لخّصلي

IT OCCURS TO ME, as I write this, that the foreword to this book might be better thought of as an afterword."When you grow up, are you going to be a scientist or a...chef?" Eventually the term ended and I was on the windy mountain road to camp, still slightly worried that I'd made a wrong turn in life. My doubt, however, was shortlived. The camp delivered on its promise, concentrating all the idylls of youth: beauty manifest in lakes, mountains, people; richness in experience, conversation, friendships. Nights during a full moon, the light flooded the wilderness, so it was possible to hike without a headlamp. We would hit the trail at two A.M., summiting the nearest peak, Mount Tallac, just before sunrise, the clear, starry night reflected in the flat, still lakes spread below us. Snuggled together in sleeping bags at the peak, nearly ten thousand feet up, we weathered frigid blasts of wind with coffee someone had been thoughtful enough to bring. And then we would sit and watch as the first hint of sunlight, a light tinge of day blue, would leak out of the eastern horizon, slowly erasing the stars. The day sky would spread wide and high, until the first ray of the sun made an appearance. The morning commuters began to animate the distant South Lake Tahoe roads. But craning your head back, you could see the day's blue darken halfway across the sky, and to the west, the night remained yet unconquered--pitch-black, stars in full glimmer, the full moon still pinned in the sky. To the east, the full light of day beamed toward you; to the west, night reigned with no hint of surrender. No philosopher can explain the sublime better than this, standing between day and night. It was as if this were the moment God said, "Let there be light!"The desert offered a pantheon of terrors: tarantulas, wolf spiders, fiddlebacks, bark scorpions, whip scorpions, centipedes, diamondbacks, sidewinders, Mojave greens.I found Eliot's metaphors leaking into my own language.

IT OCCURS TO ME, as I write this, that the foreword to this book might be better
thought of as an afterword. Because when it comes to Paul Kalanithi, all sense of
time is turned on its head. To begin with—or, maybe, to end with—I got to know
Paul only after his death. (Bear with me.) I came to know him most intimately when
he’d ceased to be.
I met him one memorable afternoon at Stanford in early February 2014. He’d
just published an op-ed titled “How Long Have I Got Left?” in The New York Times,
an essay that would elicit an overwhelming response, an outpouring from readers.
In the ensuing days, it spread exponentially. (I’m an infectious diseases specialist, so
please forgive me for not using the word viral as a metaphor.) In the aftermath of
that, he’d asked to come see me, to chat, to get advice about literary agents, editors,
the publishing process—he had a desire to write a book, this book, the one you are
now holding in your hands. I recall the sun filtering through the magnolia tree
outside my office and lighting this scene: Paul seated before me, his beautiful hands
exceedingly still, his prophet’s beard full, those dark eyes taking the measure of me.
In my memory, the picture has a Vermeer-like quality, a camera obscura sharpness. I
remember thinking, You must remember this, because what was falling on my retina
was precious. And because, in the context of Paul’s diagnosis, I became aware of not
just his mortality but my own.
We talked about a lot of things that afternoon. He was a neurosurgical chief
resident. We had probably crossed paths at some point, but we hadn’t shared a
patient that we could recall. He told me he had been an English and biology major as
an undergraduate at Stanford, and then stayed on for a master ’s in English literature.
We talked about his lifelong love of writing and reading. I was struck by how easily
he could have been an English professor—and, indeed, he had seemed to be headed
down that path at one point in his life. But then, just like his namesake on the road to
Damascus, he felt the calling. He became a physician instead, but one who always
dreamed of coming back to literature in some form. A book, perhaps. One day. He
thought he had time, and why not? And yet now time was the very thing he had so
little of.
I remember his wry, gentle smile, a hint of mischief there, even though his face
was gaunt and haggard. He’d been through the wringer with this cancer but a new
biological therapy had produced a good response, allowing him to look ahead a bit. He said during medical school he’d assumed that he would become a psychiatrist,
only to fall in love with neurosurgery. It was much more than a falling in love with
the intricacies of the brain, much more than the satisfaction of training his hands to
accomplish amazing feats—it was a love and empathy for those who suffered, for
what they endured and what he might bring to bear. I don’t think he told me this as
much as I had heard about this quality of his from students of mine who were his
acolytes: his fierce belief in the moral dimension of his job. And then we talked
about his dying.
After that meeting, we kept in touch by email, but never saw each other again. It
was not just that I disappeared into my own world of deadlines and responsibilities
but also my strong sense that the burden was on me to be respectful of his time. It
was up to Paul if he wanted to see me. I felt that the last thing he needed was the
obligation to service a new friendship. I thought about him a lot, though, and about
his wife. I wanted to ask him if he was writing. Was he finding the time? For years,
as a busy physician, I’d struggled to find the time to write. I wanted to tell him that a
famous writer, commiserating about this eternal problem, once said to me, “If I
were a neurosurgeon and I announced that I had to leave my guests to go in for an
emergency craniotomy, no one would say a word. But if I said I needed to leave the
guests in the living room to go upstairs to write…” I wondered if Paul would have
found this funny. After all, he could actually say he was going to do a craniotomy! It
was plausible! And then he could go write instead.
While Paul was writing this book, he published a short, remarkable essay in
Stanford Medicine, in an issue that was devoted to the idea of time. I had an essay in
the same issue, my piece juxtaposed to his, though I learned of his contribution only
when the magazine was in my hands. In reading his words, I had a second, deeper
glimpse of something of which there had been a hint in the New York Times essay:
Paul’s writing was simply stunning. He could have been writing about anything, and
it would have been just as powerful. But he wasn’t writing about anything—he was
writing about time and what it meant to him now, in the context of his illness. Which
made it all so incredibly poignant.
But here’s the thing I must come back to: the prose was unforgettable. Out of
his pen he was spinning gold.
I reread Paul's piece again and again, trying to understand what he had brought
about. First, it was musical. It had echoes of Galway Kinnell, almost a prose poem.
(“If one day it happens / you find yourself with someone you love / in a café at one
end /of the Pont Mirabeau, at the zinc bar / where wine stands in upward opening
glasses…” to quote a Kinnell line, from a poem I once heard him recite in a
bookstore in Iowa City, never looking down at the paper.) But it also had a taste of
something else, something from an antique land, from a time before zinc bars. It
finally came to me a few days later when I picked up his essay yet again: Paul’swriting was reminiscent of Thomas Browne’s. Browne had written Religio Medici
in the prose of 1642, with all its archaic spellings and speech. As a young physician,
I was obsessed with that book, kept at it like a farmer trying to drain a bog that his
father before him had failed to drain. It was a futile task, and yet I was desperate to
learn its secrets, tossing it aside in frustration, then picking it up again, unsure that it
had anything for me but, in sounding the words, sensing that it did. I felt that I lacked
some critical receptor for the letters to sing, to impart their meaning. It remained
opaque, no matter how hard I tried.
