Author: Dr. Steven Hodes

Chimpatologist Jane Goodall knows us better that we know ourselves.  In her article in the Wall Street Journal she easily dispatches those “experts” who portray us, homo sapiens, as gentle beings, corrupted by the forces of society into exhibiting the brutality and aggression which we so often manifest. Jane knows our genetic heritage and in her studies finds that the roots of aggression in our simian ancestors is all too obvious.

She points to actual research with male chimps which demonstrates rather brutal alpha male treatments of lesser chimps.  She also documents killing of weakened alpha males as well as preventive killing of potential tribal rivals. Comparions with primitive human warfare are astounding. Marching silently in the jungles, attacking and killing vulnerable chimps from outside their group, acquiring their territory, their resources as well as potential female breeding partners. 

What makes humans different from chimps is not our propensity for war and violence but our ability to make peace.  In order to avoid bloodshed we have developed protocols to diminish the potential for war.  This works….sometimes.  Her point is well taken.  Instead of fantasizing about an idyllic pre-societal nature, we should be realistic about who we are.  And, hopefully, work towards promoting what is positive. See article–http://online.wsj.com/article/SB10001424127887323874204578220002834225378.html

 

 

The tribal gene is the source of much of collective human behavior.  We may certainly decry acts of savagery, genocide and other atrocities committed by groups of our fellow human beings against other groups.  But is it possible to alter such behavior?  In his NYTimes piece http://opinionator.blogs.nytimes.com/2013/01/05/the-myth-of-universal-love/ philosopher Stephen T. Asma discusses the possibilities and essentially says “no!”. 

He discusses the philosophical notion of such utilitarian philosophers as Jeremy Rifkin and Peter Singer who believe it is possible to expand the tribal attitude to include all of humanity as well as the entire biosphere of life on this planet.  His arguments are convincing.  He refers to neurobiological studies as well as common sense.  We just are closer to those we regard as family and friends.  We do understand that there are differences between an inner circle to which we have history and affection and those who exist, for us, in ever expanding orbits of emotional distance from us.  Empathy, he points out, is not a concept but a natural biological event with a neurobiochemical basis.  He further explains that preferential treatment, nepotism, loyalty are not just choices but inbred human behaviors.  He also refers to the concept of “eudaimonia”, the good life that the psychology of happiness attempts to describe, as requiring a small circle of loved-ones who represent powerful ties.  The are not, he takes note, Facebook friends or distant strangers.  Would it be “better” if we could embrace all of humanity as if they were truly family?  Asma agrees.  But is it realistic? Will it happen? Unfortunately not.

Never thought I would agree with what any of the Emanuel brothers— Rahm, Ari or Ezekiel– would write.  But I may have some common ground with brother Zeke (Ezekiel).  A professor at University of Pennsylvania, a trained oncologist and politically to the left of Trotsky, he was influential in formulating much of the Obamacare platform.  But his opinion in the NYTimes is worth considering.  He writes about the issue of physician-assisted suicide and associated issues. He attempts to dispel four myths associated with the topic.

First “pain”.  He points out that patients who desire euthanasia (in which a doctor administers a lethal drug) or physician-assisted suicide (in which the patient himself takes the lethal drug prescribed by the physician) tend not to be motivated by pain.  His claim is that the vast majority seek such an end not because of physical pain but psychological pain.  These individuals, he believes, should be offered “counselling and caring”, but not be considered for either of the above.  This sounds rather naive to me.  Depression associated with pain and the dying process cannot be treated with drugs or therapy.  It is often a natural reaction to the suffering that occurs at the end of life.  It is not a “disease” to be treated but a reality. Of course they should be utilized if possible.  I doubt very much they will alleviate the true suffering that is both physical and mental. So suffering will remain regardless of the cause.

Secondly, “mass appeal” which implies that assisted suicide will improve the end of life for everyone.  He points out that in Oregon in which only .2% of dying patients chose this means of dying and in the Netherlands fewer than 3% did.  His left leaning politics comes raging through when he states “well-off, well-educated people, typically suffering from cancer, who are used to controlling everything in their lives–the top .2%  And who are the people most lifely to be abused if assisted suicide is legalized?  The poor, poorly educated, dying patients who pose a burden on their relatives.”  Are you for real, Zeke?  How sanctimonious can you get.  Do you really think “rich” people will choose assisted-suicide just because they like to “control” everything?  Do your honestly believe poor people will be led to slaughter because they are a “burden” on their relatives.  Come on, dude.  You are stereotyping in the worst, most obnoxious way.

A “good death”.  He points to those rare situations in which the process fails.  Assisted-suicide is not perfect, nothing is, but this is a lame attack on the system itself.  The only statement he makes that makes sense is his last paragraph in which he emphasizes that we need to improve the care of the dying.  Palliative and hospice care should reduce the need for physician-assisted suicide.  But his arguments against it are rather weak. I would not dismiss the option for those who seek it.

