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We know not if any death diminished John Donne, but certainly it diminishes modern medicine, bringing it down a peg or two in its avowed crusade to save any life at any cost. Medical science has taken upon itself such an onerous task for it has convinced itself that death is something that happens for want of something else that the medical science can offer, later if not sooner. Hence the macabre but manifest idea of preserving a cancerous cadaver in liquid nitrogen until such time that a cancer cure arrives, and presto, the Rip Van Winkle can come back to normal life.

Some Consequences of the Causal Mindset

A general conviction that rides the lay, and more so the learned, mind is: If the cause is known, the cure shouldn't lag behind. So the cliches, like unnecessary deaths, preventable deaths, premature deaths. The USA decides that since the life-expectancy of an American is 65, any death prior to that age falls into the premature-and-therefore-preventable lot, totally oblivious to the fact that the magical figure of 65 was arrived at averaging, say, 100+30. Parulkar² , at a recent Rotary meet, hurled a j'acusse at the Rotarians by declaring that any death from heart attack before the age of 80 is YOUR FAULT. Medical men tend to be too poor in biological perspective, with consequences nothing short of tragicomic.

October 10, 1974, the Karolinska Institute awarded the Nobel to Claude, de Duve and Palade with the citation³ that the three together had demonstrated that "what used to be a cell with often mysterious parts is really a sophisticated organisation with units for the production ... of life and units for disposal of worn-out parts, and for defence against bacteria and other foreign organisms." Nowhere is there a mention that the cell has within itself a mechanism to end its own existence, as also of the owner. Little wonder, then that medical curricula, world over, give no room to the most certain event within or without the hospital.

Thanatology that started off with a bang after Kubler-Ross⁴ lifted her pen, has ended with a whimper. The psychodynamics that underline the avoidance that greets thanatology in medical circles is rooted in the continuing faith that sees death as but an avoidable failure of modern medicine. Till medical science chooses to come to terms with the integrality, nay, the cliché-worn but remarkably well-structured inevitability of death, death will continue to be obscene.

The gigantic edifice of modern medicine rests on an ocean of animal blood. The telling words of Burnet⁵ , the immunoNobelist provide the basis of the astronomical animal slaughter: "I believe, however, that one might justly summarise American medicine as being based on the maxim that what can cure a disease condition in a mouse or a dog can, with the right expenditure of money, effort and intelligence, be applied to human medicine." Whatever is American, is global, is Indian, and hence so much of animal-experimentation in India.

Tenet of Causalism and Death

Causalism, as a discipline, has a 2-way tenet: For any causalism to hold water, the cause must be followed by the effect, and, the effect must invariably be preceded by the cause - without loss of time. The ordinary observable fact of the diseased often outliving the disease-free puts paid to the causalistic obsession vis-à-vis death. The italicized part of the causalism's tenet is impossible to satisfy for, any of the great "killers" - coronary, cancer, carotid (stroke) - take a leisurely long time before they dis-ease or kill. This temporal asynchrony between the presence of disease and the moment of death is the most insurmountable waterloo of disease-causes-death mindset.

Natura non facit saltum - Nature makes no leap. With this in mind, read Pickering⁶ : "Thus, the myocardial infarction, the cerebral infarction, or the gangrene of leg which terminates a patient's life may be seen as the final episode of a series which remain silent over a long period of life before they obtrude into his experience and finally terminate it." Please note, in the foregoing, that the so-called cause-of-death is coeval with the moment of death and hence held guilty, although the same disease-process had existed for too long. Talking of atherosclerosis, Boyd⁷ poetizes that it is a song that is sung in the cradle. And the so-called death-causing disease is never single, or isolated. "Most people who die of neoplastic disease," writes Smithers⁸ the noted UK oncologist, "also have a number of other senile changes, which would have carried them off fairly soon in any case."

Once again, Smithers⁸ is unable to free himself from the assumed causal link between the "senile" changes and death, forgetting that many a senile outlives a person in the pink of youth. "She was thirty-one. Not old, not young, but a viable, die-able age." (Arundhati Roy)⁹ . What medical scientists and practitioners fail to see, the poet in Chesterton saw so clearly.