Why, you ask? Why did I persevere? Who cares about Religio Medici?
Well, my hero William Osler cared, that’s who. Osler was the father of modern
medicine, a man who died in 1919. He had loved the book. He kept it on his
nightstand. He’d asked to be buried with a copy of Religio Medici. For the life of
me, I didn’t get what Osler saw in it. After many tries—and after some decades—the
book finally revealed itself to me. (It helped that a newer edition had modern
spellings.) The trick, I discovered, was to read it aloud, which made the cadence
inescapable: “We carry with us the wonders, we seek without us: There is all Africa,
and her prodigies in us; we are that bold and adventurous piece of nature, which he
that studies, wisely learns in a compendium, what others labour at in a divided piece
and endless volume.” When you come to the last paragraph of Paul’s book, read it
aloud and you will hear that same long line, the cadence you think you can tap your
feet to…but as with Browne, you will be just off. Paul, it occurred to me, was
Browne redux. (Or given that forward time is our illusion, perhaps it’s that Browne
was Kalanithi redux. Yes, it’s head-spinning stuff.)
And then Paul died. I attended his memorial in the Stanford church, a gorgeous
space where I often go when it is empty to sit and admire the light, the silence, and
where I always find renewal. It was packed for the service. I sat off to one side,
listening to a series of moving and sometimes raucous stories from his closest
friends, his pastor, and his brother. Yes, Paul was gone, but strangely, I felt I was
coming to know him, beyond that visit in my office, beyond the few essays he’d
written. He was taking form in those tales being told in the Stanford Memorial
Church, its soaring cathedral dome a fitting space in which to remember this man
whose body was now in the earth but who nevertheless was so palpably alive. He
took form in the shape of his lovely wife and baby daughter, his grieving parents
and siblings, in the faces of the legions of friends, colleagues, and former patients
who filled that space; he was there at the reception later, outdoors in a setting where
so many came together. I saw faces looking calm, smiling, as if they had witnessed
something profoundly beautiful in the church. Perhaps my face was like that, too: we
had found meaning in the ritual of a service, in the ritual of eulogizing, in the
shared tears. There was further meaning residing in this reception where we slaked
our thirst, fed our bodies, and talked with complete strangers to whom we were intimately connected through Paul.
But it was only when I received the pages that you now hold in your hands, two
months after Paul died, that I felt I had finally come to know him, to know him better
than if I had been blessed to call him a friend. After reading the book you are about
to read, I confess I felt inadequate: there was an honesty, a truth in the writing that
took my breath away.
Be ready. Be seated. See what courage sounds like. See how brave it is to reveal
yourself in this way. But above all, see what it is to still live, to profoundly influence
the lives of others after you are gone, by your words. In a world of asynchronous
communication, where we are so often buried in our screens, our gaze rooted to the
rectangular objects buzzing in our hands, our attention consumed by ephemera, stop
and experience this dialogue with my young departed colleague, now ageless and
extant in memory. Listen to Paul. In the silences between his words, listen to what
you have to say back. Therein lies his message. I got it. I hope you experience it, too.
It is a gift. Let me not stand between you and Paul. I FLIPPED THROUGH THE CT scan images, the diagnosis obvious: the lungs were
matted with innumerable tumors, the spine deformed, a full lobe of the liver
obliterated. Cancer, widely disseminated. I was a neurosurgical resident entering my
final year of training. Over the last six years, I’d examined scores of such scans, on
the off chance that some procedure might benefit the patient. But this scan was
different: it was my own.
I wasn’t in the radiology suite, wearing my scrubs and white coat. I was dressed
in a patient’s gown, tethered to an IV pole, using the computer the nurse had left in
my hospital room, with my wife, Lucy, an internist, at my side. I went through each
sequence again: the lung window, the bone window, the liver window, scrolling
from top to bottom, then left to right, then front to back, just as I had been trained to
do, as if I might find something that would change the diagnosis.
We lay together on the hospital bed.
Lucy, quietly, as if reading from a script: “Do you think there’s any possibility
that it’s something else?”
“No,” I said.
We held each other tightly, like young lovers. In the past year we’d both
suspected, but refused to believe, or even discuss, that a cancer was growing inside
me.
About six months before, I had started losing weight and having ferocious back
pain. When I dressed in the morning, my belt cinched one, then two notches tighter. I
went to see my primary care doctor, an old classmate from Stanford. Her sister had
died suddenly as a neurosurgery intern, after contracting a virulent infection, and so
she’d taken a maternal watch on my health. When I arrived, however, I found a
different doctor in her office—my classmate was on maternity leave.
Dressed in a thin blue gown on a cold examining table, I described the
symptoms to her. “Of course,” I said, “if this were a boards exam question—thirtyfive-
year-old with unexplained weight loss and new-onset back pain—the obvious
answer would be (C) cancer. But maybe it’s just that I’m working too hard. I don’t
know. I’d like to get an MRI to be sure.”
“I think we should get X-rays first,” she said. MRIs for back pain are expensive,
and unnecessary imaging had lately become a major national point of cost-saving
emphasis. But the value of a scan also depends on what you are looking for: X-rays
are largely useless for cancer. Still, for many docs, ordering an MRI at this early
stage is apostasy. She continued: “X-rays aren’t perfectly sensitive, but it makes
sense to start there.”
“How about we get flexion-extension X-rays, then—maybe the more realistic
diagnosis here is isthmic spondylolisthesis?”
From the reflection in the wall mirror, I could see her googling it.
“It’s a pars fracture affecting up to five percent of people and a frequent cause
of back pain in the young.”
“Okay, I’ll order them, then.”
“Thanks,” I said.
Why was I so authoritative in a surgeon’s coat but so meek in a patient's gown?
The truth was, I knew more about back pain than she did—half of my training as a
neurosurgeon had involved disorders of the spine. But maybe a spondy was more
likely. It did affect a significant percent of young adults—and cancer in the spine in
your thirties? The odds of that couldn’t be more than one in ten thousand. Even if it
were one hundred times more common than that, it’d still be less common than a
spondy. Maybe I was just freaking myself out.
The X-rays looked fine. We chalked the symptoms up to hard work and an
aging body, scheduled a follow-up appointment, and I went back to finish my last
case of the day. The weight loss slowed, and the back pain became tolerable. A
healthy dose of ibuprofen got me through the day, and after all, there weren’t that
many of these grueling, fourteen-hour days left. My journey from medical student
to professor of neurosurgery was almost complete: after ten years of relentless
training, I was determined to persevere for the next fifteen months, until residency
ended. I had earned the respect of my seniors, won prestigious national awards, and
was fielding job offers from several major universities. My program director at
Stanford had recently sat me down and said, “Paul, I think you’ll be the number one
candidate for any job you apply for. Just as an FYI: we’ll be starting a faculty search
for someone like you here. No promises, of course, but it’s something you should
consider.”
