Thursday, March 23, 2017

A Surgeon's Quest for Clarity

Have you ever been around a campfire with friends? It is pitch-black outside, a moonless sky covers you. Around the fire and your friends, you feel safe and you accept (perhaps timidly) that you are surrounded by the ominous darkness. You go to stand at the edge of the fire’s light and strain to peer into the darkness, trying to see something, anything. But you cannot make out anything at all. Your group arrived at night so you have yet to see the surroundings in the light of day. This is the experience Paul Kalanithi was having when trying to understand what lies in the darkness of death.

Some of us have an unquenchable thirst to understand, to know. Dr. Paul Kalanithi, an accomplished neurosurgeon and neuroscientist, was of that sort. Where some, perhaps many, physicians emotionally distance themselves from a patient that is near death, Paul made it a primary goal to come to know the patients in his care. He wanted to know the person beyond the charts. Although there can be huge emotional backlashes for subjecting one’s self to this, Paul bravely engaged his patients and, in so doing, engaged and stared down death itself. I call this brave because Paul recounts a friend and colleague of his that, after losing a patient, committed suicide. It can really be that traumatic on a physician. Even in difficult cases where the patient lives but the surgery took a ghastly number of hours, the exhaustion is not only a physical but psychological drain as well. On this, Paul wrote: "Before operating on a patient's brain, I realized I must first understand his mind: his identity, his values, what makes his life worth living, and what devastation makes it reasonable to let that life end. The cost of my dedication to succeed was high, and the ineluctable failures brought me nearly unbearable guilt. Those burdens are what make medicine holy and wholly impossible: in taking up another's cross, one must sometimes get crushed by the weight." (P.53)


Chris, a young man I met at his parent's mom/pop coffee shop, has noble aspirations of becoming a cardiologist. On a recent visit to the shop, Chris showed me a book he was reading and highly recommended. "When Breath Becomes Air," by Paul Kalanithi. Before I explain why we even discussed this book, I need to back up a bit. When I first met Chris he was thinking that maybe a career as a heart surgeon would be good. But over time he changed his mind. He explained that he is more a "people person," and wants to build relationships with patients. Surgeons typically don't do that. After getting about half way through the book, I sent a text to Chris: "Knowing how you want to deal with the human, compassionate side of life, instead of the nuts and bolts side of surgery, I can see that this book was the right choice for you." So my knowledge of Chris' professional goals coupled with his knowledge of my failing health and struggles with cancer are the reasons we shared in the interest of this book.


The "human tragedy" of sickness and "accidents," is something doctors are constantly subjected to. The tragedies in Paul’s life were that he didn't even make it to age 40; didn’t get to see his baby daughter grow; didn’t get to achieve other goals he surely would have achieved had he lived longer than 37 years. Some of the more profound reflections he writes of are his search to understand the point at which the brain becomes the mind and, what the meaning, purpose, and point of life is. Paul wrote that in his college admissions essay, he "argued that happiness was not the point of life." He never does state what his final conclusion was on this matter. The closest he comes is when he says, "A word meant something only between people, and life’s meaning, its virtue, had something to do with the depth of the relationships we form." In saying this, he seems to have a foggy realization that being happy has its benefits. However, he summizes the real meaning in life is to embrace all the challenges, good and bad, and face them bravely with lion-like resolve -- with family and friends.

However, in the issue of life’s meaning, it really struck me that, whether he knew it or not, Paul was looking to understand God, the greater, intangible consciousness in mankind’s collective existence, and who we are as individuals. Beyond the biological, understanding death as a human experience seemed to elude him. Especially with his own mortality staring him in the face, he wrote he saw nothing but "a blank, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity." To further the despair of the situation, "The sun was setting." (P.65) Later in the book, Paul wrote: "Where did biology, morality, literature, and philosophy intersect?" On page 53 he wrote: "I still felt literature provided the best account of the life of the mind, while neuroscience laid down the more elegant rules of the brain."

At another point in the book he wrote: "I had started in this career, in part, to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. Neurosurgery attracted me as much for its intertwining of brain and consciousness as for the intertwining of life and death. I had thought that a life spent in the space between the two would grant me not merely a stage for compassionate action but an elevation of my own being: getting as far away from petty materialism, from self-important trivia, getting right there, to the heart of the matter, to truly life-and-death decisions and struggles...surely a kind of transcendence would be found there?" This was the reason for my introduction about the campfire and staring off into the unknowable darkness.


