In the eighth century, when the Abbasid Caliph Harun ur Rashid ruled a vast empire from the storied city of Baghdad, people on the average lived only into their early forties if they were fortunate enough to have survived various pandemics and early childhood diseases. The legendary Caliph himself lived for only about 46 years.

Millions of women died young during child birth by bacterial infections such as puerperal fever. Over time, and especially during the past century, there has been a dramatic increase in the human lifespan. In Pakistan, the current lifespan is estimated to be 60-65 years, while for Canada and Japan the figure approaches 80 years.

Most of the gains in longevity have resulted from a spectacular reduction in infant mortality, aided by the advent of modern immunisation methods, the availability of antibiotics, and later in life from an appreciation of the beneficial role of a healthy lifestyle. There is an ongoing debate among scientists and geriatricians, whether the human lifespan has an upper ceiling, and if so are we about to reach it. Empirical evidence suggests that while more people are living longer, the absolute individual lifespan has not varied significantly in centuries.

The increase in longevity has not been entirely a blessing. It has raised myriad epidemiological, ethical and eschatological issues. Many people especially those growing up in the affluent western societies have been fed exaggerated stories about golden retirement years, an idyllic period lasting until the end of life. The reality, however, is often very different. In many cases, the twilight years are spent combating a constellation of degenerative illnesses and infirmities. An estimated half of the population in their eighties suffers from Alzheimer’s disease or some other form of irreversible dementia, and needs full-time care.

In the US, where this article is being written, it is estimated that a third of all medical expenses for treatment of elderly patients, paid by the Government Insurance Plan known as Medicare, are incurred in the final year of life and fully one-third of that in the last month. The spectacular advances in the prevention, diagnosis and treatment of disease in the past century have created the illusion that somehow the medical profession can help us vanquish death or at least keep it at bay indefinitely. These perceptions are sustained by the advent of medical devices such as defibrillators, feeding tubes, ventilators and other life-supporting equipment that can keep patients alive for weeks, months and, in a few cases, years albeit with little or no quality of life.

In the past, victims of catastrophic diseases did not survive long, however powerful or rich, especially if their vital organs, their respiratory system, heart or kidneys failed. In the Middle Ages, death came swiftly, although not painlessly, caused by such dreaded infectious diseases as bubonic plague, cholera and typhoid. Catherine the Great, the Czarina of Russian (1762-1796 AD), famed for her dazzling conquests and number of lovers, suffered a stroke at age 67 and went into a coma and died less than 24 hours later. There were no artificial support mechanisms to keep her alive, no feeding tubes and no respirators.

The situation is very different today. The former Israeli Prime Minister, Ariel Sharon, known for his antagonism to Palestinians, suffered a massive hemorrhagic stroke in January 2006. Soon thereafter he lapsed into a coma and today remains in a vegetative state. Yet, technically, he is still alive, six years after his stroke, attached to expensive life-support equipment and helped by round-the-clock nursing care. Recently, one of his close friends and confidante commented that it would not have been Sharon’s choice to be kept alive in this demeaning state.

In a highly publicised case, Teresa Shiva, a housewife in Florida, suffered a massive stroke in 1990 that led to extensive brain damage, causing her to slip into a coma. Her doctors diagnosed that she would never regain consciousness. However, she was kept alive in a nursing home by feeding tubes and other therapeutic measures, as her life support could not be removed without the family’s permission. After eight years, her husband, despaired of her recovery, partitioned that the tube be removed and she be permitted to die in dignity.

The motion was opposed by her parents, however, who claimed that she still had some residual consciousness. The legal wrangling continued for some years until the court finally ruled in favour of the husband, and the feeding tube was withdrawn. She died two weeks later, having lived in the comatose state for a total of 15 years.

How long should patients be kept alive by artificial means, at great expense and effort, when there is no reasonable chance that they will ever survive on their own? No clear answer exists. However, in many cases the heroic measures instituted only postpone the inevitable outcome by a few days or weeks. In the US, one-third of $2 trillion of the annual health care cost results from unnecessary tests, unneeded treatments and useless care delivered at the end of life. Much of it is driven by fear of malpractice suits brought by the family, and the practice that in some cases doctors are paid by the number of tests they order.

Of course, all of us wish that our lives would end at a ripe-old age, peacefully and without pain. In reality, it often does not happen. Instead, life ends by tortuous, slow stages. One only has to visit any large modern hospital, even in Pakistan, where one can observe patients in the intensive care units shackled to tubes and intimidating monitoring machines, which in most cases bring only temporary reprieve. And, the bereaved family is left to face hefty hospital bills. At some stage, when there is no hope of survival, it might be best to say no to all artificial means of support and let the patient go in serenity and with dignity.