Facilitating the inevitable when there is unremitting suffering (physical or mental) need not justify itself to anyone.

Who knew?

Our big brains evolved not because we were great thinkers, but great runners.  The article in the NYTimes adds an interesting twist to the question of how we evolved from our primate ancestors.  My interest in anthropology is no more unusual than that of metaphysics in general—what is the nature of reality, or who we are and how we got here.

Our australopithecine ancestors (Google ” Lucy”  for further info) found themselves in a progressively changing environment. Tectonic shifts in the African continent, climate change resulted in diminishing jungles.  Their protective trees gave way to open savannas with grasslands.  They rose up on two legs  to survey their landscape.  That position enabled them to look at their surroundings, utilize both hands for carrying objects and tool making, and to move relatively long distances in open savannas in order to “run down”  and consume swifter prey.  This ability to do long distance jogging provided them with the protein infusion, animal protein (sorry to our vegan friends) that promoted brain development.

Our less simian ancestors that came after “Lucy”  such as  homo habilis and  homo erectus evoled this larger brain capacity.  But protein was needed to fuel the metabolically active central nervous system characteristic of our lineage and our ancestry.

This process of natural selection would further promote bipedalism, long- distance movement and associated brain development.

This theory fits in well with recent studies demonstrating neurogenesis in adults by virtue of aerobic exercise. In all likelihood it was the younger australopithecines  who did the long distance running/hunting.  Excessive training was unnecessary.  Running was for day to day survival not gold medals. But just perhaps the secondary gain of all this aerobics was the enlargement and improved function of our cerebral cortex.

Of course modern research has demonstrated that excessive aerobics over a period of time is not only not conducive to longevity, but quite the opposite, it is associated with reduced life spans. So once again the “secret” to life is moderation.  Exercise was and is important to our collective and individual health.  Extreme exercise is not.  Our ancestors were successful joggers, not marathon winners.

Who knew?  Our big brains evolved not because we were great thinkers, but great runners.  The article in the NYTimes http://well.blogs.nytimes.com/2012/12/26/exercise-and-the-ever-smarter-human-brain/?src=me&ref=general adds an interesting twist to the question of how we evolved from our primate ancestors.  My interest in anthropology is no more unusual than that of metaphysics in general—what is the nature of reality, or who we are and how we got here.  Our australopicine ancestors rose up on two legs before their brains grew beyond chimp size.  That position enabled them to look at their surroundings, utilize both hands for carrying and tool making, and to move relatively long distances in open savannahs in order to “run down”  and consume swifter prey.  This ability to do long distance jogging provided them with the protein infusion (sorry to our vegan friends) that promoted brain developement. This process of natural selection would further promote bipedalism, long- distance movement and associated brain developement.  This theory fits in well with recent studies demonstrating neurogenesis in adults by virtue of aerobic exercise.  Of course the caveat remains and is consistent with this hypothesis–extreme exercise is deleterious to our health.  So once again the “secret” to life is moderation.  Exercise was and is important to our collective and individual health.  Extreme exercise is not.  Our ancestors were successful joggers, not marathon winners.

I pulled an interesting article from a newspaper I rarely read–New Jersey Jewish News.  The piece http://www.njjewishnews.com/article/15575/rabbis-frown-on-assisted-suicide-legislation discusses the ethics of assisted suicide.

Regarding the Jewish perspective on end of life, it cites a story from the second-century about a much revered rabbi Judah HaNasi who was suffering at the end.  His students prayed for his survival.  A servant girl through down a jug from a rooftop.  Startled, the students stopped praying–long enough for the Rabbi to pass away.  So the message here is powerful.  Praying for continued life, like entending a dying person’s life through extraordinary medical technology is not necessarily the moral/ethical/religious thing to do.  Doing so because WE don’t want our loved-ones to die is being selfish. Placing the best interest of those we love above our own sometimes requires that death be welcomed.

While affirming the sanctity of life, the perpetuation of suffering without hope of improvement is wrong.  The issues that confront us in 2013 differ greatly from the second century—and even from just 50 years ago.  Then there was no technology to continue life, no additional procedures, tests, drugs we could order to try to overcome the process of dying.  Now we can. But is assisted-suicide just too much of an intrusion on the process of dying itself?

Is euthanasia equivalent to murder?  These issues are not limited to debate among Jews.  All human beings will be faced with them.  Dr. Kevorkian pushed the envelope on this matter and brought much public attention to it.  Several states have passed laws legalizing it.

I believe ultimately this should be a private matter.  But like issues of same sex marriage, when private concerns cross over into public policy with medical, drug related, legalities etc., they become issues for us all.

