The inevitability of death and taxes

While the debate on tax continues to rage and the productivity commission looks into the medical workforce, a topic crucial to both is rarely mentioned. Death. That’s right. I said it.

Death, perhaps along with money, remains one of the last taboos in Western conversation. It is routinely something to be banished, as if to hope that it may not exist, at least not while we’re still alive. In fact, half of deaths now occur in the hospital setting, 3 times the rate of 20 years ago. Death is now seen as an illness.

Australia spends about $60 billion dollars on health, or around 9 per cent of our total gross domestic product. This puts us in tenth place in the OECD. But it is believed that the greatest proportion of health costs, up to one third from some estimates, is in the immediate period surrounding death. This means that almost 3 per cent of our GDP goes into trying to sustain or revive the dying.

What’s wrong with that? There is nothing wrong with trying to save lives. That should be the prime purpose of our health system. It’s hard to argue for many better ways to spend our tax dollars.

But the truth is that the vast majority of investigations and technological fanfare that surrounds the theatre of death is superfluous, driven by legal caution, cure-obsessed doctors or relatives in denial. I have lost count of the number of times I have been asked to counsel relatives about the inevitability of death while the patient lies with tubes in every orifice, a machine doing their breathing and more audible beeps than a teenager with a mobile phone.

One of the most confronting experiences of a being a young doctor is when you certify your first death. It is largely for bureaucratic purposes, but in practice it involves touching and feeling someone you knew to be alive only hours ago. Especially for those who have never lost anyone close, it forces you to question your deepest beliefs surrounding our existence.

It also makes you realise how little death we see or discuss in our regular lives.

The growing medicalisation of our lives has become so complete, that even death is now seen as something to be cured relentlessly. It is seen as a private affair where the bereaved and dying are to be isolated. Furthermore, the sight of death is now so abhorrent and offensive, that even morticians are asked to decorate the body as if to create the illusion of life.

Western attitudes to death have progressed from it being a public and familiar event, to it being the moment when our souls are up for judgment to present day attitudes of material finality.

Part of the reason is the success of medical science. Advances in medical care have transformed our relationship to death. We have become so good at postponing death that it seems to be less than ever a natural process, rather than an inevitable and important aspect of the continuity of human life.

By and large, Western health systems now treat diseases of decay, such as arthritis or dementia, or diseases of excess such as heart disease and obesity. The vast majority of what the family doctor now sees are what’s called psycho-social problems, such as depression and anxiety. Furthermore, our life expectancies are continuing to increase and the average is now into the ninth decade.

So in practice, many of us will not have to face up to the complexities and implications of death until our parents are very old and we are well and truly into middle age. Then when the time does arrive, a mixture of guilt, panic and confusion in the face of mortality can lead to unrealistic expectations and demands of the health system.

Medical technology will force us to examine what we mean by death and what its relation to our lives should mean. In fact, the growing ability of technology to keep people alive is blurring the boundary between life and death.

A taste of what is to come was foreshadowed in the 2003 Victorian Supreme Court case where it was deemed that food given through a tube did not constitute medical treatment, in the case of a nursing home resident suffering the degenerative Pick’s disease. This allowed the husband of the patient to withdraw treatment. The patient had not communicated for three years, could not move and could not eat.

These kings of ethical dilemmas can only accelerate into the future.

The desire to postpone death indefinitely is understandable, if lamentable. And who would not want everything done for their relatives if there was a chance of cure.

But our limited contact with death should not necessarily postpone our discussion of it. It is not only causing great angst, it is also proving to be very expensive. Our lives may increasingly depend on it.