At age thirty-six, I had reached the mountaintop; I could see the Promised Land,
from Gilead to Jericho to the Mediterranean Sea. I could see a nice catamaran on
that sea that Lucy, our hypothetical children, and I would take out on weekends. I
could see the tension in my back unwinding as my work schedule eased and life
became more manageable. I could see myself finally becoming the husband I’d
promised to be.
Then, a few weeks later, I began having bouts of severe chest pain. Had I
bumped into something at work? Cracked a rib somehow? Some nights, I’d wake up
on soaked sheets, dripping sweat. My weight began dropping again, more rapidly
now, from 175 to 145 pounds. I developed a persistent cough. Little doubt remained.
One Saturday afternoon, Lucy and I were lying in the sun in Dolores Park in San
Francisco, waiting to meet her sister. She glimpsed my phone screen, which
displayed medical database search results: “frequency of cancers in thirty- to fortyyear-
olds.”
“What?” she said. “I didn’t realize you were actually worried about this.”
I didn’t respond. I didn’t know what to say.
“Do you want to tell me about it?” she asked.
She was upset because she had been worried about it, too. She was upset
because I wasn’t talking to her about it. She was upset because I’d promised her one
life, and given her another.
“Can you please tell me why you aren’t confiding in me?” she asked.
I turned off my phone. “Let’s get some ice cream,” I said.
—
We were scheduled for a vacation the following week to visit some old college
friends in New York. Maybe a good night’s sleep and a few cocktails would help us
reconnect a bit and decompress the pressure cooker of our marriage.
But Lucy had another plan. “I’m not coming to New York with you,” she
announced a few days before the trip. She was going to move out for a week; she
wanted time to consider the state of our marriage. She spoke in even tones, which
only heightened the vertigo I felt.
“What?” I said. “No.”
“I love you so much, which is why this is so confusing,” she said. “But I’m
worried we want different things from our relationship. I feel like we’re connected
halfway. I don’t want to learn about your worries by accident. When I talk to you
about feeling isolated, you don't seem to think it’s a problem. I need to do something
different.”
“Things are going to be okay,” I said. “It’s just residency.”
Were things really so bad? Neurosurgical training, among the most rigorous
and demanding of all medical specialties, had surely put a strain on our marriage.
There were so many nights when I came home late from work, after Lucy had gone
to bed, and collapsed on the living room floor, exhausted, and so many mornings
when I left for work in the early dark, before she’d awoken. But our careers were
peaking now—most universities wanted both of us: me in neurosurgery, Lucy in internal medicine. We’d survived the most difficult part of our journey. Hadn’t we
discussed this a dozen times? Didn’t she realize this was the worst possible time for
her to blow things up? Didn’t she see that I had only one year left in residency, that I
loved her, that we were so close to the life together we’d always wanted?
“If it were just residency, I could make it,” she said. “We’ve made it this far. But
the problem is, what if it’s not just residency? Do you really think things will be
better when you’re an academic neurosurgery attending?”
I offered to skip the trip, to be more open, to see the couples therapist Lucy had
suggested a few months ago, but she insisted that she needed time—alone. At that
point, the fuzziness of the confusion dissipated, leaving only a hard edge. Fine, I
said. If she decided to leave, then I would assume the relationship was over. If it
turned out that I had cancer, I wouldn’t tell her—she’d be free to live whatever life
she chose.
Before leaving for New York, I snuck in a few medical appointments to rule
out some common cancers in the young. (Testicular? No. Melanoma? No.
Leukemia? No.) The neurosurgical service was busy, as always. Thursday night
slipped into Friday morning as I was caught in the operating room for thirty-six
hours straight, in a series of deeply complex cases: giant aneurysms, intracerebral
arterial bypasses, arteriovenous malformations. I breathed a silent thanks when the
attending came in, allowing me a few minutes to ease my back against a wall. The
only time to get a chest X-ray was as I was leaving the hospital, on the way home
before heading to the airport. I figured either I had cancer, in which case this might
be the last time I would see my friends, or I didn’t, in which case there was no
reason to cancel the trip.
I rushed home to grab my bags. Lucy drove me to the airport and told me she
had scheduled us into couples therapy.
From the gate, I sent her a text message: “I wish you were here.”
A few minutes later, the response came back: “I love you. I will be here when
you get back.”
My back stiffened terribly during the flight, and by the time I made it to Grand
Central to catch a train to my friends’ place upstate, my body was rippling with pain.
Over the past few months, I’d had back spasms of varying ferocity, from simple
ignorable pain, to pain that made me forsake speech to grind my teeth, to pain so
severe I curled up on the floor, screaming. This pain was toward the more severe
end of the spectrum. I lay down on a hard bench in the waiting area, feeling my back
muscles contort, breathing to control the pain—the ibuprofen wasn’t touching this—
and naming each muscle as it spasmed to stave off tears: erector spinae, rhomboid,
latissimus, piriformis…
A security guard approached. “Sir, you can’t lie down here.”
“I’m sorry,” I said, gasping out the words. “Bad…back…spasms.”
“You still can’t lie down here.”
I’m sorry, but I’m dying from cancer.
The words lingered on my tongue—but what if I wasn’t? Maybe this was just
what people with back pain live with. I knew a lot about back pain—its anatomy, its
physiology, the different words patients used to describe different kinds of pain—
but I didn’t know what it felt like. Maybe that’s all this was. Maybe. Or maybe I
didn’t want the jinx. Maybe I just didn’t want to say the word cancer out loud.
I pulled myself up and hobbled to the platform.
It was late afternoon when I reached the house in Cold Spring, fifty miles north
of Manhattan on the Hudson River, and was greeted by a dozen of my closest friends
from years past, their cheers of welcome mixed with the cacophony of young,
happy children. Hugs ensued, and an ice-cold dark and stormy made its way to my
hand.
“No Lucy?”
“Sudden work thing,” I said. “Very last-minute.”
“Oh, what a bummer!”
“Say, do you mind if I put my bags down and rest a bit?”
I had hoped a few days out of the OR, with adequate sleep, rest, and relaxation
—in short, a taste of a normal life—would bring my symptoms back into the
normal spectrum for back pain and fatigue. But after a day or two, it was clear there
would be no reprieve.
