Seamus O'Mahony


Reviewed by Mira de Vries

“We have lost the ability to deal with death” reads the super-title on the dustcover.

The author is a gastroenterologist at a large (he calls it busy) university hospital in Cork, Ireland. Death is part of his daily routine.

He posits that about half of all deaths occur in hospital, less than 20% in nursing homes, a similar figure “at home” and a tiny 5% in hospices. The unmentioned miscellaneous rest is presumably unanticipated death, which is not relevant to the theme of this book.

Hospice care is a fairly new phenomenon, dating back only as far as the eighties of the previous century. Some physicians as well as patients oppose it as they see it as “giving up.” O'Mahony endorses hospices. They are equipped to provide the kind of end-of-life care that in former times was provided by the family, but today’s families can often not cope at home. He refers to a study that found that moribund patients cared for in a hospice rather than in a hospital lived, on average, 25% percent longer, which apparently means that the treatments employed in the hospital are more likely to shorten than extend life. However, in spite of his enthusiasm for hospices, the author believes that “‛palliative care’ should be at the centre of what all doctors do.” (his italics)

Hospital deaths are highly medicalized. That is what hospitals are for. You cannot expect the – usually young, overworked, and under-experienced – physician confronted with a dying patient in the emergency room to refrain from initiating the invasive procedures that rob the dying of a peaceful death. S/he is simply doing what s/he was trained to do. Not doing it could result in disciplining. One of the reasons for so many medicalized deaths in hospital is that patients, physicians, and family entertain delusions of death being defeatable, that all illness is potentially curable.

Intensive Care Units are considered the epitome of technology, but actually, the author points out, they are a relatively pleasant place to die, with their high level of attention. Much worse is death in the messy, squalid, chaotic, noisy, unprivate hospital corridor.

Nursing homes send their elderly dying tenants to hospital to spare themselves the hassle of filling out the forms, facing the family, and taking responsibility.

O'Mahony criticizes a general practitioner who publicly complained about the way her dying patient was treated in hospital thusly:
“If [she] was so concerned about her elderly patient, she could have exercised her right as the patient's GP to resist her admission to hospital and simply have treated her at home, in her own familiar environment, without the clot-busting drugs and other nasty things doled out by the uncaring hospital.”
Hospitals, he posits,
“have become a dustbin for all sorts of societal problems, not just dying ... Ireland has a long and unedifying tradition of medicalizing social problems. At one period in the mid twentieth century, the country had proportionately more people (2 per per cent of the entire adult population) in longterm psychiatric care than Stalin’s Soviet Union. Many of these ‛patients’ had no psychiatric illness as such.”
Though not directly related to his subject of medicalized death, this gastroenterologist's offhand position on psychiatry is worth mentioning because it is by the (dis)grace of somatic medicine which tolerates it as a colleague specialty that the shameful sham of psychiatry continues to exist. If physicians would boycott psychiatry and refuse to cooperate with it, the way they boycott alternative medicine, it would be forced off the medical market.

Elsewhere the author writes,
“We are now also expected to police lifestyles that others disapprove of.”
Refreshingly, he follows,
“... a doctor’s role is limited: our job should be the treatment of illness.”
I would change that to the healing of illness. When illness cannot be healed, treatment other than palliative is not appropriate, which is precisely the main tenet of his book.

An entire chapter is devoted to cancer, a disease which in spite of Nixon’s “War on Cancer” remains resistant to cure. Most cancer treatment is futile, causes unnecessary additional suffering and enormously wastes resources. The cancers that seem to be cured were not life-threatening to begin with. He quotes Richard Smith, former editor of the British Medical Journal who suggested that “we should ‛stop wasting billions trying to cure cancer’.” I cannot help but agree with this sentiment. At the same time I have heard firsthand of cancer patients in my country (Netherlands) who were given up and refused further treatment, whereupon the family moved them to a different hospital, where they were sufficiently patched up to be able to return to their former lives for another several years.

He states that
“despite all the advances in genetics, including the sequencing of the entire human genome, there have been precious few applications for treatment of cancer and other serious diseases.”
I suspect that “precious few” is a euphemism for no. His further contention that
“basic science has benefited from the Human Genome Project”
can probably be read as people who earn their livings in the field of science have benefited...

Advance directives are commonly ignored and “provide endless potential opportunity for conflict.” Furthermore, what seems unwanted at the moment such a directive is composed may be fathomable when the time actually comes.

Many of O'Mahony's dying patients are alcoholics younger than 50. He is as concerned about their dignity as he is about that of every other patient.

He has no need for euthanasia or its variants.
“I cannot recall a single patient, in over thirty years of practice at the front line, who wished I had been able to ‛assist’ [him to die].”
Some of his observations apply not only to medical care around death, but to medicine in general. For instance, he states,
“Doctors, by the nature of their selection and training, are conformist... a good doctor sometimes has to tell a patient things they do not want to hear. ... it is much easier ... to order another scan than to have the Difficult Conversation.”
He speaks of  “a deluded optimism about the benefits of medical treatment ... disguised as ‛giving hope’” which abounds among lay people as well as physicians. “Irrationality pervades all aspects of medicine.”

He discounts the idea that physicians can have or be taught the skill of informing a patient or family of hopelessness in a way that will make the bad news palatable. The much touted empathy, too, cannot be taught. He rejects advice for physicians to “stray from their core professional duties into uncharted waters, to take on roles such as spiritual adviser, social worker, life-coach, friend.”

He is surely right that “Families and patients ... may lack the necessary education and medical knowledge to make truly informed decisions” and “informed consent is a legalistic fantasy.” However, physicians are not necessarily in a better position given the pressures under which they operate. “[D]octors routinely subject their patients to treatments that they wouldn’t dream of having themselves.” MeTZelf advocates inclusion of medical education in the general school curriculum.

For the sake of brevity I have not covered all the thought-provoking subjects O’Mahony discusses, for example his views on longevity. I can but highly recommend reading this book. The language is comfortable, not clogged with medical jargon. To handle the few medical terms used, a glossary is provided. Some of the news stories to which he refers will be unfamiliar to the non-UK reader, but in this age of the Internet anyone wishing to know more about them can readily find the information.

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