Sunshine Recorder

Todd May is the Class of 1941 Memorial Professor at Clemson University—a very fancy title for a very non-fancy guy. He is bald, plays basketball, has a wife and two kids, and kind of looks like Michel Foucault (which is weird, because Todd has written a book about him). He’s written nine other books, too—including a volume about poststructuralist anarchism and another about friendship under neoliberalism—but with Todd, talking about his resume somehow feels beside the point.

The first time I met Todd was at Nội Bài Airport in Hanoi. I was living there, and Todd had decided to fly over for a visit. My best friend Dan (one of Todd’s students) had put us in touch, and we spent a couple of days riding around on motorbikes and talking about whatever came to mind.

Looking back, I’m amazed at how patient Todd was. He treated me like an equal, never pulling rank or bringing the philosophical hammer down, and at some point it became clear how little stock he put in his own credentials. We became friends—just two curious people trying to figure out what was going on in this life.

Todd’s books read the way he talks—simply and clearly, without pretense. The first one I read—Our Practices, Our Selves: Or, What It Means to be Human—is maybe the humblest treatment of a big existential question that I’ve ever seen from a professional philosopher. It’s just so obvious: Todd doesn’t write to look cool or show you how much he knows. He writes because he’s been thinking about some interesting things, and he wants to share them with you, and maybe you can relate.

Todd’s book about death (the subject of this interview) feels the same way. He’s taken on biggest and scariest topic there is, but you wouldn’t know it from his tone. There’s a lightness, a sense that whatever we learn by thinking honestly and clearly about dying, it’ll somehow be OK. After all, here we are, talking together.

This interview took place over Skype. I was in Cambridge, Massachusetts, and Todd was in the rec room of his house in Clemson. The room reminded me of my friends’ basements growing up—there were wood-paneled walls, gym equipment strewn about, and a general sense that the rules didn’t quite apply.

THE BELIEVER: I finished the book this morning. About halfway through, I began thinking about Indiana Jones and The Last Crusade. Have you seen it?

TODD MAY: I don’t know if I’ve seen The Last Crusade. I’ve seen several of them.

BLVR: It’s the one where they’re going after the Holy Grail, and it’s a race between Indy and the Nazis.

TM: Yes, I have seen that movie.

BLVR: OK. So, at the very end, they find the Holy Grail, but the Nazis shoot Indy’s dad—Sean Connery—and he’s dying. Indy saves his dad by giving him a sip of water from the Holy Grail (which, as we know, provides everlasting life). Indy then takes a sip himself—for some reason, he doesn’t offer any to his two friends—and then they vanquish the Nazis and ride off into the sunset.

Now, the movie makes all this out to be great, but I remember watching it and feeling really unsettled. True, Indy has saved his dad’s life, but he’s also consigned his dad to living forever. Everyone else around them is going to die at some point, but the two of them will live on in perpetuity.

My sense is that you might actually think Indy made the wrong call—that he did his dad a disservice by giving him everlasting life. Let’s start there.

TM: I think it’s actually more complicated than that. Indy can let his dad die, and that was probably a really bad time for him to die. Or he could extend his life indefinitely, which in the end probably wouldn’t be such a good thing either. So, the paradox I really wanted to press in the book is that neither of these options—dying or being immortal—is a good option.

BLVR: But you ultimately do settle on the side of death, no? You compare death to “a disease whose cure, if it existed, would be worse than the disease itself.” You also write that the things that make our lives distinctive and meaningfully human would fade or would have to be “reconfigured” if we were immortal. In other words, you’re ultimately glad that we have to die, even if you don’t actually look forward to your own death.

TM: Right. I think that’s fair enough. We have to add to that the idea that…well, that life is short, and if death were to be a good thing, it would be a better thing much further down the road than it is for human lives now. All of this, by the way, raises some interesting questions, which I tried to deal with a little bit in the book, in terms of whether I’m the only one who would be immortal or whether everyone would be immortal.

I did an interview with a filmmaker yesterday, and we were talking about this. And he said that he would like to be immortal but would like to be the only one. He said that way, he could see life changing around him enough so that he might not get bored.