My own perspective is to expand the role of Hospice at end of life.  Hospice allows for “passive” rather than “active” euthanasia.   We don’t necessarily have to hook up an iv to potassium or a lethal dose of anesthesia but make sure our loved-ones do not suffer.  We can refuse medical therapy for our loved-ones when it will only bring more discomfort.  We can honor their wishes at the end of life, rather than contradicting them because we can’t make that call.

We can keep them at home, allow them not to be fed if they choose not to eat, don’t force iv fluids on them, keep them “snowed” with narcotics even if it reduces their respirations.  If such acts of loving-kindness hastens their physical demise–so be it.  This is not about life-saving, it is about facilitating the dying process.

I prefer the concept of assisted dying, not assisted suicide.

We are all guilty of the same failing–immersed in self-pity regarding our own problems.

Of course life arranges obstacles in our path.  Our momentary peace and tranquility is bombarded by stresses which arise from our own life’s journey.

Our minds are co-conspirators–we examine our negative experiences, dwell in them like a tightly fitting cocoon, and decide we can never emerge from them.

And then there are the lives of others around us.

The devastation that some families experienced during Sandy, the unspeakable horror that engulfs those who lost children in Newtown, CT, and the CAT scan report of James Borawski (name changed).

I should be “used” to diagnosing terrible conditions.  As a gastroenerologist for over thirty years I’ve seen many patients get diagnosed and die from serious illness, particularly cancer.  But it doesn’t get any easier.  Having a patient close in age to me only adds to the difficulty in maintaining that professional perspective.

He just wasn’t quite feeling well.  He had vague abdominal complaints, his appetite wasn’t his usual and he had lost weight.  He and his wife,a  nurse, were concerned enough to see me.  He had had a colonoscopy two years before.  We decided that a CAT scan would be a reasonable diagnostic test.

None of us were truly prepared for the results.  It showed that he most likely has pancreatic cancer, and it has spread to his liver and other vital organs.  His prognosis is extremely poor.  I had to deliver the news right before Christmas.

He doesn’t feel that sick right now.  Unfortunately this calm before the storm will not last. I discussed referring him to an oncologist for an opinion.  I am not sure what their recommendation will be.

The Borawski Effect is a universal one.  We do not wish our fellow human beings any suffering or tragedy.  But this will occur.  It reminds us all, even physicians, of the fragility of life and the serenity we so desperately seek.

What we do, what we should do is to open out hearts to their personal suffering.  Silently we take a moment to revisit what bothers us– and pause.  Our problems pale in comparison with some others.  We could easily be those people. Someday we may be there ourselves.

The Borawski effect puts it all into perspective.   And yet we can’t sit back and obsess over what will befall us or our loved ones either.  That only brings potential suffering into the present moment.  This brings us pain now.

If we learn anything at all from it, it is this– be grateful for what we have, not what we don’t.  Place our problems in the perspective they deserve.  Live life as much in the present moment as is reasonable.

Our next could be a Borawski moment.  But not now.

I was recently struck by the term quality of death.

Of course we are more familiar with the notion of quality of life.  It usually implies that we should strive to prolong a basic quality of existence until our lives near their end.  It implies that we and our loved-ones should consider various options when it comes to medical treatments, procedures and medications as we advance in age and frailty.

The concept of quality of death, I believe, is a natural consequence of the process.   It emphasizes the real meaning behind the topic–how we and our loved ones die.  I understand how difficult this topic is for most of us. Death is that 800lb gorilla in the room that we pretend isn’t there. My readers know that I do not regard the issue of death as morbid or depressing.  I feel it should be regarded as the unequivocal reality that it is.  It should be seen as important as life insurance and estate planning.  Do we relish the idea of discussing death?  Of course not.  Is it necessary? Certainly.

Generalizations are always easy to discuss.  Dealing with real people and their families when these issues arise are far more complex.  There will never be a formula, an algorithm which can be applied to any individual life.  This difficulty often dissuades us from attempting to deal with end of life/ approaching death topics.  This is a mistake.

The consequences of putting off serious discussions leads to last minute grasping for choices, emotional stress which is immeasurable, family infighting and literal chaos.  The risk is also that regret may follow after a loved-one dies. As a physician (and metaphysician) I have seen this throughout  my  over 30 year medical career.  As a human being who has experienced the loss of loved-ones I know it on a first hand basis.