Six detectives went fishing
Down by the sea-side.
They found a Dead Body
And enquired how it died.
Father Brown he informed them
Quite mild and without scorn:
'Like you and me and the rest of us,
He died of being born.'

Isn't DEATH the 5-lettered obverse of BIRTH both covering a coin called LIFE?

DEATH : Designed Event Acclimaxing Timed Happenings

If the whole Earth¹⁰ were to be reduced to the density of a black hole, it will not be larger than a golf ball. If the whole Earth comprises so little of spaceless, pure matter, what to talk of the miniscule men? Alfred Portmann¹¹ , thus, was right when he described animal life as configured time. The configuration, disfiguration, dissolution of human life is time itself. One dies when, they say, one's time is up.

Conception onwards through embryogenesis, fetal growth, birth, milestones, puberty, sexual maturity and decline, reading glasses and arthritis are all a part of more or less precisely timed trajectory. If configuration is precisely timed, so is disfiguration so that you have repetitive statistics of heart attacks, cancer and stroke, with their age-distributions spanning from one end of the lifespan to another. Dobzhansky¹² , the Harvard biologist, calls all stages of human existence as continuing development, whose climactic acme is death. Death is but a step in development, resulting, as some would like to put, in the next birth.

"As a first generalization, it may be said that the length of life itself, the span of the natural life cycle, is one of the organism's most integral characteristics, genetically programmed in some mysterious way by a kind of biologic death clock. Each species has a characteristic average life span. For the mouse, this is two years; for the rhesus monkey, 20 to 25 years; for the African elephant, 70 to 75 years; for the Galapagos tortoise, 100 years; and for human beings, about 85 years. Many years ago, the German physiologist Max Rubner pointed out that the total number of calories burned per gram of body weight and the total number of heartbeats in the lifetime of each of these vertebrate species, including humans, are about the same, despite the great differences in their size and life span. Further, the span of human and other animal life correlates roughly with the size of the brain".

ADAMS, VICTOR AND ROPPER¹³
Principles of Neurology

The Biblical three scores and ten and the Vedic blessings of Satam Jiva Sharada - May you live a 100 years - comprise human life span, being the maximal time that an individual of that species can live. The average life-time of a group of a herd is the life-expectancy - being about 63 in India and 75+ in the West. Yet death, as a programmed event¹⁴ stalks life from conception to 100 years. The very high mortality at conception dwindles to its minimum at five years after birth (herd quality control), is at its lowest from five to fifteen (herd stability), and, then, obeying Gompertz curve, steadily mounts up (herd lysis) for every year of human existence, doubling every eight years, to reach its high between 45-55 years. Death at 19 is as well-timed and programmed as death at 91.

"The common belief that medical science has greatly lengthened life is a misconception, arising from a failure to distinguish between life span and life expectancy." Having so generalised, Adams et al¹³ declare that even if all coronary artery disease were eliminated, life expectancy would possibly be extended by 3.1 years, and if all cancer were eliminated, another 3.5 years. So, even if the circle were squared, and the apple made to fall up, human life-expectancy will remain far short of human life span for most people and will never exceed it. Therefore such Quixotic ideas as No More Dying¹⁵ are good on paper, but totally irrational in reality. Living to 100¹⁶ is the latest in the line of books that presuppose that any death on this side of 100 or 76 or 65 is an outcome of some exercise not taken, some antioxidant missed out, some Methuselah Enzyme¹⁷ not made available to you in good time.

Chronicle of A Death Foretold

As a designed event, death is thoughtful. Strange as it may seem, it is a common experience that an uncluttered mind gets the whisperings of death's imminence at least 3 days in advance. So the Indian scriptures aver. And so does Aries¹⁸ who studied the modes of dying in medieval Europe. Aries records that, before medical men started to claim and assure that they can pull you out of the jaws of death, a foreknowledge of one's death was a common experience. If someone died without communication to others in advance of the would-be-death, such a person was assumed to have had mors repentina - a repentable death. Such a person's burial was not ceremonalised by the church.