BLVR: Someone said something similar to me the other day. And my first thought was, I can’t imagine anything lonelier than knowing that everyone around me will die one day. In fact, the first thing I imagined was jealousy—jealousy of the solidarity and bonds that arise among people who have to live in the face of death, knowing that I’d be on the outside of that.

TM: That’s a very powerful thing you said, and I don’t think I’d thought of that until you just said this now. But I think that’s right—it’s a powerful bond that keeps us together.

There are certain things we can be that are meaningful to us, and other things that we cannot be. If we’re immortal but no one around us is, the same question arises—whether one is simply doing the same thing that one does, just with other people. It becomes like telling a story. You know how you tell a story, and it seems like an interesting story the first bunch of people you tell it to. But at some point in telling that story, if you’ve told it twenty or thirty times, it feels a little… you feel disconnected from the story. I would think that that would happen as well.

BLVR: In my mind, one of the features that makes us who we are is our ethical impulse, our desire to know out how to live well. You say that under conditions of immortality, “Even justice would be imperiled.  The needs of others would not urge themselves on us in the same way, since their existence would not be threatened by our neglect.”

Obviously it’s true that if we can’t die, we needn’t worry about preventing other people’s deaths. But surely people could still suffer, and I’m wondering whether you think that under conditions of immortality, we would be any less concerned by that.

TM: If I remember Borges’ story The Immortal correctly, there is a point where one of the immortals falls into a ravine or something like that and is left there—

BLVR: For decades.

TM: Yeah, for decades. And they said, “Look, we’ll get him, but surely there’s no rush.”

I’m of two minds about that moment. On the one hand, it seems callous in a way that I don’t think one’s immortality would necessarily bequeath. Because if you see somebody suffering, that’s surely going to be reason to stop, to do something to intervene.

BLVR: Yup.

TM: On the other hand, I could imagine they’re thinking this: Well, we’ll get him out of the ravine, but it’s just going to bring him back into this shapeless life that he’s in now. So, the difference between the suffering in the ravine and the shapelessness of our lives is not so great as to foster an urgency. And I don’t know what I think about that.

In the story, all of the monuments among which the immortals lived were left to erode, because they just didn’t have the meaning that they once had and the immortals said they could always rebuild them back at any time. So, I suspect that was the kind of thought that Borges had in mind when they left the person in the ravine.

I work in a place of death. People come here to die, and my co-workers and I care for them as they make their journeys. Sometimes these transitions take years or months. Other times, they take weeks or some short days. I count the time in shifts, in scheduled state visits, in the sham monthly meetings I never attend, in the announcements of the “Employee of the Month” (code word for best ass-kisser of the month), in the yearly pay increment of 20 cents per hour, and in the number of times I get called into the Human Resources office.

The nursing home residents also have their own rhythms. Their time is tracked by scheduled hospital visits; by the times when loved ones drop by to share a meal, to announce the arrival of a new grandchild, or to wait anxiously at their bedsides for heart-wrenching moments to pass. Their time is measured by transitions from processed food to pureed food, textures that match their increasing susceptibility to dysphagia. Their transitions are also measured by the changes from underwear to pull-ups and then to diapers. Even more than the loss of mobility, the use of diapers is often the most dreaded adaptation. For many people, lack of control over urinary functions and timing is the definitive mark of the loss of independence.

Many of the elderly I have worked with are, at least initially, aware of the transitions and respond with a myriad of emotions from shame and anger to depression, anxiety, and fear. Theirs was the generation that survived the Great Depression and fought the last “good war.” Aging was an anti-climactic twist to the purported grandeur and tumultuousness of their mid-twentieth-century youth.

“I am afraid to die. I don’t know where I will go,” a resident named Lara says to me, fear dilating her eyes.

“Lara, you will go to heaven. You will be happy,” I reply, holding the spoonful of pureed spinach to her lips. “Tell me about your son, Tobias.”

And so Lara begins, the same story of Tobias, of his obedience and intelligence, which I have heard over and over again for the past year. The son whom she loves, whose teenage portrait stands by her bedside. The son who has never visited, but whose name and memory calm Lara.

