He was in his mid-thirties, and was counted successful by any standard. He’d graduated from Harvard, succeeded on Wall Street, and had a family. But on that particular day, a video of him was displayed prominently in the auditorium, his every move scrutinized by a room full of strangers. Outside, the hospital bustled with activity. Tubes of blood shuttled about, microscopes flickered, MRI machines roared to life. The auditorium, on the other hand, was silent; we were all sitting on the edge of our seats, trying to get a better glimpse of the video. The patient had suffered a violent stroke a month earlier. Since then, his personality had become increasingly erratic and violent. He had to quit his job, and was admitted into a nursing home. Shortly afterwards, he began experiencing seizures, and was brought to the epilepsy unit where I am doing my observership.
A week after I saw that case, I received another piece of news. This time it was about Dave*, an employee at the soup kitchen I volunteer for. Dave was in his mid-forties, and confined to a wheelchair. He’d been haunted by drugs and booze for decades, and had gotten in and out of jail several times, each time for increasingly serious misdemeanors. At one point, he decided that he’d had enough. He took adult classes, learned financial accounting, and became a bookkeeper for the soup kitchen, a post that he held for several years until a week ago. He had succumbed to stage four colon cancer. I mourned at the loss of human potential. Why did Dave and the executive have to suffer? Why can’t we do better? Why did medicine fail?
It’s easy to ask these questions given today’s climate around medicine. In the 1920s, life expectancy in Canada was 60 years, lower than today’s age of retirement by five. The discovery of penicillin by Alexander Fleming in 1928, followed by other antibiotics, marked a pivotal point in the history of medicine. Time magazine’s May 15, 1944 cover featured an intense looking Fleming in a white lab coat. The article ran like this:
“Medical news last week vied with news of the days before invasion. Under the aspect of eternity, the medical news might even be more important than the military. WPB announced that the wonder drug penicillin, for three years practically a monopoly of the Army & Navy, was now being manufactured in such quantity that it can be issued to civilians. Some 1,000 hospitals will be allowed to buy generous monthly quotas for distribution to patients and other hospitals as they see fit.”
Clearly, antibiotics were exciting news, so much so that it vied for headlines with the war effort 3 weeks before D-Day. Scientific discoveries like these, along with increasing public health awareness in the 20th century, led to a dramatic increase in life expectancy. Canada’s rose by 20 years since the 1920s, and it now sits at number thirteen in the world.
With the advancement of medicine came the denial of its potential to fail. As Siddhartha Mukerjee writes in The Emperor of All Maladies, “When a doctor has to tell a patient that there is no specific remedy for his condition, [the patient] is apt to feel affronted, or to wonder whether the doctor is keeping abreast of the times”. Just weeks ago, an article posted on Science Alert ran the sensational headline: “Immortality is one step closer as scientists turn off the ageing process in worms”. (In truth, in the original paper, researchers prevented the decline of heat shock response with age in nematode worms.)
In this climate, it’s no wonder that talking about death, which was once considered bad luck, is now considered taboo. So-called “new-age religions” are more preoccupied with living than with the afterlife. A casual search on Google revealed that the proportion of books mentioning “death” decreased by half since the 1800s. In this “age of immortality”, Hades is no longer a horror; death no longer holds sway in the public imagination.
According to Atul Gawande, a New York surgeon, this has implications for healthcare. In Being Mortal, Gawande argues that ignoring the eventuality of death deters people from discussing about their values. In Canada and the US, if a person becomes legally incompetent because of illness, her Substitute Decision Maker (SDM) makes medical decisions for her. If the patient had not made explicit directives before she became incompetent, the SDM must make judgement calls based on the “patient’s best interest”. If the patient had not made her values clear beforehand, the SDM is left in a grey area. Should the patient remain on life support, if it means more suffering in exchange for a slim chance of recovery? Should a doctor recommend aggressive chemotherapy for an aged patient who might prefer palliative treatment?
On the individual level, forgoing value discussions with ourselves can lead to a feeling of loss and purposeless. In an article published by the New York Times, Julie Lythcott-Haims, dean of freshmen at Stanford, remarked that “[students] could say what they’d accomplished, but they couldn’t necessarily say who they were”. This loss of identity lies at the root of many psychiatric manifestations, according to the psychiatrist and Holocaust survivor Victor Frankl. During his time as an inmate in a concentration camp in Auschwitz, Frankl personally witnessed the disintegration of personhood. He observed that the inmates who had seemed the most carefree were the first to give up hope, whereas those who had been more thoughtful and introspective proved more resilient. His experiences counselling inmates shaped logotherapy, a form of psychotherapy that helps the patient identify his values and meaning in life.
At the end of the day, death is an integral part of our existence. When the sun sets, when the curtain closes, when the hand strikes twelve, how will we face our mortality? How will we measure the life we’ve lived?
Last week, we held a minute of silence for Dave at the soup kitchen. I bowed my head, violin in hand, and uttered a silent prayer. I did not know Dave very well, only that he’d always seemed positive and hopeful, and that he had a glint in his eyes. That light which had inspired so many has faded, its flame now lit elsewhere. Dave’s story was one of ultimate redemption, from a drug addict and criminal offender to a contributing member of society. As I stood in silence, I remembered the video of that Wall Street executive in a hospital wheelchair, and I realized how closely he must have resembled Dave in his last days. In the end, we are all reduced to our insignificant idiosyncrasies. The way we’ve smiled, the way we’ve talked, the private passions that we’ve shared only with our loved ones. Hopefully, when we meet our inevitable end, we would, like Dave, have left behind a courageous life lived according to our values.
*Names and other identifying information are altered in this article.