Active aging vs dying

One of the biggest fear of mankind is dying or death. Almost everyone of us suffers from thanatophobia, the fear of death, some time or the other. "I'm not afraid of death," Woody Allen, famous Hollywood director, had once said. "I just don't want to be there when it happens." But death does come looking for us.

In Philip Larkin's great but chilling poem Aubade, a man woke at 4 in the morning and agonised fearfully about "unresting death". At the crux of his terror is that annihilation of consciousness and awareness: "That this is what we fear - no sight, no sound,/No touch or taste or smell, nothing to think with,/Nothing to love or link with,/The anaesthetic from which none come round."

Several philosophers through the ages have, however, exhorted that none should fear this absolute dissolution since being dead is akin to a state of dreamless sleep or being unborn - a perpetual nothingness. The focus, hence, ought to be on living and that includes dying since dying, too, is an act of living. "True philosophers," Plato wrote, "are always occupied in the practice of dying."

In a 2014 essay in the New York Times, Dr Paul Kalanithi, a 36-year-old doctor who was at the cusp of finishing his training in neurosurgery, wrote of that moment of confirmation (he had been suspecting it for some time, with his excruciating backache, weight loss and fatigue) that he had Stage 4 lung cancer. As he methodically scrutinised the CT films that revealed the cancer mottling his lungs and eating into his liver and spine, he registered his initial feeling. "I wasn't taken aback. In fact, there was a certain relief," he wrote. "The next steps were clear: Prepare to die. Cry. Tell my wife that she should remarry, and refinance the mortgage. Write overdue letters to dear friends. Yes, there were lots of things I had meant to do in life, but sometimes this happens…" He spent the remaining 22 months of his life learning how to die - or in the words of journalist Christopher Hitchens, "living dyingly".

Dr Kalanithi did not divorce his wife; they chose to have a child. Distilling his experiences and thoughts on his own dying into an autobiographical book entitled When Breath Becomes Air, which was published in early 2015. It was the first and only book that he had written. He wrote it for his only child and daughter and for other people "to understand death and face their mortality" and to get them into his shoes and "walk a bit, and say, 'So that's what it looks like from here… sooner or later I'll be back here in my shoes'… Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here's what lies up ahead on the road". After trying whatever treatments he could find tolerable and acceptable, and having made a decision together with his family and his attending doctors not to carry on any further, he died with his family at his bedside.

If there can ever be one, Dr Kalanithi's death could possibly be called "a good death" or at least a good enough death. When asked what a good death is, most people would say that it is a sudden and painless death - and probably would add that this is what they would want for themselves. But is it? Such a sudden and unexpected death would usually leave behind a detritus of unfinished and unresolved matters, and a clutch of traumatised survivors who had been denied of being able to express or hear what they have meant to that person, robbed of any opportunity to express gratitude or regrets, and deprived of any hope of reconciliation.

If it is any consolation, most of us would not go this way; we would have to endure that variable period of dying. The intervention of modern medicine can drag this process for months or even years with a progressive accretion of debilities and miseries. It might seem, then, that most of us would have the time to plan for our imminent death: to grieve, to come to terms with things, to provide for others, to try to live out the remaining time with some purpose and meaning, to voice our preference for life support or not, and plan for our funeral - but we often do not do many of these.

In mediaeval Christian Europe, it was widely subscribed that the preparation for one's earthly death and the celestial judgment that would follow were matters of immense importance. Such preparation was even celebrated in the arts and literature as Ars moriendi, the art of dying. The Ars moriendi provided practical guidance on reaffirming one's faith in God, remembering the right values and taking the right attitude in composing oneself to meet death fearlessly and stoically.

Today, we are a "death avoidance" society. Perhaps we are less religious now; maybe our blind faith in medical advances has given us that illusion that we can postpone death each time it comes threateningly close, and our various superstitions and cultural aversion towards death have certainly not made discussion of dying and death any easier. It is also very likely that the public still possess little information - let alone knowledge - of end-of-life options, including hospice and palliative care, and the legal rights to refuse or withdraw life-prolonging treatments.

We talk about active ageing but ageing, whether active or otherwise, would eventually lead to death - yet there is no talk of "dying well". Granted that it is difficult to attend to the thoughts and concerns of the dying; not to discuss it is to ignore - using that old phrase - that 800-pound gorilla in the room. Perhaps, together with active ageing, we should also start talking about our own version of the Ars moriendi.

