On the Reasons Not to Treat Terminally Ill Patients
The idea that one's life span is fixed can also be used for the opposite argument: that treatment cannot effect cure because a patient's life span has come to an end (gatāyus). Caraka says as much in Ind.11.27: “The four pillars (even when) united and endowed with effective qualities are useless for one whose lifespan has come to an end.”
The medical authors give two essential arguments or explanations of why a dying patient should not be treated. The first argument is that treatment would be futile since it would have no effect: the patient's case is hopeless. The medical authors explain the ineffectiveness of medical treatment not merely as a result of the end of an allotted life span, but as an effect of active intervention by hostile entities. Vāgbhaṭa, for example, warns that “one who is dying is approached by Yama's messengers and demons and so on, which destroy the potency of medicines. Therefore one should abandon him.”373
Note that this argument does not even allow for the possibility of palliative care for the dying, that is, any form of treatment that concentrates on reducing the severity of disease symptoms rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. It seems that the line of reasoning is that since nothing can be done, nothing should be done.
The second argument or explanation pertains to the consequences failed treatment would have for the physician. As in their statements regarding treating those who are in some sense socially unacceptable, the medical authors maintain that treating a terminally ill patient would damage a physician's reputation. Caraka, for example, explains that “were a physician to treat anincurable disease, he would inevitably suffer the loss of wealth, knowledge, and renown and would meet with censure and rejection.”374Cakrapāṇidatta refers to this passage in his comment on Caraka's last statement in his four-pillar definition (Ca.Sū.9.26) regarding a physician's detachment from those who are approaching death. Cakrapāṇidatta says: “In this case, indifference is necessary; under this circumstance, medicine should not be administered, and so (p.114) on, for fear of damaging one's reputation.”375 In another place, Caraka notes that a physician who attends upon a patient “whose strength, flesh, and blood are too depleted, who is afflicted with an incurable disease, and who shows the signs of impending death…gets saddled with a bad reputation.”376 Suśruta gives equal warning: “By treating someone whose life span has come to an end one would suffer failure in society. Hence, a skilled physician should observe the signs of impending death with care.”377 There is one dissenting voice on this topic: Discussing As.Śā.7.29–31, which recommends that a terminally ill patient should be treated up to his last breath, the commentator Indu states that a physician need not worry about damaging his reputation.378 This, however, is the exception to the general rule.
Strong social forces seem to be at work here: a bad reputation, censure and rejection, failure in society, and loss of wealth, knowledge, and renown. Note that the reasons given for not treating terminally ill patients are all about the consequences for the physician, while no reasons are given that refer to the patient's welfare. There are a number of possible explanations why treating someone about to die could be seen as a disreputable action. For example, if treatment could not but fail, it could be seen as an unnecessary harassment of the helpless patient. It could also be argued that treatment would incur pointless costs, and that false hopes of recovery would be raised in the patient and those close to him. However, none of these reasons are explored by the medical authors or their commentators. Instead they frame this topic as a discourse on career advice, as it were. From the physician's point of view, treating the moribund must fail, and this means the physician was unsuccessful. Success and failure are absolute terms, with success equalling cure, and thus fame and wealth for the physician, and failure equalling the patient's lingering illness at best, and death at worst, either of which entails a bad reputation and perhaps loss of livelihood for the physician
The idea that one's life span is fixed can also be used for the opposite argument: that treatment cannot effect cure because a patient's life span has come to an end (gatāyus). Caraka says as much in Ind.11.27: “The four pillars (even when) united and endowed with effective qualities are useless for one whose lifespan has come to an end.”
The medical authors give two essential arguments or explanations of why a dying patient should not be treated. The first argument is that treatment would be futile since it would have no effect: the patient's case is hopeless. The medical authors explain the ineffectiveness of medical treatment not merely as a result of the end of an allotted life span, but as an effect of active intervention by hostile entities. Vāgbhaṭa, for example, warns that “one who is dying is approached by Yama's messengers and demons and so on, which destroy the potency of medicines. Therefore one should abandon him.”373
Note that this argument does not even allow for the possibility of palliative care for the dying, that is, any form of treatment that concentrates on reducing the severity of disease symptoms rather than striving to halt, delay, or reverse progression of the disease itself or provide a cure. It seems that the line of reasoning is that since nothing can be done, nothing should be done.
The second argument or explanation pertains to the consequences failed treatment would have for the physician. As in their statements regarding treating those who are in some sense socially unacceptable, the medical authors maintain that treating a terminally ill patient would damage a physician's reputation. Caraka, for example, explains that “were a physician to treat anincurable disease, he would inevitably suffer the loss of wealth, knowledge, and renown and would meet with censure and rejection.”374Cakrapāṇidatta refers to this passage in his comment on Caraka's last statement in his four-pillar definition (Ca.Sū.9.26) regarding a physician's detachment from those who are approaching death. Cakrapāṇidatta says: “In this case, indifference is necessary; under this circumstance, medicine should not be administered, and so (p.114) on, for fear of damaging one's reputation.”375 In another place, Caraka notes that a physician who attends upon a patient “whose strength, flesh, and blood are too depleted, who is afflicted with an incurable disease, and who shows the signs of impending death…gets saddled with a bad reputation.”376 Suśruta gives equal warning: “By treating someone whose life span has come to an end one would suffer failure in society. Hence, a skilled physician should observe the signs of impending death with care.”377 There is one dissenting voice on this topic: Discussing As.Śā.7.29–31, which recommends that a terminally ill patient should be treated up to his last breath, the commentator Indu states that a physician need not worry about damaging his reputation.378 This, however, is the exception to the general rule.
Strong social forces seem to be at work here: a bad reputation, censure and rejection, failure in society, and loss of wealth, knowledge, and renown. Note that the reasons given for not treating terminally ill patients are all about the consequences for the physician, while no reasons are given that refer to the patient's welfare. There are a number of possible explanations why treating someone about to die could be seen as a disreputable action. For example, if treatment could not but fail, it could be seen as an unnecessary harassment of the helpless patient. It could also be argued that treatment would incur pointless costs, and that false hopes of recovery would be raised in the patient and those close to him. However, none of these reasons are explored by the medical authors or their commentators. Instead they frame this topic as a discourse on career advice, as it were. From the physician's point of view, treating the moribund must fail, and this means the physician was unsuccessful. Success and failure are absolute terms, with success equalling cure, and thus fame and wealth for the physician, and failure equalling the patient's lingering illness at best, and death at worst, either of which entails a bad reputation and perhaps loss of livelihood for the physician
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