The title to this section is the title of a novel by Gabriel Garcia Marquez¹⁹ , the 1982 literary Nobelist of Colombia. In contrast to the macabre plot of the novel, one's Foretold Death is a gentle event, rehearsed and rerehearsed for a lifetime before the final dramatic exit. A human being with life-expectancy ranging from conception to 100 years has the maximum of 4 billion heartbeats and 1 billion breaths. Each heartbeats records the lubb of life and the dupp of death. More significantly, with each breath one first inspires, and then, expires. So you expire every moment of your existence till you can expire no more. Death, in a way, is an end to all dying. And Nature in its infinite foresightedness has organised your psyche to feel death's aura 72 hours well in advance.

You Die, You Aren't Killed

If you don't know how to die, don't worry; Nature will tell you what to do on the spot, fully and adequately. She will do the job perfectly for you; don't bother your head about it!

AMBROISE PARE¹
Of Physiognomy

Killer-disease is a favourite phrase of Reader's Digest writers and of medical conferences. Heart attack is killer No.1, cancer No.2, and stroke No.3, a rating that has remained unchanged for decades, showing that there is some method even in death's madness. Is one killed, or does one die?

As lexicons^20,21 imply, to die is "to cease to live" whereas to kill is "to deprive of life/put to death/cause death of." You die yourself - as an active measure. You are killed - by an external agency that did not allow you to die for, in the first place, it did not allow you to live. A knife, a bullet, a vehicular accident, drowning, even a rope round your neck put by your own hands, the cup of hemlock that Socrates was given - all these arrested your living processes and so you were killed. To kill is akin to quell, meaning to smother, to extinguish. A glowing candle, not yet at the end of the quota of wax, gets blown, extinguished. You didn't die; you were declared dead after you were killed. It's a pity that as yet the lexicons have no word for death by killing. How about quelled = dead by factors that did not allow living?

Thanatologists have talked of, searched for a death hormone but have found none. Malarial parasites causing Acute Respiratory Distress Syndrome (ARDS) or cerebral malaria, sepsis following surgery or trauma, even the virus of Guillian-Barré, one and all secrete no death-causing toxin, but interfere with life-processes. This is where medical science has an edge, a choice. The person did not want to die, and hence could be saved. This classically illustrates the Chinese proverb¹ : A doctor's medicine works on a patient who is fated to survive. This may smack of fatalism, yet the need for the finer distinction between dying and getting-killed necessitates such an approach.

Coming back to the killer-diseases that we all carry with ourselves through life, do they really, can they really kill us? The fact of their being present non-lethally for a long time, the fact that a person with no such disease or such disease in a milder form should die and the diseased/more-diseased should survive denies to these diseases the right of being killers. You die with them; you don't die because of them, since through all your life, and in terms of cytofibral realities, they comprise, what the lovable rascal Mr. Doolittle said of Elisa in the movie is My Fair Lady: "Me own flesh and blood!"

Euthanasia Dysthanasia Tachythanasia

The foregoing has now brought us to the intellectually ripe stage of discussing the art of dying. Dying is the final, active act of the living and therefore it is a mere climax to the sustained, uninterrupted art of living, of savoring joie de vivre, of feeling happy within and without, in communion with whichever God you believe in, or choose to deny.

To die when you are fully fit to live, when you are manifestly in compos mentis et somatis, to die without an identifiable cause rightly so because you were born without any identifiable reason, is to die actively, abjuring the body as an act of programmed will of the body, your final bow to the global audience before, like Rabelais²² , you jestfully declare: "Let down the curtain, the farce is over." Put clinically, you euthanatazie, you die well when you foreknowingly die even when your own doctor felt that you were fully fit to live. Three hundred years before Christ, Aristotle¹ summed up euthanasia succinctly: "It is best to quit life, just as we leave a banquet, neither thirsty, nor drunken."