On recent case stands out in my mind (there are thousands very similar to it).  I was called in to evaluate a 60 year old gentleman with gastrointestinal bleeding.  It is a common problem that gastroenterologists deal with.  But upon reviewing his record it turns out that he is suffering from metastatic cancer–from two separate primary lesions!  His wife had just approved him to be a DNR (do not resuscitate) which also implied an end of life understanding.  I decided not to perform an endoscopy (a scoping into the upper gi tract ) or a colonoscopy on him because of this situation.  I spoke to the wife and asked her if she had considered Hospice for him.  She said that she did and would contact them immediately.  Now this patient was in the ICU receiving intensive care nursing, blood transfusions and extremely expensive medical/nursing care.  Did he belong there?  No.  Did her or the family want him to die in the ICU setting? No.  I encouraged them to let him go home and receive palliative/Hospice care.  Was I doing this for financial reasons?  On the contrary.  I am compensated for doing procedures, not talking families out of them.  But was that the ethical approach? Absolutely.

This situation is occurring as I blog this piece in thousands of hospital ICU/CCU settings across the country.  The cost to families in terms of emotional strain and struggle, the financial burden to the health care system is immense as well.  Should resources be re-directed to individuals who lack insurance but who would truly benefit from them?  Again, absolutely.  Is this an example of a “death panel” decisions.  Of course not.  The problem is endemic within the health care system.  Fifty years ago it wasn’t.  Medical technology didn’t exist to prolong life.  Now it does.  Now the discussion needs to be whether or not to use the technology when it is no longer appropriate to do so.  The issue is complex with ethical, religious, spiritual, and economic ramifications.  And it applies to health care providers such as physicians as much, if not more, than anyone.  How do physicians direct their patients regarding such decisions?  Are we at all objective? Do our own beliefs and fears come to the fore? Do we need to look within ourselves at our own attitudes and beliefs regarding the issue of quality of death?  Absolutely. But we need to address them–as individuals and as a society.

The issue of quality of death should move to the forefront of societal discourse as for health care providers.  Personally, I would like to find a way of becoming a part of that discussion.

Understanding what has just happened in New Town, Connecticut? Let me answer this one in two words–we can’t!!

I don’t pretend to know what evil is.  I don’t pretend to understand the disordered, chaotic mind of a cold-blooded killer of innocent children.  I don’t pretend to know  what went so horribly wrong in the brain/mind of that young killer.  Was it a biochemical distortion, was it the result of some genetic mutation in the way his thought processes worked?  Even the most hardened criminal would be sickened by what occurred in Sandy Hook.

Can we prevent such horrific acts from occurring again? Can we identify disturbed individuals and forcibly engage them in therapy and perhaps drug treatment? Can we protect our schools with armed guards?  And what can we offer to the grieving families?

As with 9/11 we are humbled by the  enormity of the suffering. Our power to understand anything dissolves in an instant.

For a moment we hug our own kids more.  We forget the distractions and worries about our personal problems, things that pale in comparison to what suffering has just occurred.  We can only offer condolences.

We can remain silent right now.

We can step outside of our analytic minds, the part of us that tries to bring meaning to all situations.  We can move from our heads into our hearts, a place of feeling, not thinking.  Just now we can’t understand what has occurred, we shouldn’t try.

In this moment, our spiritual presence, our wish to relieve the suffering of strangers who are like ourselves, our prayers.  For a moment these people are not strangers.  Our common humanity binds us in a shared grief.  For a moment all barriers dissolve. It is place of deep feeling, not of thinking.

It is a place that surpasses all understanding.

How should any of us view death?

Ah, a loaded question if there ever was one.  But in this context I am referring to one Farish Jenkins, who died recently after succmbing to pneumonia complicating multple myeloma  http://www.nytimes.com/2012/12/01/us/farish-jenkins-fossils-expert-dies-at-72.html?emc=eta1&_r=

A well respected paleontologist and professor at Harvard University, Jenkins, when asked about his impending demise responded, “I am quite familiar with extinction.”

As a man whose professional life involved delving into fossilized remains of creatures that lived and died millions of years in the past as well as entire species and varieties of animals now extinct, he had a perspective on the nature of existence that few of us do.

Now none of us can  truly know our mental/emotional state of mind when we die. Will we be racked with fear and agitation?  Or will we accept the impending inevitability with grace and acceptance?

Of course I have no idea what Jenkins believed about regarding  the afterlife or survival of consciousness after death.  Perhaps he did have some sense of it, perhaps not.  Ironically both an understanding of the nature of reality from a spiritual and scientific perspective might offer all of us a level of serenity when our time comes.

If Jenkins died with a sense of deeper understanding regarding the ephemeral nature of life, he might have made his transition in peace.  At least I would like to believe he did.

We should all live with the awareness that personal extinction is our destiny.  It is not something to be obsessed over. It is certainly not a concept which should paralyze us with fear and anxiety.  If anything it gives our lives a greater sense of value and meaning.

The quality of our lives, the deeper meaning we give to it, the ability to place our fears and anxieties in perspective, the notion that life is a gift and that opportunities await us at the next moment—all of these are not diminished by our awareness of our personal “extinction”.

It gives us a moment to pause and consider–don’t waste this incarnation, this one, too, shall pass.