Lara is always on the lookout, especially for Alba and Mary, the two women with severe dementia who sit on both sides of her in the dining room. To find out if Alba is enjoying her meal, she will look to my co-worker Saskia to ask, “Is she eating? If she doesn’t want to, don’t force her to eat. She will eat when she is hungry.” Alba, always cheerful, smiles. Does she understand? Or is she in her usual upbeat mood? “Lara, Alba’s fine. With you watching out for her, of course she’s OK!” We giggle. These are small moments to be cherished.

In the nursing home, such moments are precious because they are accidental moments.

The residents run on stolen time. Alind, like me, a certified nursing assistant (CNA), comments, “Some of these residents are already dead before they come here.”

By “dead,” he is not referring to the degenerative effects of dementia and Alzheimer’s disease but to the sense of hopelessness and loneliness that many of the residents feel, not just because of physical pain, not just because of old age, but as a result of the isolation, the abandonment by loved ones, the anger of being caged within the walls of this institution. This banishment is hardly the ending they toiled for during their industrious youth.

By death, Alind was also referring to the many times “I’m sorry,” is uttered in embarrassment and the tearful shrieks of shame that sometimes follow when they soil their clothes. This is the dying to which we, nursing home workers, bear witness every day; the death that the home is expected, somehow, to reverse.

So management tries, through bowling, through bingo and checkers, through Frank Sinatra sing-a-longs, to resurrect what has been lost to time, migration, the exigencies of the market, and the capriciousness of life. They substitute hot tea and cookies with strangers for the warmth of family and friends. Loved ones occupied by the same patterns of migration, work, ambition, ease their worries and guilt with pictures and reports of their relatives in these settings. We, the CNAs, shuffle in and out of these staged moments, to carry the residents off for toileting. The music playing in the building’s only bright and airy room is not for us, the immigrants, the lower hands, to plan for or share with the residents. Ours is a labor confined to the bathroom, to the involuntary, lower functions of the body. Instead of people of color in uniformed scrubs, white women with pretty clothes are paid more to care for the leisure-time activities of the old white people. The monotony and stress of our tasks are ours to bear alone.

The nursing home bosses freeze the occasional, carefully selected, picture-perfect moments on the front pages of their brochures, exclaiming that their facility, one of a group of Catholic homes is, indeed, a place where ”life is appreciated,” where “we care for the dignity of the human person.” In reality, they have not tried to make that possible. Under poor conditions, we have improvised for genuine human connection to exist. How we do that the bosses do not understand.

It’s not a frequent topic of discussion, but doctors die, too. And they don’t die like the rest of us. What’s unusual about them is not how much treatment they get compared to most Americans, but how little. For all the time they spend fending off the deaths of others, they tend to be fairly serene when faced with death themselves. They know exactly what is going to happen, they know the choices, and they generally have access to any sort of medical care they could want. But they go gently.

Of course, doctors don’t want to die; they want to live. But they know enough about modern medicine to know its limits. And they know enough about death to know what all people fear most: dying in pain, and dying alone. They’ve talked about this with their families. They want to be sure, when the time comes, that no heroic measures will happen–that they will never experience, during their last moments on earth, someone breaking their ribs in an attempt to resuscitate them with CPR (that’s what happens if CPR is done right).

Almost all medical professionals have seen what we call “futile care” being performed on people. That’s when doctors bring the cutting edge of technology to bear on a grievously ill person near the end of life. The patient will get cut open, perforated with tubes, hooked up to machines, and assaulted with drugs. All of this occurs in the Intensive Care Unit at a cost of tens of thousands of dollars a day. What it buys is misery we would not inflict on a terrorist. I cannot count the number of times fellow physicians have told me, in words that vary only slightly, “Promise me if you find me like this that you’ll kill me.” They mean it. Some medical personnel wear medallions stamped “NO CODE” to tell physicians not to perform CPR on them. I have even seen it as a tattoo.

