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- 1. Open EndedAfter I was caught returning at dawn from one such late-night escapade, my worried mother thoroughly interrogated me regarding every drug teenagers take, never suspecting that the most intoxicating thing I'd experienced, by far, was the volume of romantic poetry she'd handed me the previous week.
- 2. Open EndedMeaning seemed inextricable from human relationships and moral values. T.S. Eliot's The Waste Land resonated profoundly, relating meaningless and isolation, and the desperate quest for human connection. I found his metaphors leaking into my own language...Literature not only illuminated another's experience, it provided the richest material for moral reflection.
- 3. Open EndedIf the unexamined life was not worth living, was the unlived life worth examining?
- 4. Open EndedThe camp delivered on its promise, concentrating all the idylls of youth: beauty manifest in lakes, mountains, people; richness in experience, conversation, friendships.
- 5. Open EndedWhere did biology, morality, literature, and philosophy intersect? Walking home from a football game one afternoon, the autumn breeze blowing, I let my mind wander. Augustine's voice in the garden commanded, "Take up and read,", but the voice I heard commanded the opposite: "Set aside the books and practice medicine."...It would mean setting aside literature. But it would allow me a chance to find answers that are not in books, to find a different sort of sublime, to forge relationships with the suffering, and to keep following the question of what makes human life meaningful, even in the face of death and decay."
- 6. Open EndedI found myself increasingly often arguing that direct experience of life-and-death questions was essential to generating substantial moral opinions about them. Words began to feel as weightless as the breath that carried them. I wanted that direct experience. It was only in practicing medicine that I could pursue a serious biological philosophy. Moral speculation was puny compared to moral action.
- 7. Open EndedHer capacity to love was barely finite, and a session to me. One night on the sofa in my apartment, while studying the reams of wavy lines that make up EKGs, she puzzled over, then correctly identified a fatal arrhythmia. All at once, it dawned on her and she began to cry: wherever this "practice EKG" had come from, the patient had not survived. The squiggly lines on that page were more than just lines; they were ventricular fibrillation deteriorating to asystole, and they could bring you to tears.
- 8. Open EndedStanding there, waiting in the OR with a nine-hour surgery stretching out before her, Mari had a whisper of a thought: I'm so tired - please God, let there be mets. There were. The patient was sewn back up, the procedure called off. First came relief, then a gnawing, deepening shame.
- 9. Open EndedWhile all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves, and every conversation with a patient undergoing brain surgery cannot help but confront this fact.
- 10. Open EndedHow much neurologic suffering would you let your child endure before saying that death is preferable? Because the brain mediates our experience of the world, any neurosurgical problem forces a patient and family to answer this question: What makes life meaningful enough to go on living?
- 11. Open EndedI had started in this career to pursue death: to grasp it, uncloak it, and see it eye-to-eye, unblinking. I had thought that a life spent in the space between life and death would grant me not merely a stage for compassionate action but an elevation of my own being: 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? I began to suspect that being so close to the fiery light of such moments only blinded me to their nature, like trying to learn astronomy by staring directly at the sun. I was not yet WITH patients in their pivotal moments, I was merely AT those pivotal moments.
- 12. Open EndedAll my occasions of failed empathy came rushing back to me: the times I had pushed discharge over patient worries, ignored patients' pain when other demands pressed. The people whose suffering I saw, noted, and neatly packaged into various diagnoses, the significant of which I failed to recognize - they all returned, vengeful, angry, and inexorable. I feared I was on the way to becoming Tolstoy's stereotype of a doctor, preoccupied with empty formalism, focused on the rote treatment of disease, and utterly missing the larger human significance.
- 13. Open EndedThe families who gather around their beloved do not usually recognize the full significance. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery - or, sometimes, more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death's enemy, but as its ambassador.
- 14. Open EndedBefore operating on a patient's brain, 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. Those burdens are what make medicine holy and wholly impossible: in taking up another's cross, one must sometimes get crushed by the weight.
- 15. Open EndedThe pain of failure had led me to understand that technical excellence was a MORAL requirement. Good intentions were not enough, not when so much depended on my skills, when the difference between tragedy and triumph was defined by one or two millimeters.
- 16. Open Ended"Fourteen one two eight," he said mournfully, staring into my eyes. And then I left to catch up to the team. He died a few months later, buried with whatever message he had for the world.
- 17. Open EndedMost lives are lived with passivity towards death - it's something that happens to you and those around you. But Jeff and I had trained for years to actively engage with death, to grapple with it, like Jacob with the angel, and, in so doing, to confront the meaning of a life. We had assumed an onerous yoke, that of mortal responsibility. Our patients' lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn't. The secret is to know that the deck is stacked, that you will lose, that your hands or judgement will slip, and yet still struggle to win for your patients. You can't ever reach perfection, but you can believe in an asymptote toward which you are ceaselessly striving.
- 18. Open EndedI began to realize that coming in such close contact with my own mortality had changed both nothing and everything. Before my cancer was diagnosed, I knew that someday I would die, but I didn't know when. After the diagnosis, I knew that someday I would die, but I didn't know when. But now I knew it acutely. The problem wasn't really a scientific one. The fact of death is unsettling. Yet there is no other way to live.