Bipolar disorder vs genius-- the dilemma

Bipolar disorder is a mental condition marked by alternating periods of elation and depression. March 30 is called World Bipolar Day and its aim is "to bring world awareness to bipolar disorders and eliminate social stigma",according to the website of The International Society for Bipolar Disorders. This particular date was chosen because it is the birthday of Vincent Van Gogh, famous painter, who was posthumously diagnosed to have bipolar disorder and has since been turned into an icon of the tragic melding of genius and mental illness.

The strange association of creativity and extraordinary achievements with mental illness has long been a subject of popular fascination and scholarly studies. There is a fairly long list of individuals who have shaped history, science, culture and the arts who were thought to have been afflicted with bipolar disorder: Isaac Newton, Abraham Lincoln, Winston Churchill, Theodore Roosevelt, Florence Nightingale, Johann Goethe, Edgar Allen Poe, George Frederic Handel, Ludwig von Beethoven, Virginia Woolf and Ernest Hemingway.

Since bipolar disorder is probably as old as humankind, having persisted generation upon generation, it suggests that it confers some evolutionary advantages. In a paper published in the British Journal Of Psychiatry in August, 2015, researchers linked high childhood IQ to an increased risk of experiencing bipolar traits in later life. "There is something about the genetics underlying the disorder that are advantageous," said Daniel Smith, the lead investigator of the study. "One possibility is that serious disorders of mood - such as bipolar disorder - are the price that human beings have had to pay for more adaptive traits such as intelligence, creativity and verbal proficiency."

The finding of this study is consistent with previous research, showing that people with an increased genetic predisposition to bipolar disorder are more likely to have a repertoire of intellectual and creative abilities which can certainly be advantageous in leadership roles and in the various artistic pursuits. One of the earliest accounts of bipolar disorder comes from Aretaeus, a Greek physician who was believed to have practised in Alexandria and Rome in the second century, and had left behind a clear description of how excited and depressed states might alternate in an individual. However, the disorder was not clearly recognised nor given a name for centuries.

It was only in 1896 that Emil Kraepelin, a German psychiatrist, called it manic-depressive psychosis, having observed that the peaks of frenzied excitement and periods of abysmal melancholy were usually separated by intervals during which the person seemed normal. In 1957, another German psychiatrist, Karl Leonhard, introduced the word "bipolar" for people who experienced mania and depression, and "unipolar" for those with depression only.

In all likelihood, bipolar disorder - like all mental disorders - remains shrouded in ignorance, fear and embarrassment. And people with this disorder - as with those with other mental health issues - are likely to be avoided, mocked, misunderstood and discriminated against. That needs to change, and the call for change needs to be made again and again as long as this situation remains unchanged. The term "bipolar disorder" has since replaced "manic-depressive psychosis" in the lexicon of psychiatry.

One end of the polarity of this disorder is mania which is an abnormally expansive and euphoric mood state that can unpredictably erupt into explosive anger. There is often a shedding of the person's normal inhibition; an urge towards potentially harmful activities such as spending sprees or sexual indiscretion or foolish business ventures; an unbounded energy with decreased need for sleep; a loquacity that permits no interruption; and a sense of inflated self-worth that can sometimes morph into grandiose delusions of fabulous wealth or special powers.

There is a rich literature of autobiographical accounts of what it is like to live with bipolar disorder, and one of the most eloquent is Kay Redfield Jamison's An Unquiet Mind. A highly regarded clinical psychologist, Jamison writes of her first attack when she was a senior in high school: "I lost my mind rather rapidly… I raced about like a crazed weasel, bubbling with plans and enthusiasms, immersed in sports, and staying up all night, night after night, out with friends, reading everything that wasn't nailed down, filling manuscript books with poems and fragments of plays, and making expansive, completely unrealistic, plans for my future."

Being in the grip of a storm of such seething energy can give the illusion of power, brilliance or genius. "I felt not just great, I felt really great," writes Jamison. "I felt I could do anything, that no task was too difficult. My mind seemed clear, fabulously focused, and able to make intuitive mathematical leaps that had up to that point entirely eluded me. At that time, however, not only did everything make perfect sense, but it all began to fit into a marvellous kind of cosmic relatedness."