On page 74 Paul has a personal realization that helped him see the difference between medical (biological) prognosis (of the brain) and the potential for future hopes, aspirations, plans (of the mind). It is as if he finally realized that for all his medical training, beyond the biological, his background fell woefully short of addressing giving the mind (psyche) of the patient a sense they could still live a meaningful life -- that “who you were” before the incident (whether disease or injury), will still be “who you are” after recovery. In his own battle with cancer, treatment, therapy and more, as he made any and every small gain, he came to a point where he declared that when meeting with Emma, his doctor, “I felt like myself, like a self. Outside her office, I no longer knew who I was. Because I wasn’t working, I didn’t feel like myself, a neurosurgeon, a scientist—a young man, relatively speaking, with a bright future spread before him. Debilitated, at home, I feared I wasn’t much of a husband for Lucy.”


Paul was an unpretentious, “true heart” of a person. His quest for clarity in the meaning of life and death is the stuff of fairytales but brought into the real world; with real people; on a real journey. I admire his honesty, humility, kindness, and naked truth of his coping with cancer. I would not detract from that one bit. I wish I could have had the honor to have known him personally.

But I do have some observations of my own. Apart from acknowledging a creator, life makes no sense. Evolution cannot and will never answer why we are here. It's dismal reply that there is no reason for our existence is unacceptable to thinking people. Order in the creation is not just our imagination. Once we accept that, we can then begin to accept why we are here. But we need to get past "why are we here?,” and more accurately ask “why did God put us here?”

Paul did strike a vital note in observing that caring for each other is crucial to life having meaning. But like an arrow that fell just slightly below a bullseye, he missed the more important puzzle piece of how we come into a relationship with our creator. It is not so much having a religion that does this, as building a relationship and favorable reputation with our Creator. Paul did have a religion, but I didn’t get the sense that it answered the questions he had. Starting around page 88, Paul talks about God and religion: “During my sojourn in ironclad atheism, the primary arsenal leveled against Christianity had been its failure on empirical grounds. Surely enlightened reason offered a more coherent cosmos. Surely Occam’s razor cut the faithful free from blind faith. There is no proof of God; therefore, it is unreasonable to believe in God.”

My response to this is that there is less evidence of mythological creatures that supposedly roam the earth (Bigfoot, Loch Ness, and more). The “evidence” that believers claim to have found are usually fakes that have fooled even scientists. Yet the lack of real evidence hasn’t stopped the proliferation of speculation and publications. But speaking to God’s existence, the Bible states: “Of course, every house is constructed by someone, but the one who constructed all things is God.” (Hebrews 3:4) Not only are his creative works evidence that “God was here,” but also archaeology proves that both the people and places mentioned in the Bible existed.

Paul’s conviction in God comes across as perplexed and conflicted at best. While he appreciates that it is shortsighted to merely accept what we can see, believing in what we cannot see is very subjective. One insight Paul does have is not one I would have readily seen: “To make science the arbiter of metaphysics is to banish not only God from the world but also love, hate, meaning – to consider a world that is self-evidently not the world we live in…. If you believe that science provides no basis for God, then you are almost obligated to conclude that science provides no basis for meaning and, therefore, life itself doesn’t have any” [meaning]. He then goes on to conclude that Occam’s argument (“There is no proof of God; therefore, it is unreasonable to believe in God.”) was not so much a statement that God doesn’t exist, as it was that using scientific methods is useless to that end. (It would be akin to using a common stopwatch to measure the speed of light.)

As for Paul's frustrated attempt to understand death, I'm not quite clear where he felt the lack. I'm not sure even Paul was clear on the lack. He seemed to accept the inevitability. He understood the medical reasons and biological processes. Maybe coping and counseling, both as a patient and a physician puzzled him -- what comfort can possibly be more than mere wishful words? There again, only by including God & his promises in the equation can any of this make sense. Knowing his design & intent can offer real solace.

Coming back to my opening illustration: We all are born into a world surrounded by the darkness of the unknown -- perhaps the greatest of which is “What lays beyond death?” The light at the campfire is the vibrant life around us. At various times in our life, we find ourselves staring just beyond the light when either we or someone we know is facing a life-threatening situation. We yearn to have something to share, but like Paul’s father and others, are left “blank” mentally – staring into the dark unknown and only having a feeble hope that “we will conquer this together,” while knowing that the reality is potentially very grim. More than just the darkness of death is the spiritual darkness that exists in this world that leaves mankind with a gnawing sense of confusion as to what lays ahead. Waiting until daylight to venture beyond the campground is the same as the bright hope that we can only find in the light of the Bible to see beyond the darkness of the human condition of imperfection and death.

 After thoughts:

In the Epilogue, his wife mentions his humor -- she didn’t feel the book conveyed that side of him very well. However, the book does mention one instance: My fellow resident Jeff and I worked traumas together. When he called me down to trauma bay because of a concurrent head injury, we were always in sync. He assesses the abdomen, then asks for my prognosis on a patient's cognitive function. "Well, he could still be a senator," I once replied, "but only from a small state." Jeff laughed, and from that moment on, state population became our barometer for head injury severity. "Is he a Wyoming or a California?" Jeff would ask, try to determine how intensive his care plan should be. (P.46)

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