Mortality

  Or take an example from an altogether different and more temperate philosopher, nearer to our own time. The late Professor Sidney Hook was a famous materialist and pragmatist, who wrote sophisticated treatises that synthesized the work of John Dewey and Karl Marx. He, too, was an unrelenting atheist. Toward the end of his long life he became seriously ill and began to reflect on the paradox that— based as he was in the medical mecca of Stanford, California— he was able to avail himself of a historically unprecedented level of care, while at the same time being exposed to a degree of suffering that previous generations might not have been able to afford. Reasoning on this after one especially horrible experience from which he had eventually recovered, he decided that he would after all rather have died:

  I lay at the point of death. A congestive heart failure was treated for diagnostic purposes by an angiogram that triggered a stroke. Violent and painful hiccups, uninterrupted for several days and nights, prevented the ingestion of food. My left side and one of my vocal cords became paralyzed. Some form of pleurisy set in, and I felt I was drowning in a sea of slime. In one of my lucid intervals during those days of agony, I asked my physician to discontinue all life–supporting services or show me how to do it.

  The physician denied this plea, rather loftily assuring Hook that “someday I would appreciate the unwisdom of my request.” But the stoic philosopher, from the vantage point of continued life, still insisted that he wished he had been permitted to expire. He gave three reasons. Another agonizing stroke could hit him, forcing him to suffer it all over again. His family was being put through a hellish experience. Medical resources were being pointlessly expended. In the course of his essay, he used a potent phrase to describe the position of others who suffer like this, referring to them as lying on “mattress graves.”

  If being restored to life doesn’t count as something that doesn’t kill you, then what does? And yet there seems no meaningful sense in which it made Sidney Hook “stronger.” Indeed, if anything,it seems to have concentrated his attention on the way in which each debilitation builds on its predecessor and becomes one cumulative misery with only one possible outcome. After all, if it were otherwise, then each attack, each stroke, each vile hiccup, each slime assault, would collectively build one up and strengthen resistance. And this is plainly absurd. So we are left with something quite unusual in the annals of unsentimental approaches to extinction: not the wish to die with dignity but the desire to have died.

  Professor Hook eventually left us in 1989, and I am a generation younger than him. I haven’t sailed as close to the bitter end as he had to do. Nor have I yet had to think of having such an arduous conversation with a physician. But I do remember lying there and looking down at my naked torso, which was covered almost from throat to navel by a vivid red radiation rash. This was the product of a monthlong bombardment with protons which had burned away all of the cancer in my clavicular and paratracheal nodes, as well as the original tumor in the esophagus. This put me in a rare class of patients who could claim to have received the highly advanced expertise uniquely available at the stellar zip code of MD Anderson Cancer Center in Houston. To say the rash hurt would be pointless. The struggle is to convey the way that it hurt on the inside. I lay for days on end, trying in vain to postpone the moment when I would have to swallow. Every time I did swallow, a hellish tide of pain would flow up my throat, culminating in what felt like a mule kick in the small of my back. I wondered if things looked as red and inflamed within as they did without. And then I had an unprompted rogue thought: If I had been told about all this in advance, would I have opted for the treatment? There were several moments as I bucked and writhed and gasped and cursed when I seriously doubted it.

  It’s probably a merciful thing that pain is impossible to describe from memory. It’s also impossible to warn against. If my proton doctors had tried to tell me up front, they might perhaps have spoken of “grave discomfort” or perhaps of a burning sensation. I only know that nothing at all could have readied or steadied me for this thing that seemed to scorn painkillers and to attack me in my core. I now seem to have run out of radiation options in those spots (thirty-five straight days being considered as much as anyone can take), and while this isn’t in any way good news, it spares me from having to wonder if I could willingly endure the same course of treatment again.

  But mercifully, too, I now can’t summon the memory of how I felt during those lacerating days and nights. And I’ve since had some intervals of relative robustness. So as a rational actor, taking the radiation together with the reaction and the recovery, I have to agree that if I had declined the first stage, thus avoiding the second and the third, I would already be dead. And this has no appeal.

  However, there is no escaping the fact that I am otherwise enormously weaker than I was then. How long ago it seems that I presented the proton team with champagne and then hopped almost nimbly into a taxi. During my next hospital stay, in Washington, D.C., the institution gifted me with a vicious staph pneumonia (and sent me home twice with it) that almost snuffed me out. The annihilating fatigue that came over me in consequence also contained the deadly threat of surrender to the inescapable: I would often find fatalism and resignation washing drearily over me as I failed to battle my general inanition. Only two things rescued me from betraying myself and letting go: a wife who would not hear of me talking in this boring and useless way, and various friends who also spoke freely. Oh, and the regular painkiller. How happily I measured off my day as I saw the injection being readied. It counted as a real event. With some analgesics, if you are lucky, you can actually feel the hit as it goes in: a sort of warming tingle with an idiotic bliss to it. To have come to this—like the sad goons who raid pharmacies for OxyContin. But it was an alleviation of boredom, and a guilty pleasure (not many of those in Tumortown), and not least a relief from pain.