In a way, it can be so intoxicating that there are some patients who want this manic phase. They miss the pleasurable excitement, the preternatural elation and the apparent creativity of mania, and they resent the levelling effect of medication. But this tumultuous brainstorm and frenetic overdrive of mania are not sustainable. The mania is ultimately exhausting and alienates others. Mania gets those who experience it into messes which they regret when they come out of it, and wrecks their life and work. Van Gogh had lamented that "if I could have worked without this accursed disease, what things I might have done".

And there is the other polarity; that same person who experiences such exultation of mood can plunge into a state of depression that brings in its wake abject misery, apathy, dejection and hopelessness that can make suicide seem the only way out.

Ten years ago, the British actor and comedian Stephen Fry, who has bipolar disorder, starred in a BBC television documentary called The Secret Life Of The Manic Depressive. In it, he spoke about his life with the disorder and went on to interview other celebrities, including British pop singer Robbie Williams and Hollywood actress Carrie Fisher, as well as other people with bipolar disorder.

A few years after the airing of this programme, psychiatrists Diana Chan and Lester Sireling reported in a 2010 publication of the British College of Psychiatrists, The Psychiatrist, on the phenomenon of a rising tide of people actively seeking out psychiatrists - either of their own accord or at the instigation of family members - and wanting to be diagnosed with bipolar disorder.

The two doctors speculated that the increased media coverage and the line-up of famous people of high social status talking about their own personal experiences have not only made bipolar disorder less stigmatising but possibly even desirable. They posited that beneath the quest for a diagnosis of bipolar disorder is the person's aspiration for a higher status which is vicariously attained through association.

Therein lies the potential treachery of such well-meaning efforts to enlighten and raise awareness of mental illness. In banishing those disparaging stereotypes and replacing them with positive ones, there lies the risk of romanticising and glamorising the condition. The onus lies with the psychiatrist to ensure that the right diagnosis is made. There are obvious dangers in misdiagnosing bipolar disorder: a person could end up being shunned by others, discriminated against by employers and insurance companies, and being prescribed medication with potential side effects. But it is just as harmful, if not more so, to miss a true bipolar diagnosis. All things considered, it is better for people who think they have this disorder to err on the side of safety and seek help.

In all likelihood, bipolar disorder - like all mental disorders - remains shrouded in ignorance, fear and embarrassment. And people with this disorder - as with those with other mental health issues - are likely to be avoided, mocked, misunderstood and discriminated against. That needs to change, and the call for change needs to be made again and again as long as this situation remains unchanged.

Concerns of parenting today's kids

In today's The Straits Times, an article appeared written by Dr Chong Siow Ann, vice-chairman of the medical board (research) at the Institute of Mental Health, Singapore. I liked it as I also experienced the type of childhood which the writer has described, and hence thought of sharing parts of it on my blog:

"Growing up in the 1960s and 70s, I (Dr Chong) had what could be accurately called a carefree childhood. Mostly I was left to my own devices to entertain myself. I wasn't taught to read or write until I went to primary school nor was I enrolled in a kindergarten; I think now it was because my parents couldn't afford the additional expense (there were already four other children at school) and they probably felt that it was unnecessary.

My mother, who had a few years of formal education and could read and write only in Chinese, proceeded to coach me on that single subject and kept an eye out that I would complete whatever homework I was given - even though she couldn't understand most of the other subjects. Schooling was relatively straightforward then: You went through primary school, took the Primary School Leaving Examination - which had no aggregate score - and, having cleared that, you proceeded to secondary school which, in my case, was the one that was nearest to my home.

And if you did reasonably well by Secondary 2, you were expected to go to the "science stream". I made that decision myself as with all other decisions about my subsequent education: which extra-curricular activities to join, which junior college to go to, and what university degree to pursue.

I felt no pressure from my parents, though, of course, they were proud (and probably surprised) that I was admitted into medical school. What mattered to them was that I should at least have a university degree and thereafter a steady job, and be an honest, decent and useful person - and they tried to ensure all that in a rather instinctual way.

HELICOPTER PARENTS
Within two generations, Singapore has catapulted itself into the First World. Meritocracy has been the organising principle of that transformation; and for better or worse, it has also been imprinted into our psyche.

With growing affluence and with most couples having fewer children, the latter have become the most precious of all possessions and, in tandem, parenting has become a very deliberate, self-conscious and angst-riven activity - particularly with the so-called helicopter parenting which is that odd amalgam of pampering and achievement pressure. Overprotective, over- controlling and intrusive, these helicopter parents would hover and keep their children on their radar screen: orchestrating and monitoring their activities, and swooping to blast away any obstacles in their path.