To administer medical care that makes people suffer is anguishing. Physicians are trained to gather information without revealing any of their own feelings, but in private, among fellow doctors, they’ll vent. “How can anyone do that to their family members?” they’ll ask. I suspect it’s one reason physicians have higher rates of alcohol abuse and depression than professionals in most other fields. I know it’s one reason I stopped participating in hospital care for the last 10 years of my practice.

How has it come to this–that doctors administer so much care that they wouldn’t want for themselves? The simple, or not-so-simple, answer is this: patients, doctors, and the system.

(Source: sunrec)

How Tolstoy’s obsession with mortality became a teachable moment.

In 1869, just after he finished War and Peace, Leo Tolstoy experienced a profound spiritual crisis as the result of an incident during a journey through the city of Arzamas, which is on the Tyosha River about 250 miles east of Moscow. As he described it in his unfinished story Notes of a Madman (so titled because Tolstoy was convinced his readers would find the tale implausible), a few hours after midnight he awakened “seized by despair, fear and terror such as [he had] never before experienced.” After asking himself what there was to be afraid of, none other than Death himself answered, “I am here.” Tolstoy, confronting the inescapability of his own death, panicked and raged against its power.

That evening stayed with Tolstoy for the rest of his life; he became permanently preoccupied with mortality. Writing his Confessions a decade later, Tolstoy would ask: “Is there any meaning in my life that will not be destroyed by my inevitably approaching death?” “He engaged in long and laborious meditations”, wrote Tolstoy’s long-suffering wife, Sonya. “Often he said his brain hurt him, some painful process was going on inside it, everything was over for him, it was time for him to die.”

Tolstoy’s “Arzamas Horror”, as the Russian dramatist Maxim Gorky called it, also served as the basis for his masterful novella, The Death of Ivan Ilych. In this slim book, a 45-year-old Russian judge realizes he is dying and acknowledges that he has wasted his life attaining comfort and status. While outwardly appearing successful, Ilych suffers from an unhappy marriage, a meaningless career and a selfish existence. “Ivan Ilych’s life had been most simple and most ordinary and therefore most terrible”, reads one typically devastating Tolstoyan line.

Melancholy as this is, the most harrowing parts of the story lie in Ilych’s terror at confronting his own mortality, much as Tolstoy had years earlier in the dark morning hours in Arzamas. Perhaps nowhere else in all of world literature is the sheer horror of the fact of death laid so bare: “He would go to his study, lie down, and again remain alone with it. Face to face with it, and there was nothing to be done with it. Only look at it and go cold.”

(Source: sunrec)

When your Jeep spins lazily off the mountain road and slams backward into a snowbank, you don’t worry immediately about the cold. Your first thought is that you’ve just dented your bumper. Your second is that you’ve failed to bring a shovel. Your third is that you’ll be late for dinner. Friends are expecting you at their cabin around eight for a moonlight ski, a late dinner, a sauna. Nothing can keep you from that.

Driving out of town, defroster roaring, you barely noted the bank thermometer on the town square: minus 27 degrees at 6:36. The radio weather report warned of a deep mass of arctic air settling over the region. The man who took your money at the Conoco station shook his head at the register and said he wouldn’t be going anywhere tonight if he were you. You smiled. A little chill never hurt anybody with enough fleece and a good four-wheel-drive.

But now you’re stuck. Jamming the gearshift into low, you try to muscle out of the drift. The tires whine on ice-slicked snow as headlights dance on the curtain of frosted firs across the road. Shoving the lever back into park, you shoulder open the door and step from your heated capsule. Cold slaps your naked face, squeezes tears from your eyes.

You check your watch: 7:18. You consult your map: A thin, switchbacking line snakes up the mountain to the penciled square that marks the cabin.

Breath rolls from you in short frosted puffs. The Jeep lies cocked sideways in the snowbank like an empty turtle shell. You think of firelight and saunas and warm food and wine. You look again at the map. It’s maybe five or six miles more to that penciled square. You run that far every day before breakfast. You’ll just put on your skis. No problem.