  In my English family, the role of national poet was taken not by Philip Larkin but by John Betjeman, bard of suburbia and the middle class and a much more mordant presence than the rather teddy–bearish figure he sometimes presented to the world. His poem “Five O’Clock Shadow” shows him at his least furry:

  This is the time of day when we in the Men’s Ward

  Think “One more surge of the pain and I give up the fight,”

  When he who struggles for breath can struggle less strongly:

  This is the time of day that is worse than night.

  I have come to know that feeling all right: the sensation and conviction that the pain will never go away and that the wait for the next fix is unjustly long. Then a sudden fit of breathlessness, followed by some pointless coughing and then—if it’s a lousy day—by more expectoration than I can handle.Pints of old saliva, occasionally mucus, and what the hell do I need heartburn for at this exact moment? It’s not as if I have eaten anything: a tube delivers all my nourishment. All of this, and the childish resentment that goes with it, constitutes a weakening. So does the amazing weight loss that the tube seems unable to combat. I have now lost almost a third of my body mass since the cancer was diagnosed: It may not kill me, but the atrophy of muscle makes it harder to take even the simple exercises without which I’ll become more enfeebled still.

  I am typing this having just had an injection to try to reduce the pain in my arms, hands, and fingers. The chief side effect of this pain is numbness in the extremities, filling me with the not irrational fear that I shall lose the ability to write. Without that ability, I feel sure in advance, my “will to live” would be hugely attenuated. I often grandly say that writing is not just my living and my livelihood but my very life, and it’s true. Almost like the threatened loss of my voice, which is currently being alleviated by some temporary injections into my vocal folds, I feel my personality and identity dissolving as I contemplate dead hands and the loss of the transmission belts that connect me to writing and thinking.

  These are progressive weaknesses that in a more “normal” life might have taken decades to cat
ch up with me. But, as with the normal life, one finds that every passing day represents more and more relentlessly subtracted from less and less. In other words, the process both etiolates you and moves you nearer toward death. How could it be otherwise? Just as I was beginning to reflect along these lines, I came across an article on the treatment of post-traumatic stress disorder. We now know, from dearly bought experience, much more about this malady than we used to. Apparently, one of the symptoms by which it is made known is that a tough veteran will say, seeking to make light of his experience, that “what didn’t kill me made me stronger.” This is one of the manifestations that “denial” takes.

  I am attracted to the German etymology of the word “stark,” and its relative used by Nietzsche, stärker, which means “stronger.” In Yiddish, to call someone a shtarker is to credit him with being a militant, a tough guy, a hard worker. So far, I have decided to take whatever my disease can throw at me, and to stay combative even while taking the measure of my inevitable decline. I repeat, this is no more than what a healthy person has to do in slower motion. It is our common fate. In either case, though, one can dispense with facile maxims that don’t live up to their apparent billing.

  I may have made one exception to my emerging rule that Nietzsche was to be distrusted, or to my pretense to myself that I had resources that I may not have truly possessed. A good deal of cancer life has to do with the blood, of which cancer is indeed the particular malady. A sufferer will find himself “giving” quite a quantity of the fluid, either to facilitate the opening of a catheter or to help test the levels of blood sugar and other material. For years, I found it absurdly easy to undergo routine blood tests. I would walk in, sit down, endure a brief squeeze from a tourniquet until a usable vein became available or accessible, and then a single small stab would allow the filling of the relevant little tubes and syringes.

  Over time, however, this ceased to be one of the pleasurable highlights of the medicalized day. The phlebotomist would sit down, take my hand or wrist in his or her hand, and sigh. The welts of reddish and purple could already be seen, giving the arm a definite “junkie” look. The veins themselves lay sunken in their beds, either hollow or crushed. Very occasionally, they would cooperate with a junkie–based strategy that consisted of slowly smacking them with taut fingertips, but this seldom yielded a robust result. Large swellings would occur, usually just near the elbow or wrist joint, or anywhere they would do the least good.

  In addition, one had to stop pretending that the business was effectively painless. No more the jaunty talk of “one little pinch.” It doesn’t actually hurt that much to have a probing needle inserted for a second time. No, what hurts is having it moved to and fro, in the hope that it can properly penetrate the vein and release the needful fluid. And the more this is done, the more it hurts. This illustrates the whole business in microcosm: the “battle” against cancer reduced to a struggle to get a few drops of gore out of a large warm mammal that cannot provide them. Please believe me when I say that one quickly comes to sympathize with the technicians. They are proud of their work, and do not enjoy imposing “discomfort.” Indeed, they will regularly and with relief give place to another volunteer or submit to another’s expertise.