Sheep-like, disempowered and bereft of any sense of agency, these children are ferried, guided and nudged along the highways and byways of a demanding terrain of academic and extra-curricular activities. Having imbibed the ambitions of their parents and squinting through the parental prism, they see only one narrow path to success in life. The consequence - as we are told by concerned scholars and educators in a slew of scholarly studies, best-selling books and newspaper and magazine articles - is that these children who are consumed with the fear of not measuring up, don't learn to cope effectively with problems nor do they know how to soothe themselves when they are distressed.

There is "declining student resilience" and "emotional fragility", according to the Boston College psychologist Peter Gray. "Students are afraid to fail; they do not take risks; they need to be certain about things," he wrote of the students in the United States and the growing mental health crisis among them. "For many of them, failure is seen as catastrophic and unacceptable. External measures of success are more important than learning and autonomous development."

A five-year study from the National University of Singapore published in the Journal Of Personality this year showed that local children of intrusive parents who have high academic expectations of them are likely to be more self-critical and more inclined to feel that they fall short. "The child may become afraid of making the slightest mistake and will blame himself or herself for not being 'perfect'," said the study's lead investigator Ryan Hong, who warned bleakly that "it increases the risk of the child developing symptoms of depression, anxiety and even suicide in very serious cases".

Other research elsewhere has shown that students with "helicopter" parents are more likely to be medicated for anxiety and depression.

TIGER MUMS
To a certain extent, some parents may feel as hapless as their children, being compelled as they were in a meritocratic elitist society where - so goes the popular narrative - the best chance of material success in later life is attaining the requisite academic credentials earlier in life. And which parent would not be beset by that raft of guilt, uncertainty and anxiety of not doing enough in securing that head start for their child?

But still there is a general feeling that such values and expectations are wrong. The tendency is to blame the education system for being that crucible of feverish competition and high pressure. There have been many calls for changes. As The Straits Times editorial of July 16 said, the recent revamp of the PSLE nurtures the hope that primary education should be for children "to develop their passion for learning, grow in values and character, and explore their strengths and interests".

That sounds intuitively and sensibly right but there is a salutary lesson to be learnt from the experience of the world's most powerful nation. Americans have been drilled to respect the individuality of their children, to support them in their self-chosen passions, and to boost their self-esteem which is supposed to make them learn better.

But as the American journalist Elizabeth Kolbert pointed out in her piece in The New Yorker a few years ago: "After a generation or so of applying this theory, we have the results. Just about the only category in which American students outperform the competition is self-regard." She highlighted a study by the Brookings Institution that compared students' own assessments of their abilities in maths with their actual scores on a standardised test. Nearly 40 per cent of American students declared that they usually do well in mathematics, but only 7 per cent of them actually did well enough on the test to qualify as advanced.

In contrast, 18 per cent of Singaporean students said they usually did well in maths; 44 per cent qualified as advanced on the test, with even the least self-confident Singaporean students outscoring the most self-confident Americans. As Ms Kolbert commented wryly: "You can say it's sad that kids in Singapore are so beaten down that they can't appreciate their own accomplishments. But you've got to give them this: At least they get the math right."

And it's not just maths - American students are far from the top in international rankings for excellence in science. This Western orthodoxy of nurturing the self-esteem of the children and allowing them unfettered expression is anathema to Amy Chua, Yale law professor and author of that controversial book, Battle Hymn Of The Tiger Mother, where she expounded her exacting Chinese child-rearing of her two high-achieving daughters.

She argued that the sort of parenting which emphasises self-esteem without an accompanying insistence on actual accomplishment will set the children up to accept mediocrity. And it has another darker implication - a society that nurtures and blithely accepts unearned self-esteem could turn out entitled narcissists and weaken its global competitiveness.

The changes to Singapore's own education system are made in the hope that our children will have a less burdened childhood. But there is, I think, another intent, which is to help them be more creative, more original and more imaginative as adults - attributes that are essential for a "knowledge economy".

Let's hope that it will achieve all that, though Amy Chua's stern assertion might be something to be borne in mind. However, being what we are, it is unlikely that our tiger mums and cubs would be an endangered species any time soon."