizing work. Apart from the ethical-political questions of the English colonization, which escape the subject of this work, it is important to note that by adopting this attitude the English colonizers were recognizing the existence of the OTHER and that the other had a way of life that, if Well it was different from the one known to them, it had to be taken into consideration. Thus, they were recognizing to some extent the existence of cultural pluralism.
Since then it has been considered "culture" to the set of material goods produced by a people (material culture), as well as beliefs, norms and customs (spiritual culture). And in the last decades the definition has also incorporated the universe of the symbolic that accompanies the vision of the world of each people and that is inseparable from it.
"Culture is better understood not as complexes of concrete patterns of behavior - customs, customs, traditions, sets of habits - but as a series of control mechanisms - plans, recipes, formulas, rules, instructions - that govern behavior"
Culture does not refer, then, only to the objects produced or to the customs of a people, but to the meaning that those customs have for that people and the set of norms and symbolic devices that make this custom perpetuate itself. Culture brings with it the existence of cultural schemes that are "systems of meaning created historically, by virtue of which we form, order, sustain and direct our lives" Thus, culture is all the ways in which the people of a certain society relate to each other. with the others and with their environment, including in this relationship the way in which the members of the society producing that culture explain the world and all the material objects or icons of another nature that contribute to its continuity.
Applying that definition, it can be affirmed that each society has its particular symbols, its explanatory myths about the origin and the end of man. When it comes to the end of man, each culture has its imagination regarding not only the future of that man out of this world, but also the meaning of the abandonment of this world by the dying, an act surrounded by a ceremonial appropriate to this belief that has its specific rules and symbols that identify it.
Thus, each society has its traditions around death and control mechanisms to be fulfilled. Within these customs there are also rules by which each society understands that there is a better or more adequate way to die.
Death through history
The concept of culture should not be confused with other concepts that agglutinate human groups, such as nationality. Within the same country there may be different cultures, according to the native population of each region or the geographic and climatic conditions. Culture, on the other hand, is not unique or universal, but is rather restrictive in geographical scope and is subordinated to peculiarities of the historical and economic process.
The relationship of people with their death and with death in general also varies within the same culture in different periods. For example, in classical Greek culture, the direct antecedent of our current Western culture, it was believed in a certain life after death and for this reason the dead were the object of attention during the first days after death.
"The ghosts were entitled to three days of presence in the city... Everyone felt bad in those days. On the third, all the spirits were invited to enter the houses, they were then served a meal prepared on purpose; then, when it was considered that they had satisfied their appetites, they were told firmly: Beloved spirits, you have already eaten and drunk; now go away! "
At present, different ways of relating to death coexist in the world. Among the Eskimos, for example, the death immediately after birth is the fate of most of the firstborn, and the old choose the moment of death, retreating to the ice where they die of cold and starvation. Starting to reconnect with their ancestors is also a practice in some African tribes.
Some indigenous tribes of the Amazon do not allow children born with some type of disability to live. And within the Eastern cultures, predominantly in the Hindu, the Chinese and a large part of the Japanese, death is not considered as an end of life but as the entrance to it: death is celebrated, but it is not crying for the dead.
The people who lived in previous centuries believed that death was something natural, part of the cycle of life. This can be seen both in classical Greece and in the Middle Ages or in the nineteenth century among the Russian peasants or among the pioneers who went to populate the United States.
"We find from Homer to Tolstoy the constant expression of the same global attitude towards death ... it is at once close, familiar, diminished, desensitized "
Both fiction literature and travel stories show that death was something natural, that it did not hide, that it did not have great drama. There was even a reluctance to name children at birth, and in fact a reasonable time was expected to see if they survived.
This attitude of resignation in the face of infant death can also be observed among poor communities (even in rich countries), within which the struggle for survival is great and death a daily possibility. It is not uncommon to naturally hear a father or mother say that they had a certain number of children, of whom only a few survived.