I slept through breakfasts and shambled to the lunch table to stare at ample
plates of cassoulet and crab legs that I couldn’t bring myself to eat. By dinner, I was
exhausted, ready for bed again. Sometimes I read to the kids, but mostly they played
on and around me, leaping and yelling. (“Kids, I think Uncle Paul needs a rest. Why
don’t you play over there?”) I remembered a day off as a summer camp counselor,
fifteen years prior, sitting on the shore of a lake in Northern California, with a
bunch of joyous kids using me as an obstacle in a convoluted game of Capture the
Flag, while I read a book called Death and Philosophy. I used to laugh at the
incongruities of that moment: a twenty-year-old amid the splendor of trees, lake,
mountains, the chirping of birds mixed with the squeal of happy four-year-olds, his
nose buried in a small black book about death. Only now, in this moment, I felt the
parallels: instead of Lake Tahoe, it was the Hudson River; the children were not
strangers’, but my friends’; instead of a book on death separating me from the life
around me, it was my own body, dying.
On the third night, I spoke to Mike, our host, to tell him I was going to cut the
trip short and head home the next day.
“You don’t look so great,” he said. “Everything okay?”
“Why don’t we grab some scotch and have a seat?” I said.
In front of his fireplace, I said, “Mike, I think I have cancer. And not the good
kind, either.”
It was the first time I’d said it out loud.
“Okay,” he said. “I take it this is not some elaborate practical joke?”
“No.”
He paused. “I don’t know exactly what to ask.”
“Well, I suppose, first, I should say that I don’t know for a fact that I have
cancer. I’m just pretty sure of it—a lot of the symptoms point that way. I’m going to
go home tomorrow and sort it out. Hopefully, I’m wrong.”
Mike offered to take my luggage and send it home by mail, so I wouldn’t have
to carry it with me. He drove me to the airport early the next morning, and six hours
later I landed in San Francisco. My phone rang as I stepped off the plane. It was my
primary care doctor, calling with the chest X-ray result: my lungs, instead of being
clear, looked blurry, as if the camera aperture had been left open too long. The
doctor said she wasn’t sure what that meant.
She likely knew what it meant.
I knew.
Lucy picked me up from the airport, but I waited until we were home to tell her.
We sat on the couch, and when I told her, she knew. She leaned her head on my
shoulder, and the distance between us vanished.
“I need you,” I whispered.
“I will never leave you,” she said.
We called a close friend, one of the attending neurosurgeons at the hospital,
and asked him to admit me.
I received the plastic arm bracelet all patients wear, put on the familiar light
blue hospital gown, walked past the nurses I knew by name, and was checked in to a
room—the same room where I had seen hundreds of patients over the years. In this
room, I had sat with patients and explained terminal diagnoses and complex
operations; in this room, I had congratulated patients on being cured of a disease
and seen their happiness at being returned to their lives; in this room, I had
pronounced patients dead. I had sat in the chairs, washed my hands in the sink,
scrawled instructions on the marker board, changed the calendar. I had even, in
moments of utter exhaustion, longed to lie down in this bed and sleep. Now I lay
there, wide awake.
A young nurse, one I hadn’t met, poked her head in.
“The doctor will be in soon.”
And with that, the future I had imagined, the one just about to be realized, the culmination of decades of striving, evaporated. I KNEW WITH CERTAINTY that I would never be a doctor. I stretched out in the sun,
relaxing on a desert plateau just above our house. My uncle, a doctor, like so many
of my relatives, had asked me earlier that day what I planned on doing for a career,
now that I was heading off to college, and the question barely registered. If you had
forced me to answer, I suppose I would have said a writer, but frankly, thoughts of
any career at this point seemed absurd. I was leaving this small Arizona town in a
few weeks, and I felt less like someone preparing to climb a career ladder than a
buzzing electron about to achieve escape velocity, flinging out into a strange and
sparkling universe.
I lay there in the dirt, awash in sunlight and memory, feeling the shrinking size
of this town of fifteen thousand, six hundred miles from my new college dormitory
at Stanford and all its promise.
I knew medicine only by its absence—specifically, the absence of a father
growing up, one who went to work before dawn and returned in the dark to a plate
of reheated dinner. When I was ten, my father had moved us—three boys, ages
fourteen, ten, and eight—from Bronxville, New York, a compact, affluent suburb
just north of Manhattan, to Kingman, Arizona, in a desert valley ringed by two
mountain ranges, known primarily to the outside world as a place to get gas en
route to somewhere else. He was drawn by the sun, by the cost of living—how else
would he pay for his sons to attend the colleges he aspired to?—and by the
opportunity to establish a regional cardiology practice of his own. His unyielding
dedication to his patients soon made him a respected member of the community.
When we did see him, late at night or on weekends, he was an amalgam of sweet
affections and austere diktats, hugs and kisses mixed with stony pronouncements:
“It’s very easy to be number one: find the guy who is number one, and score one
point higher than he does.” He had reached some compromise in his mind that
fatherhood could be distilled; short, concentrated (but sincere) bursts of high
intensity could equal…whatever it was that other fathers did. All I knew was, if that
was the price of medicine, it was simply too high. From my desert plateau, I could see our house, just beyond the city limits, at the
base of the Cerbat Mountains, amid red-rock desert speckled with mesquite,
tumbleweeds, and paddle-shaped cacti. Out here, dust devils swirled up from
nothing, blurring your vision, then disappeared. Spaces stretched on, then fell away
into the distance. Our two dogs, Max and Nip, never grew tired of the freedom.
Every day, they’d venture forth and bring home some new desert treasure: the leg of
a deer, unfinished bits of jackrabbit to eat later, the sun-bleached skull of a horse, the
jawbone of a coyote.
My friends and I loved the freedom, too, and we spent our afternoons
exploring, walking, scavenging for bones and rare desert creeks. Having spent my
previous years in a lightly forested suburb in the Northeast, with a tree-lined main
street and a candy store, I found the wild, windy desert alien and alluring. On my
first trek alone, as a ten-year-old, I discovered an old irrigation grate. I pried it open
with my fingers, lifted it up, and there, a few inches from my face, were three white
silken webs, and in each, marching along on spindled legs, was a glistening black
bulbous body, bearing in its shine the dreaded blood-red hourglass. Near to each
spider a pale, pulsating sac breathed with the imminent birth of countless more
black widows. Horror let the grate crash shut. I stumbled back. The horror came in a
mix of “country facts” (Nothing is more deadly than the bite of the black widow
spider) and the inhuman posture and the black shine and the red hourglass. I had
nightmares for years.
The desert offered a pantheon of terrors: tarantulas, wolf spiders, fiddlebacks,
bark scorpions, whip scorpions, centipedes, diamondbacks, sidewinders, Mojave
greens. Eventually we grew familiar, even comfortable, with these creatures. For
fun, when my friends and I discovered a wolf spider ’s nest, we’d drop an ant onto its
outer limits and watch as its entangled escape attempts sent quivers down the silk
strands, into the spider ’s dark central hole, anticipating that fatal moment when the
spider would burst from its hollows and seize the doomed ant in its mandibles.