The lexicographic error is to define euthanasia as 'mercy killing;' a classical example of the bad use of a good word. An editorial in The Medical Journal of Australia²³ pointed out that by conventional standards and by the law as it is, euthanasia means murder: "Behind this is the blunt fact that euthanasia, for all the mildness of its root meaning, in current usage means the active and deliberate ending of a life - that is killing." A British Medical Journal²⁴ editorial written in a similar vein concluded that what now connotes euthanasia had better be replaced by the concept of assisted suicide. The conundrum is traceable to the fact that, as a cover for our conceptual inadequacies, euthanasia has been forced to mean the monstrous hybrid called mercy-killing.

Many a thought is unthinkable without appropriate vocabulary and a frame of reference. Let us clear the seemingly insoluble confusion and to return to euthanasia its pristine benignity and glory. Towards this, it needs to be realised that we indispensably need new words to keep abreast of new ideas. The intellectual cycle of new concepts spawning new terms that in turn beget newer ideas is the heartthrob of expansion of mental horizons.

Eu- as a prefix clearly implies 'good' or 'well'; thus we have eupepsia, euphoria, eugenics and so on. Euthanasia then means good death, and not, as the British Medical Journal²⁴ erroneously assumed, an 'easy death.' What the so-called euthanasia or mercy-killing purports to provide is a swift end to the process of dying, a quick death that could logically be called tachythanasia (tachy meaning 'quick' or 'rapid'). When Sigmund Freud suffering at 83 from an obstinate oral carcinoma for 17 years was injected with four centigrams of morphine by his physician-friend Max Schur, he was not euthanatized, but tachythanatized. Tachythanasia could be defined as a medically-eased-death.

The distinction between euthanasia and tachythanasia is in order: euthanasia is self-earned, self-willed dignified departure unsullied by any medical intervention or condescension. Tachythanasia is a medically offered facility that helps to expedite the task a patient is already engaged in - protracted dying. It should be clear that tachythanasia is not assisted suicide. Jumping into the Thames or off the Eiffel Tower also is not tachythanasia. It is suicide. Dysthanasia, a bad death, on the other hand is, in the opinion of many, a common sin of modern medicine. Medical technology has made dying lonely, gruesome, dehumanised, mechanical, obscene and immensely troublesome. The fact that modern medicine has chosen to distort euthanasia to suit itself, and has not bothered to label as dysthanasia much that it does, speaks of the current intellectual crisis in medical thinking.

The balancing opposite of, and the highway to, euthanasia is euvivasia - a good life, a yea-saying to life that ends with a yea-saying to death. Describing euvivasia is too tall an order, but an attempt may be made by weaving the theme around Schweitzer's concept - reverence for life. The meaning of existence is to preserve unspoiled, undisturbed and undistorted the image of eternity with which each person is born. A genuine sense of reverence for the elements within and around us can help each one of us steer our life towards imparting to our existence a meaning, towards living a good life culminating in a good death. Only an euvivatic can be, climactically, euthanatic.

How Does One Die?

A way of defining death is to define life; from the womb to the tomb. The human body is an assemblage of different, highly specialized systems that are reciprocally connected to one another and to the external world by the universal network of blood vessels that derive their life-giving throb from a vigorous central pump called the heart. Even the nascent human embryo, which starts as an amorphous mass of cells in no way recognizable then as a human form, presages this need: the very first functioning system it fashions is the heart and its blood vessels that are present by the fourth week after fertilization, at a time when no other system is anywhere around. Students of the chick embryo can see, by the forty-fourth hour of the development of a chick, the tiny, bright, red heart with its blood vessels as the island throbbing with life in the otherwise absolutely featureless egg. The cell-to-cell universality of the circulatory system - heart and blood vessels - provides it with the pristine primacy of enlivening and interconnecting all other systems, giving each of them a meaning, a purpose, be it in a fully health individual, a deeply comatose patient, or a crusader fasting to death. We can generalize that the heartbeat - as felt over the heart or the peripheral pulse - representing active circulation of blood is the lowest common, debate-free denominator of life. The heartbeat is life. Its absence is death. Human life, in a manner of speaking, is a brief spell of existence between two heartbeats, man's first and man's last.

