Monday, January 13, 2014

Bill Keller's "Heroism"

Heroic Measures?

400-odd years ago, John Donne took on a topic that still ignites controversy today: what is the right way to die? And by “right,” I mean socially acceptable, which is to say, most considerate of our friends and loved ones. In “A Valediction: Forbidding Mourning,” Donne praises those who are capable of managing their deaths in such a gentle fashion as to make the fact of their passing unclear. Such people are “virtuous men,” who “pass mildly away,” by “whisper[ing] to their souls to go.” Less appreciated by all concerned are those whose passage to the afterlife is a far more tempestuous journey.

Bill Keller, in his NYT article “Heroic Measures,” paints a carefully-phrased criticism of Lisa Adams’s cancer blog which details her battle with metastatic cancer. In it, he sides with those who prefer a model of death managed by palliative care rather than “heroic measures.” He quotes Steven Goodman, an associate dean of the Stanford University School of Medicine, who says that Adams’s blog “shouldn’t be unduly praised” for being an adherent of the “combat metaphor.” Equal praise,” he says, “is due to those who accept an inevitable fate with grace and courage.”

It is clear that Keller’s opinion has been shaped by his own father’s death from cancer, where in England, he was provided with “a humane and honorable alternative” by being “unplugged from everything except pain killers and allowed to slip peacefully from life.” Certainly, Keller sides with Donne here, and why shouldn’t he? No-one wants to see their loved ones suffer in their last days.

But his article has caused controversy because of the implied suggestion that a) the American model of managing death as a kind of “frantic medical trench warfare” is wrong, and b) that people have a choice when it comes to these things. What Keller critiques is an expensive universal protocol that really ought to provide more leeway for dying people to manage their ends — but what gets him into hot water is the notion that individuals can somehow escape the system.

For a start, it’s not always easy or possible for a dying person to think clearly enough to make decisions, especially about something of which they are likely to be profoundly afraid (and afraid of admitting: that they are indeed dying). It’s not easy for the dying person, and it isn’t easy for their family, who are often the ones making end-of-life decisions which err on the side of doing everything they possibly can to extend the life of their loved one, cost be damned. It feels unseemly to think about finances when someone’s life hangs in the balance. Then there is the overwhelming opinion of the medical professionals to whom we turn in search of answers to questions we probably have not ever had to consider. They, too, err on the side of the preservation of life (and the hospital’s bottom line).

Keller cites a study that “suggests that patients given early palliative care instead of the most aggressive chemotherapy not only have a better quality of life, they actually live a bit longer.” While this may indeed be true, what he may not be sensitive to is that for the person with the cancer, all decisions loom like the sword of Damocles over the precariously thin kite-string that has become their life: one wrong decision and whoops! there you go floating into a tree. Deciding whether to have “aggressive chemotherapy” (all chemo is “aggressive,” BTW), or forego it for palliative care is a tough call for those who may have been dealing with this disease for years. Choosing to opt out of the clinical cycle, even if it may provide more time, inevitably feels like giving up.

So much about handling cancer is about attitude: maintaining control over your treatment is seen as being proactive; hopeful; strong — and it will seem odd for someone to make that switch from choosing action to deciding against taking action and leaving one’s fate to the gods.

Susan Sontag wrote artfully of the way in which language and vocabulary has helped shape our comprehension of disease, especially cancer. When one considers the way in which the language of warfare dominates the conversation, it is no surprise that people view cancer as a battleground with winners and losers. Keller’s article maintains this metaphor even while quoting Goodman, who “cringes” at it.

Ultimately, there are no winners and losers when it comes to cancer, and dying. There are only folks standing around, like Donne’s “sad friends,” arguing over how well you went.

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