“Country facts” became my term for the rural cousin of the urban legend. As I first
learned them, country facts granted fairy powers to desert creatures, making, say,
the Gila monster no less an actual monster than the Gorgon. Only after living out in
the desert for a while did we realize that some country facts, like the existence of the
jackalope, had been deliberately created to confuse city folk and amuse the locals. I
once spent an hour convincing a group of exchange students from Berlin that, yes,
there was a particular species of coyote that lived inside cacti and could leap ten
yards to attack its prey (like, well, unsuspecting Germans). Yet no one precisely
knew where the truth lay amid the whirling sand; for every country fact that seemed
preposterous, there was one that felt solid and true. Always check your shoes for
scorpions, for example, seemed plain good sense.
When I was sixteen, I was supposed to drive my younger brother, Jeevan, to school. One morning, as usual, I was running late, and as Jeevan was standing
impatiently in the foyer, yelling that he didn’t want to get detention again because of
my tardiness, so could I please hurry the hell up, I raced down the stairs, threw open
the front door…and nearly stepped on a snoozing six-foot rattlesnake. It was
another country fact that if you killed a rattlesnake on your doorstep, its mate and
offspring would come and make a permanent nest there, like Grendel’s mother
seeking her revenge. So Jeevan and I drew straws: the lucky one grabbed a shovel,
the unlucky one a pair of thick gardening gloves and a pillowcase, and through a
seriocomic dance, we managed to get the snake into the pillowcase. Then, like an
Olympic hammer thrower, I hurled the whole out into the desert, with plans to
retrieve the pillowcase later that afternoon, so as not to get in trouble with our
mother.
—
Of our many childhood mysteries, chief among them was not why our father
decided to bring his family to the desert town of Kingman, Arizona, which we grew
to cherish, but how he ever convinced my mother to join him there. They had
eloped, in love, across the world, from southern India to New York City (he a
Christian, she a Hindu, their marriage was condemned on both sides, and led to
years of familial rifts—my mother ’s mother never acknowledged my name, Paul,
instead insisting I be called by my middle name, Sudhir) to Arizona, where my
mother was forced to confront an intractable mortal fear of snakes. Even the
smallest, cutest, most harmless red racer would send her screaming into the house,
where she’d lock the doors and arm herself with the nearest large, sharp implement
—rake, cleaver, ax.
The snakes were a constant source of anxiety, but it was her children’s future
that my mother feared for most of all. Before we moved, my older brother, Suman,
had nearly completed high school in Westchester County, where elite colleges were
the expectation. He was accepted to Stanford shortly after arriving in Kingman and
left the house soon thereafter. But Kingman, we learned, was not Westchester. As my
mother surveyed the Mohave County public school system, she became distraught.
The U.S. census had recently identified Kingman as the least educated district in
America. The high school dropout rate was somewhere north of 30 percent. Few
students went on to college, and certainly none to Harvard, my father ’s standard of
excellence. Looking for advice, my mother called her friends and relatives from
wealthy East Coast suburbs and found some sympathetic, others gleeful that their
children no longer had to compete with the suddenly education-starved Kalanithis.
At night, she broke into tears, sobbing alone in her bed. My mother, afraid the
impoverished school system would hobble her children, acquired, from
somewhere, a “college prep reading list.” Trained in India to be a physiologist,
married at twenty-three, and preoccupied with raising three kids in a country that
was not her own, she had not read many of the books on the list herself. But she
would make sure her kids were not deprived. She made me read 1984 when I was ten
years old; I was scandalized by the sex, but it also instilled in me a deep love of, and
care for, language.
Endless books and authors followed, as we worked our way methodically
down the list: The Count of Monte Cristo, Edgar Allan Poe, Robinson Crusoe,
Ivanhoe, Gogol, The Last of the Mohicans, Dickens, Twain, Austen, Billy Budd…By
the time I was twelve, I was picking them out myself, and my brother Suman was
sending me the books he had read in college: The Prince, Don Quixote, Candide, Le
Morte D’Arthur, Beowulf, Thoreau, Sartre, Camus. Some left more of a mark than
others. Brave New World founded my nascent moral philosophy and became the
subject of my college admissions essay, in which I argued that happiness was not the
point of life. Hamlet bore me a thousand times through the usual adolescent crises.
“To His Coy Mistress” and other romantic poems led me and my friends on various
joyful misadventures throughout high school—we often sneaked out at night to, for
example, sing “American Pie” beneath the window of the captain of the
cheerleading team. (Her father was a local minister and so, we reasoned, less likely
to shoot.) After 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. Books became
my closest confidants, finely ground lenses providing new views of the world.
In her quest to see that her children were educated, my mom drove us more
than a hundred miles north, to the nearest big city, Las Vegas, so we could take our
PSATs, SATs, and ACTs. She joined the school board, rallied teachers, and
demanded that AP classes be added to the curriculum. She was a phenom: she took it
upon herself to transform the Kingman school system, and she did. Suddenly there
was a feeling in our high school that the two mountain ranges that bounded the town
no longer defined the horizon: it was what lay beyond them.
Senior year, my close friend Leo, our salutatorian and the poorest kid I knew,
was advised by the school guidance counselor, “You’re smart—you should join the
army.”
He told me about it afterward. “Fuck that,” he said. “If you’re going to Harvard,
or Yale, or Stanford, then I am, too.”
I don’t know if I was happier when I got into Stanford or when Leo got into
Yale.
Summer passed, and since Stanford began classes a month later than every
other school, all of my friends scattered, leaving me behind. Most afternoons, I’d
trek into the desert alone and nap and think until my girlfriend, Abigail, got off her
shift at Kingman’s lone coffee shop. The desert offered a shortcut, through the
mountains and down into town, and hiking was more fun than driving. Abigail was
in her early twenties, a student at Scripps College who, wanting to avoid loans, was
taking a semester off to stockpile tuition money. I was taken with her worldliness,
the sense that she knew secrets one only learned at college—she had studied
psychology!—and we’d often meet as she got off work. She was a harbinger of the
sub rosa, the new world awaiting me in just a few weeks. One afternoon, I woke
from my nap, looked up, and saw vultures circling, mistaking me for carrion. I
checked my watch; it was almost three. I was going to be late. I dusted off my jeans
and jogged the rest of the way through the desert, until sand gave way to pavement,
the first buildings appeared, and I rounded the corner to find Abigail, broom in
hand, sweeping the coffee shop deck.
“I already cleaned the espresso machine,” she said, “so no iced latte for you
today.”
The floors swept, we went inside. Abigail walked to the cash register and
picked up a paperback she’d stashed there. “Here,” she said, tossing it at me. “You
should read this. You’re always reading such high-culture crap—why don’t you try
something lowbrow for once?”
