In my beginning, is my end.
T.S. EliotOur lives are continually punctuated by endings and beginnings. Life-cycle celebrations, new jobs, business failures, a sunset. And of course, death. Flux, not steady-as-she-goes, is the stuff of life.
Next month after seven years, I shall leave the Peter MacCallum Cancer Centre in Australia to take up a new position (still in palliative medicine) at the Davidoff Cancer Centre in Israel. It has been seven marvellous years in a fabulous institution, whose philosophy is dedicated to discovering, curing, and relieving. These are not vacuous platitudes. The ideas, the research, and the learning at Peter Mac are incredibly stimulating. The attitude of all and sundry is to make the journey less painful for the patient (and the family) in body and mind. I have not seen one negligently rough transfer of a patient from a trolley. Every time I pass a patient being readied for a radiological procedure I hear courteous and gentle murmurings. There are a couple of grumps, but every family has them, and they only emphasize the compassion and politeness that is Peter Mac. Colleagues—medical and nursing—are superb and I shall miss them.
A full-time academic–clinical appointment allows one the freedom to practice and to be creative. The production line in Charlie Chaplin's Modern Times produces products not ideas. Creativity requires time to free-associate, daydream, muse, and serendipitously chat to colleagues. By the same token, clinical contact is a necessary cross-fertilizer. Peter Mac is the example par excellence of the virtues of translational medicine. The only cloud on the horizon is that in recent times the bureaucrats at Peter Mac have inveigled their thinking into the hospital. A distance has developed between those in charge and those that do. I am told it is necessary, but it is nevertheless unfortunate.
Seven is an interesting number. In Hebrew seven has the meaning of being satisfied and having a rest. On the seventh day Joshua walked around Jericho seven times and blew the ram's horn seven times before the city walls came a-tumbling down. This year, in Israel, is the shmitta year. Every seventh year, since time immemorial, the land in Israel lies fallow. The Sabbath is the seventh day of the week. Hence the English word sabbatical. It is a wonderful application of an ancient idea—to provide sabbatical leave for academics. A time to replenish. So it is with some portent that after seven years I am leaving to take up a new position in palliative medicine—an ending and a beginning. A new cycle of seven that I hope will both stimulate and satisfy.
The gist of palliative medicine is its clinical scenarios. Oftentimes when I return to work on Monday, I am struck afresh by the struggle of people to live. Not the suffering as much as the struggling. It seems at times that the patient's whole life is consumed by the struggle—when is there time to live?
Is it sufficient to spend all one's time and energy struggling? And with what hope?
Camus tackled this issue through interpreting a Greek myth:
The gods had condemned Sisyphus to ceaselessly rolling a rock to the top of a mountain, whence the stone would fall back of its own weight. They had thought with some reason that there is no more dreadful punishment than futile and hopeless labor … . I leave Sisyphus at the foot of the mountain! One always finds one's burden again. But Sisyphus teaches the higher fidelity that negates the gods and raises rocks. He too concludes that all is well … . The struggle itself toward the heights is enough to fill a man's heart. One must imagine Sisyphus happy. (Camus, Reference Camus1942)
There is a lesson here for doctors and nurses. In the event that cure is not possible we are not permitted to despair. It does not matter how desperate things appear nor how indignant we may be at life's vagaries. We are not contracted to cure every person, but neither are we free from the obligation to provide solace. Our moral imperative is to relieve suffering, not to preempt the end of life.
Palliative care is replete with endings and beginnings. Patients start chemotherapy filled with hope. Then the chemotherapy fails. A new treatment starts but hope is jaded. Finally treatment ends altogether and hope hangs by Damocles' sword. The journey then starts its penultimate stage, and it is hard. Nonetheless I look forward to new referrals. A new acquaintance, an interesting life, an unrecognized clinical quirk. Alas there are many endings, many deaths. Using our five senses (and common sense) death appears to those left behind to be the final exit. John Donne (Reference Donne and Gardner1952) disagreed. Donne wrote in his Holy Sonnets: “One short sleep past, we wake eternally; And death shall be no more, death thou shalt die.” Tolstoy (Reference Tolstoy1868) in his masterpiece The Death of Ivan Ilych, wrote similarly: “‘Death is finished’ he said to himself. ‘It is no more!’ He drew in a breath, stopped in the midst of a sigh, stretched out, and died.”
Can we ultimately be “victorious” over death? Or is a belief in an afterlife and a continuation of the soul merely an elaborate culturally sanctioned denial of death?
We recently held a conference, “Consciousness—the final frontier.” It was to explore the nature of consciousness and how the brain gives rise to the mind—or poetically, how water is turned into wine. Mainstream scientists claim that the mind is what the brain does—nothing more nor less. They believe that when the brain is dead, there is no mind (or soul for that matter). We asked the audience—about 100 doctors, nurses, and psychologists—whether they thought consciousness continued in some form after death. Approximately 50% answered in the affirmative.
More poignant are the relationships that end. Parents, siblings, children. How many rivers of tears have been shed since Abel? Ultimately, however, tears are good. They tell us that the death was not one of indifference. Tears are droplets of love, which herald the process of mourning and remembrance. The beginning of forgetting. As the years pass room is often made for a new relationship, a new beginning.
Consciousness would appear to be a key criterion that separates life from death. The assumption from this side of death is that consciousness ceases after death. In fact the Talmud (Berachot, 59:b) suggests “that sleep is one sixtieth of death,” wherein sleep is a form of unconsciousness and thus a foretaste of death. Shakespeare however raised the issue that Hamlet's bad conscience might follow him into the afterworld: “To sleep! perchance to dream: —ay, there's the rub; For in that sleep of death what dreams may come, When we have shuffled off this mortal coil.”
From medical and legal vantages the absence of consciousness does not necessarily equate to death. Fins (Reference Fins2006) wrote an insightful article exploring the Terri Schiova case. He noted the important neurophysiological distinction between vegetative and minimally conscious states. The argument unfolds—what is the relation between death and the absence of consciousness? Is not death the irreversible absence of consciousness? Not quite. Death of the human being is determined by either the absence of cardiac function and/or the loss of certain brain stem reflexes. Neither of these is predicated on the absence of consciousness.
I have sat many times with a relative at the bedside of an unconscious, dying parent and watched the tears and memories flow. Mum is still very much a person even if she is unable to speak and respond. However a person lying unconscious for years is a different challenge. And with what hope?
