Death and the medicalisation of death

1. Death and the medicalisationof death Dr. Yoga NathanSenior Lecturer in Public HealthGEMS UL

2. Learning Objectives • Describe the historical and social changes that have occurred in the meanings associated with death. • Explore the social issues surrounding the so-called 'medicalisation of death and dying' in modern health care systems.

3. Throughout the world, death and the rituals that surround it are steeped in taboos. • Death is celebrated, embraced and feared. • Around death and the dead, cultures put in place diverse restrictions and practices associated with clothing, food and ritual.

4. Nonetheless, death, dying, and grieving in the traditional model were an important part of everyday cultural practices. • And the rituals they spawned connected dying and grieving persons to a broader community and set of meanings. • In this way, the ordeal of dying was never just personal, it was communal.

5. These great ceremonies, along with their deep religious and social meanings, accompanied dying persons into their deaths. • They provided a sense of strength for the broader community that was being threatened by the loss of one of its members. • Additionally, these traditional rituals were a healing balm to dying persons and their intimates, offering strength and comfort to both.

6. In the twentieth century, the social and psychological landscape was transformed, redefining modern cultural, social, and personal experiences of death. • The result of this transformation is that dying, once an integral and meaningful part of social life, has become a source of terror and thus largely vanquished from public visibility.

7. Four major social trends are responsible: (1) the abdication of community to a pervasive sense of individualism; (2) the replacement of a predominantly religious worldview with one that is secular; (3) the sweeping power that materialism holds on the values, interests, and behaviours in modern society; and (4) the influential place of science and technology in daily life.

8. As individualism replaces community in daily life, community presence and support is withdrawn from the dying and grieving processes. • Secularism as a way of life offers many opportunities and great pleasures, but is ultimately unable to offer meaning and comfort at the end of life.

9. Like secularism, materialism poorly equips individuals and societies to grapple with the mystery of death. • In addition, technological achievement and dependence have enabled humanity to actively fight against dying, thus forestalling death for countless numbers of individuals.

10. In this technological framework, dying is no longer a natural, necessary, and important part of life. Rather, it is as if it has become an enemy. • Success lies in its control and defeat; failure becomes defined as the inability to turn it away. • These social changes have given rise to a new model of death, wherein dying and grieving are atomized and disconnected from everyday pathways of life, leading to their social isolation.

11. Dying has become deeply feared and a new image has replaced the traditional patterns of acceptance: the ugly and hidden death, hidden because it is ugly and dirty. • As death has become frightening and meaningless, a culture of avoidance and denial has correspondingly emerged. • Specifically, it has led to widespread pretence that suffering, dying, death, and grief do not exist.

12. When individuals are forced to confront these inevitable experiences in their personal lives, they typically do so without social support and the comfort of participatory rituals or shared meanings. • A pattern of death entirely unfamiliar in the traditional era has hence emerged.

13. What is medicalisation? • Medicalisation is the process of defining an increasing number of life’s problems as medical problems

15. Ivan Illich's critique of the medicalisation of dying • A loss of the capacity to accept death and suffering as meaningful aspects of life • A sense of being in a state of "total war" against death at all stages of the life cycle

16. Ivan Illich's critique of the medicalisation of dying • A crippling of personal and family care, and a devaluing of traditional rituals surrounding dying and death • A form of social control in which a rejection of "patienthood" by dying or bereaved people is labelled as a form of deviance

17. Medicalisation of death • People want to die at home but mostly they die in hospital • Increasingly everybody must “have their chance in intensive care” before being allowed to die • Palliative care started as a response to medicalisation of death but may now be part of the medicalisation process

18. Elements of a "good death" in modern Western culture • Pain-free death • Open acknowledgement of the imminence of death • Death at home, surrounded by family and friends

19. Elements of a "good death" in modern Western culture • An "aware" death in which personal conflicts and unfinished business are resolved • Death as personal growth • Death according to personal preference and in a manner that resonates with the person's individuality

20. Why might medicalisation be a problem? • People are treated when they are “normal” • Non-medical, perhaps traditional, ways of managing difficulties are devalued and even destroyed • We see ourselves as victims and perhaps fail to take action ourselves

21. Why might medicalisation be a problem? • All effective treatments have side effects • Political and social problems demand political and social solutions but may be treated medically

22. Why might medicalisation be a problem? • An increasing proportion of a country’s wealth is spent on health care • Doctors are oppressed by being under pressure to “solve” problems they cannot solve

23. Forces promoting medicalisation • “Patients” • The decay of cultural, particularly religious, ways of managing difficulties • Pharmaceutical companies • Doctors, particularly specialists

24. Forces promoting medicalisation • “In Scotland, where I was born, death was seen as imminent. In Canada, where I trained, it was thought inevitable. In California, where I now live, it’s seen as optional.” • Ian Morrison, former president of the Institute for the Future

25. Forces promoting medicalisation • "In a morbid society the belief prevails that defined and diagnosed ill-health is infinitely preferable to any other form of negative label or to no label at all. • It is better than criminal or political deviance, better than laziness, better than self-chosen absence from work.

26. Forces promoting medicalisation • More and more people subconsciously know that they are sick and tired of their jobs and of their leisure passivity's, but they want to hear the lie that physical illness relieves them of social and political responsibilities.

27. They want their doctor to act as lawyer and priest. • As a lawyer, the doctor exempts the patient from his normal duties and enables him to cash in on the insurance fund he was forced to build. • As a priest, he becomes the patient's accomplice in creating the myth that he is an innocent victim of biological mechanisms rather than lazy, greedy, or envious deserter of a social struggle over the tools of production.

28. Social life becomes a giving and receiving of therapy: medical, psychiatric, or geriatric. • Claiming access to treatment becomes a political duty, and medical certification a powerful device for social control.” Ivan Illich

29. Forces promoting medicalisation • ".....an expanding medical establishment, faced with a healthier population of its own creation, is driven to medicating normal life events (such as the menopause), to converting risks into diseases, and to treating trivial complaints with fancy procedures.

30. Forces promoting medicalisation • Doctors and 'consumers' alike are becoming locked within a fantasy that unites the creation of anxiety with gung-ho 'can-do, must- do' technological perfectibilism: everyone has something wrong with them, everyone can be cured." Roy Porter

31. How to respond to medicalisation • Encourage debate and understanding of medicalisation • Help people understand that diseases are medically and socially created • Help people understand the severe limitations and risks of medicine

32. How to respond to medicalisation • Move away from using corporate funded information on medical conditions/ diseases • Generate independent accessible materials on conditions and diseases • Promote non-medical ways of responding to problems

33. How to respond to medicalisation • Spread knowledge--for example, through the internet • Encourage self care • Resist the constant growth in health budgets