“My whole life long I’ve

sharpened my sword

And now, face to face

with death

I unsheathe it, and lo...

The blade is broken...

Alas!”

“Death Poem” of Dairin Soto, Japanese Monk (died 1568)

A few days after I had been diagnosed with Covid-19, news came in our school class fellows’ WhatsApp group of the death of a friend’s father. I was caught up in our own medical emergency so had not reached out to him at the time. Once I finally got hold of him on the phone, I discovered that both his parents had contracted Covid and his mother was still fighting for her life in an ICU. I offered whatever words of consolation I could and hung up the phone.

All of a sudden, what my family and I were going through did not seem so overwhelming after all. My friend, T, belonged to a business family and we had met when we had been medical students together. Like many of our class fellows, disillusioned with the prospect of being a practicing doctor in Pakistan, he had bid farewell to the profession and joined another one of our class fellows, an old and very dear friend since school days in starting a textile business. Since I had left for post-graduate studies in the US soon after graduating medical college, we had lost touch but, after some initial bumps, both friends thrived and became successful businessmen in Lahore. I had re-connected with T after I came back to Lahore and we had remained in touch off and on. His children were older and I had had the pleasure of attending his daughter’s wedding a few years ago and enjoying the feeling of becoming an ‘elder’ myself.

And now here we were: in the middle of Lahore’s Covid nightmare with, presumably, a son’s worst fears coming true: one parent dead, the other struggling for life in an ICU and no guarantee that his own family or he himself would be spared.

A few months ago, I had witnessed another colleague at my hospital going through a similar nightmare. Her elderly father had ended up in an ICU with Covid and, as the only doctor in her family (a situation with which I am intimately familiar), she had become the one in charge while he struggled for life. When it appeared that there was little hope left for him other than to put him on a ‘ventilator’ (an artificial breathing machine), I argued strongly against it. In addition to the fact that my friend’s father had himself forbade her to do it, the survival rate for those who are placed on ventilators because of Covid-related breathing problems is next to nil. Perhaps less than 5 percent of people survive. For most, it means simply prolonging their agony and the pain of their families.

Refusing to place a parent on a ventilator is, of course, a decision that no child should have to make; especially not while their parent is gasping for breath in front of them.

This is why we have always argued strongly at our hospital recently for advance ‘Do Not Resuscitate’ orders.

Over the course of my career, I have developed a strong interest in end-of-life care. Another term for it is ‘palliative’ care: offering treatments to terminally ill patients that keep them comfortable and pain free (but are not invasive, painful and do not unnecessarily prolong life).

Even before Covid hit, the issue of sophisticated medical interventions to prolong and preserve life was becoming an urgent one. The basic question is simple: How far should doctors go in offering various medical treatments to a patient keeping in mind what the likely outcome will be?

Even before Covid hit, the issue of sophisticated medical interventions to prolong and preserve life was becoming an urgent one. The basic question is simple: How far should doctors go in offering various medical treatments to a patient keeping in mind what the likely outcome will be?

In the mid-1990s as a young trainee psychiatrist in the USA, I was appalled by what I saw in hospitals. Elderly patients, some of them in their 90s or older, physically and mentally completely debilitated, sometimes not even aware of being awake or alive being poked, punctured with injections, being given painful, unnecessary (it appeared to me at the time) treatments with no hope of any meaningful recovery simply as a way to prolong their lives. Even then, as a young trainee doctor, I had been very outspoken about my opinions that this was wrong, so much so that one of my professors at the time used to jokingly call me ‘The Executioner’. My anger was also driven by what I saw as a tremendous waste of medical resources which could perhaps be profitably spent on interventions that could benefit so many other people, younger people, people who actually had a chance at leading meaningful lives. Having seen young, otherwise healthy people die of easily preventable diseases in Pakistan due to poverty, it infuriated me to see vast amounts of money being ‘wasted’ (as I thought), on people in the US who could never even sit up again due to old age and infirmity, let alone lead a normal life.

Since coming back to Pakistan over 10 years ago and now being a senior doctor myself, my views have not changed. If anything, I have become more outspoken about conserving our scarce medical resources so they can be deployed for maximum effect.

But this is a public health perspective. It would not help my friend if his mother’s condition deteriorated further and doctors advised that she had to be put on a ventilator to help her breathe. Even though the cost of being on a ventilator in a private hospital in Lahore could run into hundreds of thousands of rupees daily, how could a son refuse?

My friend and his family were middle-class people who had money for medical care. What about the millions of people in Pakistan who cannot even scrape together two meals a day, let alone buy medicines or medical care? Who was looking out for them?

As someone commented the other day, Covid has not broken our healthcare system. It has simply exposed how broken the system was. And, like the Japanese monk who finds his sword blade broken after a lifetime of preparation, most doctors in Pakistan eventually discover that their medical expertise, no matter how sophisticated, runs up against the cruel reality of a barbaric and unjust economic and social system.

(To be concluded)

The writer is a psychiatrist, author of Love and Revolution: Faiz Ahmed Faiz and a Trustee of the Faiz Foundation Trust.   He can be reached    at    ahashmi39@gmail.com and tweets @Ali_Madeeh