The unrestricted, unconditional and universal applicability of the above definition of life and death based on the presence or absence of a functioning circulatory system may be realized from the fact that (a) the anaesthetists who take humans into a deep, reversible coma must keep the circulatory system going, (b) the cardiac surgeons who, during surgery, put the heart and/or lungs out of action must maintain the circulatory system by machines, and (c) the resuscitators who bring back to life a person who has had a cardiac arrest or has been buried and frozen in snow, must, above all, revive the circulatory system. If blood is circulating, life is. If not, death is. Needless to say, the above definition of and approach to the ascertainment of life or death is applicable with ease by everyone, everywhere.

Knowing how one's first heartbeat is made to arrive to eventually make oneself may be the best way of comprehending how one is unmade for the final heartbeat to come to pass. This entails referring to the Indian concept of causal or celestial body or Karan shareer, subtle body or Sukshma shareer, and gross body or Sthula shareer. One's causal body is forever, having had had no need to be born and hence having no compulsion to die. Biologic facts fully support this superb concept that is encapsulated in Lord Krishna's four words: Na jaayate mriyate vaa.

When, in the celestial scheme of things, one's time to be a body arrives, the causal body, as an integral part of the cosmos, orders the formation of the subtle body. The subtle body, as it were, forms the invisible container into which the body matter is poured. The content assumes the exact shape of the container to accord to an individual tritimensional uniqueness. The nearest evidence of the subtle body is the perilife aura that Kirllian²⁵ photography so clearly demonstrates. The subtle body is one's matrix, one's angel mother, one's mind, one's interface with the cosmos. And in terms of the first and the subsequent heartbeats, it is the subtle body that powers the heart to do what it does.

When one's time is up, it is the subtle body, at the command of the cosmic causal body, that winds up the game and you declare that the heart has arrested. The sequence ab initio and ab ultimo is clear: The subtle body arrives first to initiate the heartbeat and the game called life; the subtle body and the final heartbeat leave first, and then the rest of the gross body follows suit. The universal condemnation of suicide is based on the realisation that the deliberate killing of the gross body leaves the subtle body in a lurch with consequences that are right now only in the realm of imagination.

In a life-threatening situation following an accident or infection, the subtle body plays a stellar role. It comes to the rescue of the doctor and the diseased to allow vis medicatrix naturae to play a positive role and thus to pull the chestnuts out of fire. No wonder, Ambroise Pare's lasting legacy - Je le pensay, et Dieu le guarit¹, meaning, I dressed him and God healed him - still dominates the medical scene.

Perlstein¹ , in the early part of the 20^th century, uttered an assuring aphorism: "If your time hasn't come, not even a doctor can kill you." It was around Perlstein's time only that the truth of his words was experienced in a telling fashion. In 1939, acetylcholine was injected intravenously as a therapeutic convulsant by psychiatrists in the justified expectation²⁶ that the ensuing fits would be less liable to cause fractures than those following convulsions caused by leptazol injection. Recovery rates up to 80% were claimed in various psychotic conditions. Enthusiasm however began to wane when it was realised that the fits were due to anoxia following cardiac arrest. "Forty seconds after the injection the radial and the apical pulse were zero and the patient became comatose. The pupils dilated .... In about 90 seconds, flushing of the face marked return of the pulse." The trial reports many cases and no death which means all the cardiac arrests returned to life. They did so because the acetylcholine had left the subtle body unmolested. May be this is how cardiac message gets rewarded, and the critics of modern medicine are able to declare that many a person survives despite the doctors.

The Moment of Being Born There

Rajan Parab, an intern at Seth G. S. Medical College, Mumbai died in a swimming accident while saving a drowning cousin's life. The small memoir published in his name gave his time of his birth as "Born Here" and of time of his passing away as "Born There." The word death did not feature anywhere.