It was a five-hundred-page novel called Satan: His Psychotherapy and Cure by
the Unfortunate Dr. Kassler, J.S.P.S., by Jeremy Leven. I took it home and read it in a
day. It wasn’t high culture. It should have been funny, but it wasn’t. However, it did
make the throwaway assumption that the mind was simply the operation of the brain,
an idea that struck me with force; it startled my naïve understanding of the world. Of
course, it must be true—what were our brains doing, otherwise? Though we had
free will, we were also biological organisms—the brain was an organ, subject to all
the laws of physics, too! Literature provided a rich account of human meaning; the
brain, then, was the machinery that somehow enabled it. It seemed like magic. That
night, in my room, I opened up my red Stanford course catalog, which I had read
through dozens of times, and grabbed a highlighter. In addition to all the literature
classes I had marked, I began looking in biology and neuroscience as well.
—
A few years later, I hadn’t thought much more about a career but had nearly
completed degrees in English literature and human biology. I was driven less by
achievement than by trying to understand, in earnest: What makes human life
meaningful? I still felt literature provided the best account of the life of the mind,
while neuroscience laid down the most elegant rules of the brain. Meaning, while a
slippery concept, seemed inextricable from human relationships and moral values.T. S. Eliot’s The Waste Land resonated profoundly, relating meaninglessness and
isolation, and the desperate quest for human connection. I found Eliot’s metaphors
leaking into my own language. Other authors resonated as well. Nabokov, for his
awareness of how our suffering can make us callous to the obvious suffering of
another. Conrad, for his hypertuned sense of how miscommunication between
people can so profoundly impact their lives. Literature not only illuminated
another ’s experience, it provided, I believed, the richest material for moral
reflection. My brief forays into the formal ethics of analytic philosophy felt dry as a
bone, missing the messiness and weight of real human life.
Throughout college, my monastic, scholarly study of human meaning would
conflict with my urge to forge and strengthen the human relationships that formed
that meaning. If the unexamined life was not worth living, was the unlived life worth
examining? Heading into my sophomore summer, I applied for two jobs: as an
intern at the highly scientific Yerkes Primate Research Center, in Atlanta, and as a
prep chef at Sierra Camp, a family vacation spot for Stanford alumni on the pristine
shores of Fallen Leaf Lake, abutting the stark beauty of Desolation Wilderness in
Eldorado National Forest. The camp’s literature promised, simply, the best summer
of your life. I was surprised and flattered to be accepted. Yet I had just learned that
macaques had a rudimentary form of culture, and I was eager to go to Yerkes and
see what could be the natural origin of meaning itself. In other words, I could either
study meaning or I could experience it.
After delaying for as long as possible, I finally chose the camp. Afterward, I
dropped by my biology adviser ’s office to inform him of my decision. When I
walked in, he was sitting at his desk, head in a journal, as usual. He was a quiet,
amiable man with heavy-lidded eyes, but as I told him my plans, he became a
different person entirely: his eyes shot open, and his face flushed red, flecks of spit
spraying.
“What?” he said. “When you grow up, are you going to be a scientist or
a…chef?”
Eventually the term ended and I was on the windy mountain road to camp, still
slightly worried that I’d made a wrong turn in life. My doubt, however, was shortlived.
The camp delivered on its promise, concentrating all the idylls of youth:
beauty manifest in lakes, mountains, people; richness in experience, conversation,
friendships. Nights during a full moon, the light flooded the wilderness, so it was
possible to hike without a headlamp. We would hit the trail at two A.M., summiting
the nearest peak, Mount Tallac, just before sunrise, the clear, starry night reflected
in the flat, still lakes spread below us. Snuggled together in sleeping bags at the
peak, nearly ten thousand feet up, we weathered frigid blasts of wind with coffee
someone had been thoughtful enough to bring. And then we would sit and watch as
the first hint of sunlight, a light tinge of day blue, would leak out of the eastern horizon, slowly erasing the stars. The day sky would spread wide and high, until the
first ray of the sun made an appearance. The morning commuters began to animate
the distant South Lake Tahoe roads. But craning your head back, you could see the
day’s blue darken halfway across the sky, and to the west, the night remained yet
unconquered—pitch-black, stars in full glimmer, the full moon still pinned in the
sky. To the east, the full light of day beamed toward you; to the west, night reigned
with no hint of surrender. No philosopher can explain the sublime better than this,
standing between day and night. It was as if this were the moment God said, “Let
there be light!” You could not help but feel your specklike existence against the
immensity of the mountain, the earth, the universe, and yet still feel your own two
feet on the talus, reaffirming your presence amid the grandeur.
This was summer at Sierra Camp, perhaps no different from any other camp,
but every day felt full of life, and of the relationships that give life meaning. Other
nights found a group of us on the dining room deck, sipping whiskey with the
assistant director of the camp, Mo, a Stanford alum taking a break from his English
PhD, and discussing literature and the weighty matters of postadolescent life. The
next year he returned to his PhD, and later he sent me his first published short story,
summing up our time together:
Suddenly, now, I know what I want. I want the counselors to build a pyre…and
let my ashes drop and mingle with the sand. Lose my bones amongst the
driftwood, my teeth amongst the sand….I don’t believe in the wisdom of
children, nor in the wisdom of the old. There is a moment, a cusp, when the
sum of gathered experience is worn down by the details of living. We are never
so wise as when we live in this moment.
—
Back on campus, I didn’t miss the monkeys. Life felt rich and full, and over the next
two years I kept at it, seeking a deeper understanding of a life of the mind. I studied
literature and philosophy to understand what makes life meaningful, studied
neuroscience and worked in an fMRI lab to understand how the brain could give rise
to an organism capable of finding meaning in the world, and enriched my
relationships with a circle of dear friends through various escapades. We raided the
school cafeteria dressed as Mongols; created a full fake fraternity, complete with
fake rush-week events, in our co-op house; posed in front of the gates at
Buckingham Palace in a gorilla suit; broke into Memorial Church at midnight to lie
on our backs and listen to our voices echo in the apse; and so on. (Then I learned
that Virginia Woolf once boarded a battleship dressed as Abyssinian royalty, and,
duly chastened, stopped boasting about our trivial pranks.) Senior year, in one of my last neuroscience classes, on neuroscience and
ethics, we visited a home for people who had suffered severe brain injuries. We
walked into the main reception area and were greeted by a disconsolate wailing. Our
guide, a friendly thirty-something woman, introduced herself to the group, but my
eyes hunted for the source of the noise. Behind the reception counter was a largescreen
television showing a soap opera, on mute. A blue-eyed brunette with wellcoiffed
hair, her head shaking slightly with emotion, filled the screen as she pleaded
with someone off camera; zoom out, and there was her strong-jawed, undoubtedly
gravel-voiced lover; they embraced passionately. The wailing rose in pitch. I
stepped closer to peer over the counter, and there, on a blue mat in front of the
television, in a plain flower-print dress, was a young woman, maybe twenty, her
hands balled into fists pressed into her eyes, violently rocking back and forth,
wailing and wailing. As she rocked, I caught glimpses of the back of her head,
where her hair had worn away, leaving a large, pale patch of skin.