There is no precise core temperature at which the human body perishes from cold. At Dachau’s cold-water immersion baths, Nazi doctors calculated death to arrive at around 77 degrees Fahrenheit. The lowest recorded core temperature in a surviving adult is 60.8 degrees. For a child it’s lower: In 1994, a two-year-old girl in Saskatchewan wandered out of her house into a minus-40 night. She was found near her doorstep the next morning, limbs frozen solid, her core temperature 57 degrees. She lived.

Others are less fortunate, even in much milder conditions. One of Europe’s worst weather disasters occurred during a 1964 competitive walk on a windy, rainy English moor; three of the racers died from hypothermia, though temperatures never fell below freezing and ranged as high as 45.

But for all scientists and statisticians now know of freezing and its physiology, no one can yet predict exactly how quickly and in whom hypothermia will strike—and whether it will kill when it does. The cold remains a mystery, more prone to fell men than women, more lethal to the thin and well muscled than to those with avoirdupois, and least forgiving to the arrogant and the unaware.

The process begins even before you leave the car, when you remove your gloves to squeeze a loose bail back into one of your ski bindings. The freezing metal bites your flesh. Your skin temperature drops.

Within a few seconds, the palms of your hands are a chilly, painful 60 degrees. Instinctively, the web of surface capillaries on your hands constrict, sending blood coursing away from your skin and deeper into your torso. Your body is allowing your fingers to chill in order to keep its vital organs warm.

You replace your gloves, noticing only that your fingers have numbed slightly. Then you kick boots into bindings and start up the road.

Were you a Norwegian fisherman or Inuit hunter, both of whom frequently work gloveless in the cold, your chilled hands would open their surface capillaries periodically to allow surges of warm blood to pass into them and maintain their flexibility. This phenomenon, known as the hunter’s response, can elevate a 35-degree skin temperature to 50 degrees within seven or eight minutes.

Other human adaptations to the cold are more mysterious. Tibetan Buddhist monks can raise the skin temperature of their hands and feet by 15 degrees through meditation. Australian aborigines, who once slept on the ground, unclothed, on near-freezing nights, would slip into a light hypothermic state, suppressing shivering until the rising sun rewarmed them.

You have no such defenses, having spent your days at a keyboard in a climate-controlled office. Only after about ten minutes of hard climbing, as your body temperature rises, does blood start seeping back into your fingers. Sweat trickles down your sternum and spine.

By now you’ve left the road and decided to shortcut up the forested mountainside to the road’s next switchback. Treading slowly through deep, soft snow as the full moon hefts over a spiny ridgetop, throwing silvery bands of moonlight and shadow, you think your friends were right: It’s a beautiful night for skiing—though you admit, feeling the minus-30 air bite at your face, it’s also cold.

After an hour, there’s still no sign of the switchback, and you’ve begun to worry. You pause to check the map. At this moment, your core temperature reaches its high: 100.8. Climbing in deep snow, you’ve generated nearly ten times as much body heat as you do when you are resting.

…One of the most powerful stories to influence the discussion came not from our clinical practice, but from fiction: Leo Tolstoy’s novella The Death of Ivan Ilyich. This literary account of the final thoughts and experiences of a dying man prompted reflection about suffering and the power and limits of medicine.

Tolstoy’s Ivan Ilyich is a middle-aged prosecutor in 19th-century St Petersburg who spends increasing amounts of his time climbing the social ladder, to the detriment of his already poor relationships with his wife and children. He develops a protracted, painful condition, the diagnosis of which eludes his physicians. When the doctors and others around him ultimately realise the severity of his condition, they lie to him about its terminal nature. A spiritually empty man, Ivan Ilyich’s lingering demise forces him to confront the meaning of his inevitable death. Medicine offers no consolation and he rejects the help of his physician:

‘You know perfectly well you can do nothing to help me, so leave me alone.’
‘We can ease your suffering’, said the doctor.
‘You can’t even do that; leave me alone.’

Neither the administration of opium nor the ministrations of a priest can ultimately alleviate the suffering that comes from Ivan Ilyich’s realisation “What if my entire life, my entire conscious life, simply was not the real thing?” Although his physical pain is great, Tolstoy portrays Ilyich’s moral, mental, and existential pain as even greater.