One short sleep past,
We wake eternally.
And death shall be no more;
Death thou shalt die.

The compassionate causal and the subtle bodies, thoughtfully, create for each dying person a fleeting but eternal-looking moment that heralds either the next "birth hereafter" or being "born there", or, if you are prepared a birth-and-death-free eternity.

The Tibetan Book of the Dead²⁷ and Indian thought which is in agreement with it, have it that each human being, around the time of death, is bathed in a light - 'brighter than a thousand suns' as the Gita puts it - which gives a glimpse of one's true universal, eternal nature. Having been thus taken to the edge of the infinite, the human being is now given a choice: 'Ask and it shall be given.' Most human beings, because of the state of bondage, end up wishing this and that, and the cosmos obliges; the cycle of birth and death continues. But, on the other hand, if the realization I am Brahman has truly penetrated one's being, then one asks for nothing, for how can a Brahman itself ask anything from Brahman? And that, the scriptures say, is the basis of nirvana, moksha, or eternal liberation.

Gould²⁸ has talked of animal life measurable in terms of heartbeats and breaths allotted. Neil Armstrong¹ , the pioneer astronaut put it heartily: "I believe every human has a finite number of heartbeats." A breath, a heartbeat is a measurable, calendar-event that serving as a currency of life allows the temporal measure of a given life.

Thought, on the other hand, is abstract, immeasurable. Its presence or absence, makes little difference to the body's inner clock. Hence the long life that a brain-dead person may have. In recent times, a well-known son-in-law of a leading doctor of Mumbai returned from Japan with encephalitis, turned brain-dead, and survived, through impeccable nursing, for 20 years over.

The issue of brain-dead is important in the current times that sees them as "cadaveric donors." Brain-dead people are heart-alive, and therefore not dead. The solution to the current acrimonious debate about brain-death is the medical candor that sees a live individual as live, and not as dead just because a part of the brain is not functioning. Such an unconscious patient is a live donor, like any other live donor, and should be respected and treated as such.

Cooke²⁹ , writing in extensive details about doctors in The Oxford Companion to Medical Studies, ends on a very humble, realistic note: "It needs to be more generally recognised that most of medicine is about relief of, and comfort in, suffering, and in the main very little to do with saving life." Wildavsky³⁰ , another physician on the western side of the Atlantic, writing on (medical men and manufacturers are) Doing Better and (patient are) Feeling Worse, is equally candid: "The best estimates are that the medical system (doctors, drugs, hospitals) affects about 10 per cent of the usual indices for measuring health: whether you live at all, how well you live, how long you live ... Most of the bad things that happen to people are at present beyond the reach of medicine."

Between Cooke's "very little" and Wildavsky's "10 per cent" let us see where and how really medical science saves life. Be it an obstructed labour, congenital tracheo-oesophageal fistula or duodenal atresia, polytrauma, angioneurotic oedema, increased intracranial tension, malignant hypertension, hypovolaemic shock, coronary infarction, obstructed bowel, infective peritonitis, cerebral malaria, or ARDS, modern medicine with its in-depth knowledge of normal and disturbed physiology, does its best to restore the disturbed physiology to status quo ante, without so often wanting to or being able to remove the precipitating cause. Thus it gives to the afflicted individual the right-to-live, and thus in a way, the right-to-leave. The latter explains why after the best of physiological restorations the person decides to take leave of the doctor and the world.

The entire article begs to have a heuristic value - raising more questions than answers. The following ten points - decalogue - should prove useful.

Relativity is at the heart of temporalities of all sorts. The Webster's²¹ defines relativity as (a) The quality of variability arising from necessary connection with or reference to something contingent (the ~ of beauty to taste or of rights to law), (b) the mutual dependence or concomitant variability of two or more related things, (c) dependence on the subjective nature of man or upon limitations and peculiar character of individuals (the ~ of knowledge). Time (and space) is, a la Einstein, the free creation of the mind, and has remained free of any precise definition. There are too many times to contend with, for they are all relative.