The attitude towards death also varies according to social and economic position. For the powerful classes of Western Europe, between the twelfth and fifteenth centuries the attitude towards death ceased to be of resignation and became an aversion when they realized, among other things, that they left the world of goods. "Death has not only been a conclusion of being, but a separation of being: you have to leave houses, gardens and gardens."
There was then a stage in which the death was dyed of romantic character, as well as the agony long accompanied by friends and relatives who not only honored the dying with his presence but lived the possibility of accompanying him (the dying) on his deathbed, as a distinction.
And towards the 19th century, death will be accompanied by funerary public rituals: the wake and burial, with all the pomp that is still preserved in many places, rituals that, within the cultural scheme, have their rules and symbols for demonstrate, on the one hand, what place the dead person occupied on the social scale and, on the other hand, so that those who remain can demonstrate what the dead meant to them.
“El grito” Edvard Munch, 1893
Death in the West: asepsis, mediatization, banalization
In the contemporary West a particular relationship is taking place: death was never so depersonalized, so insubstantial, so trivial or as banalized as in our culture today.
Aseptic’s death, institutionalized (in hospitals, sanatoriums or asylums) has been surrounded by a technological deployment that often prevents the dying from spending their last moments with their loved ones, which was recently considered a necessary condition of a " good death". But at the same time, aseptic death is the most accepted death, because it is clean, cared for, assisted.
On the other hand, due to the growing penetration of the media in daily life, death has become an object of consumption, as well as funerary rituals or death information in tragic circumstances (urban violence in its various forms). forms, political violence, etc.)
"Death participates in most forms of communication / spectacle: films, plays, television broadcasts, songs, novels, death enters the circuit of informational type: funeral notices, accounts of murders or fatal accidents ... Death information, such as death show, sell well"
.
It comes to consume the agony of people with their consent. At the same time, cinema and television have progressively led to a growing trivialization of death through scenes of violence that seek to have an impact on the viewer. It is the "spectacularization" of death, a phenomenon that is increasing in quantity with social effects not yet sufficiently studied.
Some journalistic studies have tried to establish a relationship between the size of the cities and the indifference of the inhabitants in front of the death of a passer-by, showing that in the large urban centers the indifference is almost total. At the same time, the concealment of death or silence about it are also part of the current urban culture, especially in regard to children, who often are not even taken to the funeral of their parents or family members.
While the "spectacularization" of death through the media or art can be considered an attempt to exorcise it or make it less feared, silence about it is a way of denying its indisputable existence.
"The negation, pathological mourning that refuses to believe in the death of the other ... simplification (escape from funerals and mourning ...) and silence (refusal to talk about death...) characterize the West from today".
The patient and death
So far, death has been talked about in the abstract. Now we analyze the attitude of a person facing his own death, as it may be the case of a patient who is under medical treatment.
In our time, death "causes so much fear that we no longer dare to say its name" fear that, in turn, is considered "normal and necessary".
When a person lives a situation in which he can no longer deny death or trivialize it, he becomes afraid. These have been described by Thomas, in our culture, as the following:
• Fear of dying
• a.1- for leaving unfinished tasks (such as raising children)
• a.2- for fear of physical pain
• a.3- for fear of psychic suffering
• a.4- for fear of corporal corruption
• Fear of after death
• b.1- uncertainty regarding the beyond
• b.2- uncertainty about the behavior of the survivors (oblivion, questions of inheritance)
• b.3- fear of nothing
In the West, one of the most common ways of dealing with these fears is to deny the existence of death, which can reach more or less pathological degrees, as well as the irony of it, that is, ridicule it.
Another way is not to see death as the end of everything, which leads to the laying down of offerings in the tombs and to talk about death in metaphorical terms such as "eternal sleep" or "to pass to a better life".
In the field of psychology, some studies have been conducted on the behavior of man in the face of his death, and in which discrepancies are observed with the historical approach of Aries, because for the psychoanalytic literature, the fear of death has been a constant in the man of all times.