In a diary entry from 1902—the year after his excommunication—Tolstoy wrote: “Peaceful deaths under the influence of the Church’s rites are like death under the influence of morphine.” We can assume this is not a complimentary statement. In the end, Tolstoy left Ivan Ilyich alone with his suffering. To the outside world he was in agony—“screaming desperately and flailing his arms”—even as he was coming to a fundamental understanding of his life and death. “For those present, his agony continued for another two hours”, the narrator tells us; yet within he seems to have eventually found a sense of peace.

Today, in the secular world of medicine, we are becoming ever more accepting of the notion that pain and suffering must be banished from the dying experience. Pain, indeed all suffering, is meaningless; it should be erased. “The RIGHT to be free of physical pain”; yet, the reality of its control is something very different. One study that changed perceptions of the care of dying patients was the 1995 Study to Understand Prognoses and Preferences for Outcomes and Risks of Treatments (SUPPORT). In this study of death in five US teaching hospitals, family members were asked about the amount of pain patients had endured during the last 3 days of their lives. They reported that 50% of conscious patients who died in the hospital had moderate or severe pain at least half the time. This finding—alongside the results of the second phase of the trial that reported no improvement in pain control among patients in the intervention group—was surprising and distressing to many. Since the SUPPORT findings, health-care professionals have been admonished for poor pain control. For example, the Medical Board of California’s Guideline for Prescribing Controlled Substances for Intractable Pain, adopted in 1994 and updated in 2007, states that failure to adequately manage pain is “inappropriate prescribing”. So that although physicians’ fear of overprescribing has been one supposed reason for poor pain management in the past, now, physicians will be subject to sanctions for underprescribing as well.

Such guidelines, allied to improved public knowledge of the issue and the ever-increasing drug and surgical armamentarium available to physicians, has led to effective medical control of pain and other end-of-life symptoms. For the conscious, competent patient, this may well be a boon, because there is less reason for a patient to die with pain he or she wants alleviated. But, more generally, when a suffering-less death becomes the medical summum bonum, morphine and other drugs become our sacraments. This is not necessarily good. Pharmaceuticals are the wrong treatment for certain kinds of suffering. In his Diaries, Tolstoy tells of how his brother’s suffering after a stroke is so much more serious for his not accepting his plight. He writes: “In such a condition there are only two solutions: defiance, irritability and an increase of suffering, as with him, or, on the contrary: submission, gentleness and a decrease of suffering, even to the extent of eliminating it altogether.” Tolstoy’s observation is perhaps pertinent in some clinical contexts.

What would happen if Ivan Ilyich—a modern day “John Doe” or “Everyman”—were dying in the USA now? At home or in the hospital, it could be the same story: when he became unable to speak coherently for himself, his wife or perhaps the ward or hospice nurse, seeing him flail and hearing him scream, would request morphine and ever-more morphine. And, if that did not work, something would be found that would work to extinguish the visible signs of discomfort: lorazepam, haloperidol, phenobarbital. Drugged, but without “pain”, what would become of Ivan Ilyich’s inner experience? Would it be transformed? Would it go away?

Now, we recognise that we are suggesting something that is potentially dangerous, and we worry about it. Pain relief should never be withheld when it is desirable. Nor do we think that physical or existential suffering is, necessarily, redemptive or edifying in any way. But, it might be for some people; there might be someone for whom, as for Ivan Ilyich, the suffering of dying is a path to self-understanding or spiritual awakening. Should this be something that matters to the physician? Physicians and nurses need to be sensitive to the suffering of those they care for, but, does this mean a sensitivity to, or a sympathetic understanding of, more than just a patient’s physical pain and symptoms, important as those are? Although many people would prefer a painless, instant death—no suffering, just lights out, quickly, permanently—others would have some variation of what seems to be Tolstoy’s version of the good death: a conscious one, with acceptance of whatever comes. For example, the Zen teacher, Shunryu Suzuki, took opioids for his painful cancer for a while—to please his doctor, he said—then stopped because he wanted his mind clear.