I stepped back to join the group, which was leaving to tour the facility. Talking
with the guide, I learned that many of the residents had nearly drowned as young
children. Looking around, I noticed there were no other visitors besides us. Was that
common? I asked.
At first, the guide explained, a family will visit constantly, daily or even twice a
day. Then maybe every other day. Then just weekends. After months or years, the
visits taper off, until it’s just, say, birthdays and Christmas. Eventually, most families
move away, as far as they can get.
“I don’t blame them,” she said. “It’s hard caring for these kids.”
A fury churned in me. Hard? Of course it was hard, but how could parents
abandon these kids? In one room, the patients lay on cots, mostly still, arranged in
neat rows like soldiers in a barracks. I walked down a row until I made eye contact
with one of them. She was in her late teens, with dark, tangled hair. I paused and
tried smiling at her, showing her I cared. I picked up one of her hands; it was limp.
But she gurgled and, looking right at me, smiled.
“I think she’s smiling,” I said to the attendant.
“Could be,” she said. “It can be hard to tell sometimes.”
But I was sure of it. She was smiling.
When we got back to campus, I was the last one left in the room with the
professor. “So, what’d you think?” he asked.
I vented openly about how I couldn’t believe that parents had abandoned these
poor kids, and how one of them had even smiled at me.
The professor was a mentor, someone who thought deeply about how science
and morality intersected. I expected him to agree with me.
“Yeah,” he said. “Good. Good for you. But sometimes, you know, I think it’s better if they die.”
I grabbed my bag and left.
She had been smiling, hadn’t she?
Only later would I realize that our trip had added a new dimension to my
understanding of the fact that brains give rise to our ability to form relationships
and make life meaningful. Sometimes, they break.
—
As graduation loomed, I had a nagging sense that there was still far too much
unresolved for me, that I wasn’t done studying. I applied for a master ’s in English
literature at Stanford and was accepted into the program. I had come to see language
as an almost supernatural force, existing between people, bringing our brains,
shielded in centimeter-thick skulls, into communion. 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. It was the relational aspect of humans—i.e., “human
relationality”—that undergirded meaning. Yet somehow, this process existed in
brains and bodies, subject to their own physiologic imperatives, prone to breaking
and failing. There must be a way, I thought, that the language of life as experienced
—of passion, of hunger, of love—bore some relationship, however convoluted, to
the language of neurons, digestive tracts, and heartbeats.
At Stanford, I had the good fortune to study with Richard Rorty, perhaps the
greatest living philosopher of his day, and under his tutelage I began to see all
disciplines as creating a vocabulary, a set of tools for understanding human life in a
particular way. Great literary works provided their own sets of tools, compelling
the reader to use that vocabulary. For my thesis, I studied the work of Walt Whitman,
a poet who, a century before, was possessed by the same questions that haunted me,
who wanted to find a way to understand and describe what he termed “the
Physiological-Spiritual Man.”
As I finished my thesis, I could only conclude that Whitman had had no better
luck than the rest of us at building a coherent “physiological-spiritual” vocabulary,
but at least the ways in which he’d failed were illuminating. I was also increasingly
certain that I had little desire to continue in literary studies, whose main
preoccupations had begun to strike me as overly political and averse to science. One
of my thesis advisers remarked that finding a community for myself in the literary
world would be difficult, because most English PhDs reacted to science, as he put it,
“like apes to fire, with sheer terror.” I wasn’t sure where my life was headed. My
thesis—“Whitman and the Medicalization of Personality”—was well-received, but it
was unorthodox, including as much history of psychiatry and neuroscience as
literary criticism. It didn’t quite fit in an English department. I didn’t quite fit in an English department.
Some of my closest friends from college were headed to New York City to
pursue a life in the arts—some in comedy, others in journalism and television—and
I briefly considered joining them and starting anew. But I couldn’t quite let go of the
question: Where 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.” Suddenly, it all seemed obvious. Although—or perhaps because—my
father, my uncle, and my elder brother were all doctors, medicine had never
occurred to me as a serious possibility. But hadn’t Whitman himself written that
only the physician could truly understand “the Physiological-Spiritual Man”?
The next day, I consulted a premed adviser to figure out the logistics. Getting
ready for medical school would take about a year of intense coursework, plus the
application time, which added up to another eighteen months. It would mean letting
my friends go to New York, to continue deepening those relationships, without me.
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.
I began working through the necessary premedical courses, loading up on
chemistry and physics. Reluctant to take a part-time job—it would slow my studies
—but unable to afford Palo Alto rent, I found an open window in an empty
dormitory and climbed in. After a few weeks of squatting, I was discovered by the
caretaker—who happened to be a friend. She provided a key to the room and some
useful warnings, like when the high school girls’ cheerleading camps would be
coming through. Thinking it wise to avoid becoming a registered sex offender, I’d
pack a tent, some books and granola, and head up to Tahoe until it was safe to
return.
Because the med school application cycle takes eighteen months, I had a free
year once my classes were over. Several professors had suggested I pursue a degree
in the history and philosophy of science and medicine before deciding to leave
academia for good. So I applied for, and was accepted into, the HPS program at
Cambridge. I spent the next year in classrooms in the English countryside, where I
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. Stepping back, I realized
that I was merely confirming what I already knew: 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. I finished my degree and headed back to the States. I was going to Yale for medical school.
—
You would think that the first time you cut up a dead person, you’d feel a bit funny
about it. Strangely, though, everything feels normal. The bright lights, stainless steel
tables, and bow-tied professors lend an air of propriety. Even so, that first cut,
running from the nape of the neck down to the small of the back, is unforgettable.
The scalpel is so sharp it doesn’t so much cut the skin as unzip it, revealing the
hidden and forbidden sinew beneath, and despite your preparation, you are caught
unawares, ashamed and excited. Cadaver dissection is a medical rite of passage and
a trespass on the sacrosanct, engendering a legion of feelings: from revulsion,
exhilaration, nausea, frustration, and awe to, as time passes, the mere tedium of
academic exercise. Everything teeters between pathos and bathos: here you are,
violating society’s most fundamental taboos, and yet formaldehyde is a powerful
appetite stimulant, so you also crave a burrito. Eventually, as you complete your
assignments by dissecting the median nerve, sawing the pelvis in half, and slicing
open the heart, the bathos supersedes: the sacred violation takes on the character of
your average college class, replete with pedants, class clowns, and the rest. Cadaver
dissection epitomizes, for many, the transformation of the somber, respectful
student into the callous, arrogant doctor.