In 1915 in Current Considerations on War and Death, Freud points out that self-death is unimaginable and our unconscious does not believe in death itself.
This vision is shared by anthropology, although it is admitted that fear has different degrees according to cultures. Except when it comes to suicides, whose exclusion from the present discussion has already been clarified.
Ph. ARIES does not explicitly say that in earlier times death was not feared but it is the impression left by his reading of the relationship with death in other times.
"The fear of death - universal fact par excellence - is, then, a normal phenomenon ... [however] the fear of death is more moderate in black Africa".
The doctor and death
There are few studies on the doctor's relationship with death in our current Western culture from an anthropological point of view on urban medicine. Medical anthropology has been more dedicated to studying the role of doctors working in rural communities or outside the civilizing process.
"Anthropologists have been relegated to study non-urban medical phenomenology, without having been given the opportunity, particularly in Europe, to study the conditions in which practice is practiced in their own social system."
Unlike mental health professionals (psychiatrists, psychoanalysts or psychotherapists), who have to discuss the anguish of death with their patients, the doctor has "a permanent and always informed contact with death".
The existing written material allows to see that the doctor and death engage in a fight in the arena of illness, which has the patient as its carrier. Sometimes the doctor wins the fight and heals the disease; others, death defeats him, leading the patient to succumb.
"In a broad sense, every death necessarily triumphs, since it necessarily ends up giving an account of us".
The doctor is often the mediator between death and the patient, the carrier of the bad news, who tells the patient that their struggle against the disease is being overcome and that the end comes.
This task of "announcer of death" was assigned to doctors by the popes in the historical period called modernity, at the end of the 18th century and the beginning of the 19th century. Practically until the twentieth century, doctors were not responsible for curing, but rather to help the patient had a "good death", being a kind of spiritual support for the patient.
"In Balzac's novels, the doctor plays a considerable social and moral role ... Take care of a little, but it does not cure, it helps to die. Or it foresees a natural course that does not correspond to him to modify".
For current doctors, admitting the death of the patient is confronted with their inability to heal, recognize that there are things that escape their universe of knowledge, admit the impotence of their scientific knowledge against the advance of agents that cause processes that can not stop.
"The acceptance of death means admitting that something is, even if it transcends our understanding. For this it is necessary to renounce a large part of the omnipotence itself."
When the disease progresses, the most the doctor can do is delay the time of death or help the patient have, as far as possible, a better death. The delay of death is the cause and consequence of the hospitalization of the dying person, which became common practice only after the Second World War.
This recent possibility gives a new leading role to the doctor, who happens to have power of decision over the life of the person. Once in the hospital, the patient and his family are subordinated to the decision of the medical body and many times justice intervenes to prevent a machine from being disconnected and allowing the patient to die as would be his or her family's desire, a time you are having vegetative life. Here arises one of the discussions of contemporary medicine: How far and how long should the doctor keep the patient alive?
Some critical versions even affirm that institutional medicine has a tendency to maintain a balance in the disease situation as a way to justify the very existence of the health system.
"Healing is not the instrument to reach the utopian goal of health, but the means to continue healing and maintain this balance in the disease that generates the reproduction of the medical ritual circuit"
The affirmation of J. Prat refers us to the cases in which the life of a patient is prolonged as a way of keeping the system functioning around him, in which the doctor is the one who makes the decision of when the patient should die, which in many cases can be subordinated to economic interests.
"Death has stopped being admitted as a necessary natural phenomenon. It is a failure, a business lost ... When death arrives, it is considered as an accident, as a sign of impotence and clumsiness, which must be forgotten".
Two questions can be inferred from this statement. First of all, it can not be generalized around it and, secondly, it is not necessarily a correct posture.
While there is an anthropological definition that associates the moral with the normal within a society, the reason must prevail in the discernment of what is an ethical behavior on the basis of the humanist values of the doctor.
