Die another day

[okarol]

Die another day

November 25, 2007

Advances in science and medicine mean we are living longer than ever. But keeping death at bay
comes at a price, and forces us to face a big question: how much is life worth? Peter Munro reports.

When Death comes calling at your door, will it ride atop a pale horse, under black cloak with scythe in hand? Or arrive as an angel with bat's wings, a decaying corpse, or Father Time whispering memento mori - remember, you too will die? In Aesop's fables, an old man labouring under a bundle of sticks for market calls on Death to take him, but when it appears as a grisly skeleton he changes his mind. "Would you help me lift this load to my shoulders?" he asks, and struggles on down the road with his heavy toll.

The destiny of that weary man bent double under a burden that grows with each step has become our own. Each year we delay Death's rattle a little longer, but with our survival comes the growing spectre of debilitation and disease. Death arrives - as it will, no matter its form - later than ever. But like old men by the side of the road we might pause to wonder whether the cost of our extended lives, in terms of expensive medical treatment and our quality of life, makes it worth the living.

Over the 20th century, with improved treatment of infectious diseases and huge falls in infant mortality, average life expectancy in Australia increased by about 2.5 years for every decade - or six hours a day. A VicHealth report last week found that babies born in 2005 could expect to live to 78.5 years for men and 83.3 years for women.

But riding alongside the remarkable increase in longevity were soaring rates of hospital admissions for chronic diseases such as depression, dementia, diabetes, cancer, asthma, heart disease and stroke.

People once prayed to be saved from an early death - now they expect to be saved, even at a cost, says Dr Bruce Rumbold, a health sociologist and acting director of the palliative care unit at La Trobe University. "In a culture like ours, we live at arm's length from the unpredictability and the horrors some people live with in Africa or the Middle East. Most of us can expect to live to an advanced age and we have somehow taken it as granted or as if it is our right," he says.

"Increasingly, we are starting to hear stories of people who are quite offended when a loved one dies because their idea of medicine is that medicine should be able to save them. In other words, we haven't really caught on to the idea that we all have to die."

Pamela Bone, author and former writer on The Age, was sharply confronted with her own mortality in late 2004, when she returned unwell from a work trip to Africa and was diagnosed with multiple myeloma, an incurable cancer of the bone marrow. In her book Bad Hair Days, she writes that in bed one night she told her partner Jurgen that she wanted to die.

"What's the use of going through all this when I'm going to die anyway," she asked.

"Because that's what human beings do," he answered.

She thought of cancer as having to wade through a dark swamp, and before she made it on to firmer and lighter ground she thought often about ending her life. "But there is an instinct for life, even in people who consciously don't want to live," she writes. "If I asked you to hold a pillow over my face, and you did, I would still struggle. Someone who wanted to die would still jump out of the way if they saw a speeding car coming towards them. Wouldn't they?"

BEV WILSON, of Wheelers Hill, turned 56 on November 17 and has already lived long enough to twice survive breast cancer. She was 32 and in bed one morning when she discovered a lump in her left breast. Then 11 years ago a tumour grew in her right breast, leading to a second bout of chemotherapy and some grave humour from one of her physicians. "At least you'll be balanced now," he said as she prepared for her second mastectomy.

"The first time I had cancer I was thinking of my kids; I didn't want to leave them," she says. "The second time they were older and I was thinking of all the things I haven't done in my life yet. I wanted to study art and I wanted to go overseas, to see my kids get married and have their own kids."

Her first grand-daughter was born 19 months ago, and next year Wilson will travel to Canada with her husband Des. She is happy to have lived so long. But she believes it is OK to decline medical treatment if someone is in great pain or enveloped in the dark cloud of dementia.

"I can understand somebody who gets breast cancer at 80 and chooses not to have chemo. I probably wouldn't have chemo either at 80."

In that case, she would pray to God to take her. But what if he didn't answer? "Well, I would just wait."

Others are not so happy to put the matter of life and death in God's hands. As many as one in two people want to live forever, according to a small survey by the University of Queensland this year. About one-fifth of those surveyed said they would settle instead for a lifespan of between 100 and 150 years, while a minority were reluctant to set a target.

Professor Helen Bartlett, founding director of the university's Australasian Centre on Ageing, said the study, which is about to be published, showed that our embrace of immortality can be swayed by perceptions about quality of life and religious beliefs. To test that theory, the next survey will include this simple question: If you had a magic pill that would let you live forever, would you take it?

Many people would reach immediately for a glass of water with which to wash it down. Groups such as the Transhumanists believe that one day the disease and debilitation common in old age will not strike until we are 150 or 160 years old, if at all - our organs will be repaired or replaced before they fail, toxins will be flushed from our bodies. We will not wilt nor fade.

But immortality can be a bitter pill to swallow. "We shouldn't assume that extended life is always a good thing no matter what," says associate professor Justin Oakley, director of the Centre for Human Bioethics at Monash University. "I think perhaps when people are younger they tend to assume the more life the better, regardless of the quality of life. But I think as people get older they start to realise by and large that the quality of life is given more by what life enables you to do and to be rather than life having an extrinsic value."

Doctors often ask him the same question: is there a point at which it is no longer worthwhile to continue trying to save a person's life? Oakley says the answer must be yes, particularly when a patient has lost their hold on life's "basic goods".