- 19. Open EndedAs a doctor, I knew not to declare "Cancer is a battle I'm going to win!" or ask "Why me?" (Answer: Why NOT me?") I learned that stage IV lung cancer today was a disease whose story might be changing, like AIDS in the late 1980s: still a rapidly fatal illness but with emerging therapies that were, for the first time, providing years of life. While being trained as a physician and scientist helped me process the data and accept the limits of what data could reveal about my prognosis, it didn't help me as a PATIENT. It didn't tell Lucy and me whether we should go ahead and have ac hold, or what it meant to nurture a new life while mine faded. Like my own patients, I had to face my mortality and try to understand what made my life worth living.
- 20. Open EndedA local meeting of former Stanford neurosurgery graduates was happening that weekend, and I looked forward to the chance to reconnect with my former self. Yet being there merely heightened the surreal contrast of what my life was now. I was surrounded by peers and seniors whose lives were running along a trajectory that was no longer mine. My senior peers were living the future that was no longer mine - grants, job offers, publications, early career awards, promotions, new awards.
- 21. Open EndedLost in a featureless wasteland of my own mortality and finding no traction in the realms of scientific studies, molecular pathways, and survival statistics, I began reading literature again - anything by anyone who had ever written about mortality. I was searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again. The privilege of direct experience had led me AWAY from literature, yet now I felt that to UNDERSTAND my own direct experiences, I would have to translate them BACK into language. Hemingway described his process in similar terms: acquiring rich experiences, then retreating to cogitate and write about them. I needed words to go forward. And so it was literature that brought me back to life during this time.
- 22. Open EndedWe had a photo of our child as a blastocyst, taken just before implantation. ("She has your cell membrane," I remarked to Lucy.)
- 23. Open EndedI came to believe in the possibility of a material conception of reality, an ultimately scientific worldview that would grant a complete metaphysics, minus outmoded concepts like souls, God, and bearded white men in robes. The problem however became evident: 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.
- 24. Open EndedYet the paradox is that scientific methodology is the product of human hands and thus cannot reach some permanent truth. We build scientific theories to organize and manipulate the world, to reduce phenomena to manageable units. As strong as that makes its ability to generate claims about matter and energy, it also makes scientific knowledge inapplicable to the existential, visceral nature of human life, which is unique and subjective and unpredictable. No system of thought can contain the fullness of human experience.
- 25. Open EndedThe ancient covenant is in pieces; man at last knows that he is alone in the unfeeling immensity of the universe out of which he emerged only by chance.
- 26. Open EndedHuman knowledge is never contained in one person. It grows from the relationships create between each other and the world, and still it is never complete.
- 27. Open Ended"You have five good years left," she said. She pronounced it, but without the authoritative tone of an oracle, without the confidence of a true believer. She said it, instead, like a plea. Like that patient who could speak only in numbers. Like she was not so much speaking to me as pleading, a mere human, with whatever forces and fates truly control these things. There we were, doctor and patient, in a relationship that sometimes carries a magisterial air and other times, like now, was no more, and no less, than two people huddled together, as one faces the abyss. Doctors, it turns out, need hope, too.
- 28. Open EndedMedical training is relentlessly future-oriented, all about delayed gratification; you're always thinking about what you'll be doing five years down the line. Graham Greene once said that life was lived in the first twenty years and there remainder was just reflection. The future, instead of the ladder toward the goals of life, flattens out into a perpetual present. Money, status, all the vanities the preacher of Ecclesiastes described hold so little interest: chasing after wind, indeed.
- 29. Open EndedMy heart swelled even as Is peeled myself, anticipating his suffering, worrying that he had only weeks left - if that. I envisioned his funeral as we held hands.
- 30. Open EndedI returned to Paul's bedside. He looked at me, his dark eyes alert above the nose bridge of the BiPAP mask, and said clearly, his voice soft but unwavering, "I'm ready." Ready, he meant, to remove the breathing support, to start morphine, to die. The family gathered together. During the precious minutes after Paul's decision, we all expressed our love and respect. Tears glistened in Paul's eyes. He expressed gratitude to his parents. He asked us to ensure that his manuscript be published in some form. He told me a last time that he loved me. With my heart breaking, I climbed into the last bed we would share.
- 31. Open EndedThis book carries the urgency of racing against time, of having important things to say. Paul confronted death - examined it, wrestled with it, accepted it - as a physician and a patient. Dying in one's fourth decade is unusual, but dying is not.
- 32. Open Ended'That's what I'm aiming for. Not the sensationalism of dying, and not exhortations to gather rosebuds, but: Here's what lies up ahead on the road." Of course he did more than just describe the terrain. He traversed it bravely...Paul faced each stage of his illness with grace - not with bravado or a misguided faith that he would "overcome" or "beat" cancer but with an authenticity that allowed him to grieve the loss of the future he had planned and forge a new one. Even while terminally ill, Paul was fully alive; he remained vigorous, open, full of hope not for an unlikely cure but for days that were full of purpose and meaning."
- 33. Open EndedPaul was buried in a willow casket at the edge of a field in the Santa Cruz Mountains, overlooking the Pacific Ocean and a coastline studded with memories - brisk hikes, seafood feasts, birthday cocktails. I visit his grave often, taking a small bottle of Madeira, the wine of our honeymoon destination. Each time, I pour some out on the grass for Paul. When Paul's parents and brothers are with me, we talk as I rub the grass as if it were Paul's hair.
- 34. Open EndedWhat happened to Paul was tragic, but he was not a tragedy.
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