"The moral is, then, that which is normal in a certain type of society and in a determined phase of its evolution. It is then up to reason to model behavior through a practical cut of ethics, derived from a scientific study of social life".
In other words, the person must decide, according to their values, what is right to do, although the normal thing in society is not exactly that.
Within this framework, there is another possible relationship of the doctor with death, which is to help the patient to have a quiet death, as it was in previous centuries, revitalizing an old axiom of healing, alleviating, accompanying.
When the doctor can not cure, he must find palliatives for the suffering of the patient, and when this is not possible either, it only remains to accompany him so that he has a death as dignified as possible.
In this sense, in the past decade the "hospicio" (with quotation marks in the original) was considered a pioneer in this type of service. Saint Chistophe, in the suburbs of London, thought not as a hospital to cure but for the terminally ill to go to die.
These were thus "hospitals specialized in sweet death and in their preparation" in which terminally ill patients have the right to decide to die when they wish.
Here arise other controversies: how to determine the time to deliver a patient to death?
Conclusions
The doctor's relationship with death is complex. In the face of death in general and that of his patients in particular, the doctor must carry out a double elaboration process: elaborate the death of the other, of his patient, who may or may not have become a loved one; and, at the same time, elaborate your professional defeat in that particular battle.
On the other hand, the doctor as a mortal human being, each time he faces the potential or consummate death of a patient does so with his potential death and with the consequent fears that she provokes. From here may emerge the apparent coldness with which doctors often face the patient's death, both at the time of the news and at the time it occurs. It is possible that at this moment all the mechanisms of defense and denial of their own death as an inevitable phenomenon play on the doctor.
Perhaps this is a component of the excessive efforts that are made to keep a person alive, regardless of the economic implications that there may be in some cases.
Seen from another point of view, one can think that the struggle that the doctor engages with death and for which he uses the entire arsenal of hospital technology, is a struggle to find the path of immortality that also seems to be the search for man through the centuries, from the alchemists to our days with the experiences of cloning.
The question then is to strike a balance between the struggle and the patient's well-being. The patient has the right to know about his illness and the doctor has the duty to inform him about all his possibilities. The patient has the right to decide what form he wants to die.
Prolong indefinitely the life of a person does not make sense, when there are no expectations of a life of good quality. At the same time, the experience is making the self-image of omnipotence diminish over the years and the doctor is faced with surprises, such as patients with little life expectancy that, for reasons inexplicable at first sight, survive for much longer than the planned.
The doctor's great challenge to death is to manage the symptoms properly to give his patient a good quality of life as long as possible, and to know when the time has come when it is not justified to continue the fight. This quality of life implies the least suffering and the greatest possible lucidity for the patient.
To further complicate the situation, in addition to the patient, they play the interests and wishes of their closest relatives, who usually delegate to the doctor the responsibility of deciding on the patient, but who sometimes demand that the doctor take a measure to prolong, or not, the life of the bereaved.
The role of the doctor in these circumstances becomes even more complex because, on the one hand, his assessment of the state of symptoms can be affected by the pressure of relatives and, on the other hand, the need to respect the will of the patient. These and the patient can interfere in their decisions about what is best for the affected.
Thus, the doctor must find a balance between respect for the wishes of the patient and his family, and what he understands, as a scientist, that is best for the welfare of his patient, which is not an easy task.
The doctor's attitude to death must be that of the mother who, when Solomon proposed cutting the girl in dispute to the environment, preferred to abdicate his daughter in favor of the other applicant, hence the term "Solomonic" when refers to something fair and equitable.
When the doctor sees that his patient is going to be dilated by the suffering caused by the disease, or he will stop being human to move to a "vegetative state", the most human thing is to deliver him to a "better life".
The challenge is to know, from the symptoms, what is the right time to do it, and that is precisely where the greatest difficulty lies in the serious and humanistic exercise of the profession.
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