It is morally defensible, he says, to deny an extremely elderly person an expensive medical treatment when they have lost the ability to communicate, to control their bodily functions or to think. Or to deny a donor kidney to an old man when a younger person in need would have a better chance of maintaining a reasonable quality of life.

"Some people would prefer to live even if their life involves great hardships and burdens," he says. "I do think that doctors can justifiably withdraw treatment from a patient that might not be in their best interests, or might be just too costly, or when other patients have a stronger claim to treatment on the grounds of justice in resource allocation."

Dr Rosanna Capolingua, president of the Australian Medical Association and chairwoman of its ethics and medico-legal committee, says doctors grapple with such issues every day. "Families quite often are very distressed and do not want to let go, do not want to let their loved one die," she says.

But she believes it is wrong to put a dollar price on someone's life or to set an upper age limit for treatment. "If we can look after people, well then why shouldn't we? Along with becoming a society where people live longer are responsibilities for looking after those people," she says.

"You mustn't necessarily believe that everyone at the age of 80 is decrepit and has no life worth living. I think we need to be very careful about starting to draw lines. Lines get very rigid and human beings are very fluid."

WHAT is a life worth? Some health economists set the figure at about $50,000 - the amount that it is acceptable to pay in medical treatment to give someone a good year of life.

Last week's VicHealth study of health trends found that improved medical treatments of fatal conditions had helped to lift life expectancy by about six years since 1987. But over the same period there was a stark rise in a range of chronic diseases that greatly increase the cost of our final years. Hospital admissions for diabetes and other metabolic disorders doubled in the past decade alone, while rates for arthritis and other musculoskeletal problems jumped 40%, and circulatory system diseases such as stroke rose by 20%.

An Australian Institute of Health and Welfare study published last year found that between 1998 and 2003 women aged 65 gained an additional 1.2 years in average life expectancy, taking them to the age of 86. But of those extra 14 months of life, they could expect to spend more than a year stricken by disability, such as loss of sight or chronic pain. Of that year, they might spend as much as half with such severe incapacity that they would be unable to go to the toilet, dress or eat without help.

The study found that for men, 67% of their gains in life expectancy would be spent suffering from a disability and 27% with severe disability.

Other studies, including some from the United States, have found to the contrary that illness and incapacity will be compressed into a shorter period at the bitter end of our long lives.

But Professor Hal Swerissen, acting dean of the faculty of health sciences at La Trobe University, says in Australia we are at a tipping point where the cost of future gains in life expectancy will be substantially increased disability and medical costs.

"Once average life expectancy starts to get up to 85-90, it is going to be very difficult to prolong life without a significant increase in the cost per life," he says. "The cost of someone over 65 is four times higher per year than someone under 65 in health-care terms. The cost of someone over 85 is six times higher."

The ageing of Australia's population will only heighten the financial burden of increased life expectancy on our health-care system. A Productivity Commission report in 2005 estimated that a quarter of Australians will be aged 65 or older by 2044-55, roughly double the present population.

The cost of keeping so many people alive for so long will be one of the great challenges of this century.

British philosopher A.C. Grayling argued in New Scientist last month that our longer lifespans will force us to face some heart-wrenching moral dilemmas. For instance, should older or ill people be coerced into killing themselves?

Victorians have the right to refuse medical treatment, and programs such as Respecting Patient Choices encourage people to make a decision on continuing treatment while they are still capable of doing so.

But in practice there is often pressure on patients from both medical professionals and particularly from their own family to continue treatment.

Reverend Dr Norman Ford, a senior fellow in the department of philosophy at the Catholic Theological College, says there is a "death angst" in the community - a drive to survive at all costs because of fear of what lies beyond.

"I used to think that doctors were pushing for it, but now I am swinging around to thinking that people are pushing doctors to do everything to save lives," he says.

He says that health spending should be devoted to curing people of their ills. When treatment would be futile, money should instead be spent on palliative care. "A point can be reached where treatment might only prolong a dying state or an awful condition, and in my view that is not a desirable option.

"We can't expect everybody to get drugs that cost $50,000 a year to keep them alive."

DAVID MENADUE, 55, has had AIDS since 1989, which is thought to make him Australia's longest living person with the terminal disease. He has looked into the faces of many friends who have died and once knew a terminally ill man who turned cartwheels across the floor of a gay club in St Kilda as a final hurrah before taking his own life.

His own mother died in great distress, after a long struggle with asthma, at age 66 in 1996, the same year he started taking the antiviral treatments that he credits for his longevity. Menadue, a former president of the National Association of People Living with HIV/AIDS, also says he has been lucky to not suffer from more than one of the major-AIDS related illnesses, such as pneumonia, at the same time.

But he is awake to the costs of living with a terminal disease. He has missed not having a partner for many years, and also suffers from the side-effects of the antivirals, including diabetes, high blood pressure, kidney problems, a bloated gut and wasted muscles.

On the day I visit his home in Balaclava the roses are blooming in his front yard but he is wilting under a spring cold and rattling cough. "I doubt I'll live until my 70s but who knows. More amazing things have happened in medical science," he says.

He imagines death as going down a tunnel and seeing snatches of his life played out on a television screen. But he spends more time thinking about his life than its end.

"For me, everything was just about survival and I never felt so miserable with my lot that I wanted to finish it all. Maybe it's blind optimism but I'm just going on in my happy little way, really. Doesn't everyone want to live?"

This story was found at: http://www.theage.com.au/articles/2007/11/24/1195753356519.html