  But the job has to be done, and there is dismay when it can’t be completed. I was recently scheduled for the insertion of a “PIC” line, by means of which a permanent blood catheter is inserted in the upper arm, so that the need for repeated temporary invasions can be obviated. The experts told me that this seldom took more than ten minutes to complete (which had been my own experience on previous visits). It can’t have been much less than two hours until, having tried and failed with both arms, I was lying between two bedpads that were liberally laced with dried or clotting blood. The upset of the nurses was palpable. And we were further off from a solution.

  As this kind of thing became more common, I began to take on the role of morale–booster. When the technician would offer to stop, I would urge her to go on and assure her that I sympathized. I would relate the number of attempts made on previous occasions, in order to spur greater efforts. My self–image was that of the plucky English immigrant, rising above the agony of a little needle–stick. Whatever didn’t kill me, I averred, would make me stronger . . . I think this began to pall on the day that I had asked to “keep going” through eleven sessions, and was secretly hoping for the chance to give up and go to sleep. Then suddenly the worried face of the expert cleared all at once as he exclaimed, “Well, twelve times is the charm,” and the life–giving thread began to unspool in the syringe. From this time on, it seemed absurd to affect the idea that this bluffing on my part was making me stronger, or making other people perform more strongly or cheerfully either. Whatever view one takes of the outcome being affected by morale, it seems certain that the realm of illusion must be escaped before anything else.

  VII

  NOT MANY WEEKS AGO, I WAS STARTING A BEDridden day in a state of acute powerlessness and quite rough pain. As I lay unable to move but braced from past experience, I heard a soothing and capable voice saying, “Now you might feel just a little prick.” (Be assured: Male patients have exhausted all the possibilities of this feeble joke within the first few days of hearing it.) And almost at once I felt reassured in a different way, because that voice and that expression and that little pang meant that the pain would lift and my limbs straighten, and my day begin. And so it proved.

  What if, though, as I once semiconsciously thought as I lay in similar distress, that friendly voice had had just the faintest hint of a taunt in it? What if it had been saying, in the merest possible way, “This won’t hurt—much”? The whole balance of power would have been violently subverted, leaving me defenseless and petrified. I would also, instantly, have to wonder how long I could coexist with such a threat. The torturer’s intricate work would have begun.

  I stress “intricate” because torture isn’t really a matter of sheer brute pain and force. As I found out when I was actually a torture victim, it is above all a matter of subtle calibration. “How are we doing today? Any discomfort?” This is made additionally problematic by the tendency of modern medicine to fall back on the use of euphemistic words in any case, the polite evasion of the weak “discomfort” being one of the most salient of these. Another avenue of euphemism is laid out by the planned and coordinated approach; thus one might hear the question, “Have you met with our ‘pain management’ team yet?” Once you have heard it the wrong way, this can seem like an echo of the torturer’s practice, of showing to the victim the instruments that will be used upon him, or describing the range of techniques, and letting these threats do the main part of the job. (Galileo Galilei was allegedly exposed to this while undergoing the graduated pressure that eventually squeezed him to recant.)

  I became a torture victim because I wanted the readers of Vanity Fair to have an idea of what was involved in the sordid and obscure controversy about “waterboarding.” And the only way left, or left untried, was to offer myself to this “procedure.” Obviously there were limits to the authenticity of its infliction—and I had to be in some sense “in control“ of the setting—but I was determined as far as possible to discover what a “waterboarded” person really undergoes. With the help of some very serious former Special Forces personnel, who knew that they were breaking American law on American soil, I arranged an appointment in the hills of North Carolina. Before we could even begin, I had signed a legal document indemnifying them in case they killed me by the infliction of physical or psychological trauma (a stronger word, there).

  What happens, you may have been told, is a “simulation” of the sensation of drowning. Wrong. What happens is that you are slowly but inexorably drowned. And if at any point you manage to evade the deadly drip of water, your torturer will know. He or she will then make a minute but effective adjustment. When I interviewed my torturers later I was particularly interested in this aspect of matters. Oh yes, they said with mild bragging,
we have lots of little moves and shakes and twists that will get the job done and not leave a mark. Again, you note this pride in technique and its almost humanist tone of professional expression. The language of torturers . . .

  The reason I have decided to write about this in the present context is as follows. Ever since I composed and published the original essay, which was some time before I was diagnosed with esophageal cancer, I had been suffering from some form of post–torture stress that probably has yet to be classified or named. In my own case at any rate, it has to do with asphyxiation. And the “aspiration” of moisture can trigger a flood of panic and has become imbricated with the larger and deadlier symptoms of my various pneumonias. And every day, I am forced to prepare myself to be tube–fed through an apparatus of liquid nourishment, or to be washed to different degrees of immersion, or to be otherwise made highly vulnerable. So I am very fortunate indeed that I have never had to hear the torturer’s odious whisper, or to shrink at the thought that I am only a wrinkle or a twist away from severe fear and “distress” (a word quite high on the euphemism scale). But I do now know how the trick could be pulled.