The enormity of the moral mission of medicine lent my early days of med
school a severe gravity. The first day, before we got to the cadavers, was CPR
training, my second time doing it. The first time, back in college, had been farcical,
unserious, everyone laughing: the terribly acted videos and limbless plastic
mannequins couldn’t have been more artificial. But now the lurking possibility that
we would have to employ these skills someday animated everything. As I repeatedly
slammed my palm into the chest of a tiny plastic child, I couldn’t help but hear,
along with my fellow students’ jokes, real ribs cracking.
Cadavers reverse the polarity. The mannequins you pretend are real; the
cadavers you pretend are fake. But that first day, you just can’t. When I faced my
cadaver, slightly blue and bloated, his total deadness and total humanness were
undeniable. The knowledge that in four months I would be bisecting this man’s head
with a hacksaw seemed unconscionable.
Yet there are anatomy professors. And the advice they gave us was to take one
good look at our cadaver ’s face and then leave it covered; it makes the work easier.
Just as we prepared, with deep breaths and earnest looks, to unwrap our cadaver ’s
head, a surgeon stopped by to chat, leaning with his elbows on the corpse’s face.
Pointing out various marks and scars on the naked torso, he reconstructed the
patient’s history. This scar is from an inguinal hernia operation, this one a carotid endarterectomy; these marks here indicate scratching, possibly jaundice, high
bilirubin; he probably died of pancreatic cancer, though no scar for that—killed him
too quick. Meanwhile, I could not help but stare at the shifting elbows that, with each
medical hypothesis and vocabulary lesson, rolled over this covered head. I thought:
Prosopagnosia is a neurological disorder wherein one loses the ability to see faces.
Pretty soon I would have it, hacksaw in hand.
Because after a few weeks, the drama dissipated. In conversations with non–
medical students, telling cadaver stories, I found myself highlighting the grotesque,
macabre, and absurd, as if to reassure them that I was normal, even though I was
spending six hours a week carving up a corpse. Sometimes I told of the moment
when I turned around and saw a classmate, the sort of woman who had a mug
decorated with puffy paint, tiptoeing on a stool, cheerfully hammering a chisel into
a woman’s backbone, splinters flying through the air. I told this story as if to
distance myself from it, but my kinship was undeniable. After all, hadn’t I just as
eagerly disassembled a man’s rib cage with a pair of bolt cutters? Even working on
the dead, with their faces covered, their names a mystery, you find that their
humanity pops up at you—in opening my cadaver ’s stomach, I found two
undigested morphine pills, meaning that he had died in pain, perhaps alone and
fumbling with the cap of a pill bottle.
Of course, the cadavers, in life, donated themselves freely to this fate, and the
language surrounding the bodies in front of us soon changed to reflect that fact. We
were instructed to no longer call them “cadavers”; “donors” was the preferred term.
And yes, the transgressive element of dissection had certainly decreased from the
bad old days. (Students no longer had to bring their own bodies, for starters, as they
did in the nineteenth century. And medical schools had discontinued their support of
the practice of robbing graves to procure cadavers—that looting itself a vast
improvement over murder, a means once common enough to warrant its own verb:
burke, which the OED defines as “to kill secretly by suffocation or strangulation, or
for the purpose of selling the victim’s body for dissection.”) Yet the best-informed
people—doctors—almost never donated their bodies. How informed were the
donors, then? As one anatomy professor put it to me, “You wouldn’t tell a patient
the gory details of a surgery if that would make them not consent.”
Even if donors were informed enough—and they might well have been,
notwithstanding one anatomy professor ’s hedging—it wasn’t so much the thought
of being dissected that galled. It was the thought of your mother, your father, your
grandparents being hacked to pieces by wisecracking twenty-two-year-old medical
students. Every time I read the pre-lab and saw a term like “bone saw,” I wondered if
this would be the session in which I finally vomited. Yet I was rarely troubled in lab,
even when I found that the “bone saw” in question was nothing more than a
common, rusty wood saw. The closest I ever came to vomiting was nowhere near the lab but on a visit to my grandmother ’s grave in New York, on the twentieth
anniversary of her death. I found myself doubled over, almost crying, and
apologizing—not to my cadaver but to my cadaver ’s grandchildren. In the midst of
our lab, in fact, a son requested his mother ’s half-dissected body back. Yes, she had
consented, but he couldn’t live with that. I knew I’d do the same. (The remains were
returned.)
In anatomy lab, we objectified the dead, literally reducing them to organs,
tissues, nerves, muscles. On that first day, you simply could not deny the humanity
of the corpse. But by the time you’d skinned the limbs, sliced through inconvenient
muscles, pulled out the lungs, cut open the heart, and removed a lobe of the liver, it
was hard to recognize this pile of tissue as human. Anatomy lab, in the end, becomes
less a violation of the sacred and more something that interferes with happy hour,
and that realization discomfits. In our rare reflective moments, we were all silently
apologizing to our cadavers, not because we sensed the transgression but because
we did not.
It was not a simple evil, however. All of medicine, not just cadaver dissection,
trespasses into sacred spheres. Doctors invade the body in every way imaginable.
They see people at their most vulnerable, their most scared, their most private. They
escort them into the world, and then back out. Seeing the body as matter and
mechanism is the flip side to easing the most profound human suffering. By the
same token, the most profound human suffering becomes a mere pedagogical tool.
Anatomy professors are perhaps the extreme end of this relationship, yet their
kinship to the cadavers remains. Early on, when I made a long, quick cut through
my donor ’s diaphragm in order to ease finding the splenic artery, our proctor was
both livid and horrified. Not because I had destroyed an important structure or
misunderstood a key concept or ruined a future dissection but because I had seemed
so cavalier about it. The look on his face, his inability to vocalize his sadness, taught
me more about medicine than any lecture I would ever attend. When I explained that
another anatomy professor had told me to make the cut, our proctor ’s sadness
turned to rage, and suddenly red-faced professors were being dragged into the
hallway.
Other times, the kinship was much simpler. Once, while showing us the ruins of
our donor ’s pancreatic cancer, the professor asked, “How old is this fellow?”
“Seventy-four,” we replied.
“That’s my age,” he said, set down the probe, and walked away.
—
Medical school sharpened my understanding of the relationship between meaning,
life, and death. I saw the human relationality I had written about as an undergraduate realized in the doctor-patient relationship. As medical students, we were confronted
by death, suffering, and the work entailed in patient care, while being
simultaneously shielded from the real brunt of responsibility, though we could spot
its specter. Med students spend the first two years in classrooms, socializing,
studying, and reading; it was easy to treat the work as a mere extension of
undergraduate studies. But my girlfriend, Lucy, whom I met in the first year of
medical school (and who would later become my wife), understood the subtext of
the academics. Her capacity to love was barely finite, and a lesson 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.
Lucy and I attended the Yale School of Medicine when Shep Nuland still
lectured there, but I knew him only in my capacity as a reader. Nuland