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Updated 28 June 2013

Mandela and the Old Man's Friend

There is a real risk that Nelson Mandela's own personal best interests could be overlooked because we find it hard to let go of him, says CyberShrink.

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Of course we're all worried by the return to hospital of our most treasured senior citizen, with a recurrence of his chest infection, and hope that he will recover comfortably to be able to enjoy his remaining time. His illnesses raise a number of important questions regarding what sort of care we might personally prefer in such circumstances, for ourselves or a loved one.

The great Canadian physician, Sir William Osler, considered by some as the Father of modern medicine, first called pneumonia "the old man's friend" (indeed it was eventually the cause of his own death). In his great textbook, he wrote: "Pneumonia may well be called the friend of the aged. Taken off by it in an acute, not often painful illness, the old man escapes those 'cold gradations of decay' so distressing to himself and his friends."

Pneumonia is called the old man's friend because, left untreated, the sufferer often lapses into a state of reduced consciousness, slipping away peacefully in his sleep, a fairly swift and dignified end to a period of what can otherwise often be considerable suffering, from illness and treatment. The more so when someone is sinking into senility, as dementia, part of the eventual fate of so many of us, diminishes them steadily, so that each day there is less and less of the much loved person there.

Must all infections be aggressively treated?

A study of severely demented patients in Boston recently confirmed that nowadays all too often that "friend" is vigorously fought with antibiotics. We need to ask ourselves whether we are treating an illness just because we can, or because we really ought to do so. Are we prescribing the antibiotics for fear of seeming negligent, or to help us feel we "did all we could", or because it genuinely benefits the person herself? 

This study showed that two out of three severely demented patients received antibiotics. Testing for severe impairment of functioning, with possible scores ranging from 0 to 24, three out of four of these people scored zero. Their ability to communicate verbally, ranged from non-existent to minimal. When we speak of quality of life, what actual enjoyable quality did these lives have for them?

In such circumstances, is the treatment genuinely prolonging life, or merely prolonging death, perhaps even prolonging suffering? If we ourselves were doubly incontinent, wholly unable to care for ourselves, and unable to recognise or speak to loved ones and friends, would we really want such treatments?  At this stage we're unable any longer to speak for ourselves, and few of us leave Advance Directives specifying what we wish to be done, and if we did they'd probably not be recognised or obeyed.

In America, in 2005 Medicare spent $ 91 billion (expected to rise to $ 160 billion by 2010) caring for people with Alzheimer's. Using antibiotics in such situations, especially repeatedly, adds to the growing problem of antibiotic-resistant germs, increasing the risk to all other patients. Unless carefully thought-through public and professional policies are devised and applied, decisions are usually made by default, without thought, and for the worst results.

Peace to Madiba
In Madiba's instance, we really don't know the situation. The style of communications about his health has improved marginally, but we know that there's been a deliberate policy of supplying us with as little information as possible, and we've been deliberately misled at certain times in the past. We hope sincerely that all decisions about his health and treatment are being made exclusively in his own best interests, in line with any wishes he may ever have expressed in this regard, and without other people's personal and political interests being allowed dominance.

Doubts about this were raised in the recent tragic farce when a senior ANC delegation, led by the President, visited Mandela, accompanied by TV cameras. Most viewers were horrified to see a virtual shell of the great man, sitting motionless and unhappy, surrounded by jolly visitors chatting over him. The whole episode showed a marked lack of respect. Telling us this immobile figure was fine, and had been chatting and telling jokes, made most viewers sick with disbelief.

Mandela is a unique human being. Nobody alive on earth is more highly valued and respected. He has led a very long and often highly stressful and unpleasant life, and we are all fortunate that he lived long enough to bring joy and hope to us all. There is a real risk that his own personal best interests could be overlooked because we find it hard to let go of him, because we might not want to allow him to leave us. He represents so much that we value, and which we know is very scarce. He was the single political leader in the world, who behaved as everyone wishes all political leaders would behave.

He should not be considered purely as the last (or perhaps first?) specimen of an exceedingly rare species, to be kept alive at all costs to himself, for the satisfaction of the rest of us. Rather let us express our fondness by learning from the great example he set us in so many ways, by following his lead. None of us will ever truly live up to him, but let us create a hundred, a thousand more Madibas, in his honour.
 
 
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