Hazel McHaffie

perfection

Living in the face of death

Every now and then a book comes into your life that stops you in your tracks. When Breath Becomes Air is one such for me. The author, Paul Kalanathi, was a neurosurgeon and writer with degrees in English literature, human biology, and history and philosophy of science and medicine, garlanded with awards and distinctions. But it’s not so much his brilliance as a scholar or clinician that makes this a stand-out work, but his humanity, his wisdom, his reverence for life even in the face of death, his empathy with people.

His writing reminds me very much of Henry Marsh, also a neurosurgeon, who revealed with brutal honesty the price these gifted surgeons pay for the high-risk work they do, where a single tiny slip of the hand, or a wrong judgement call, can wreck a life. Kalanithi describes, clearly and poignantly, and entirely without self-pity, his own journey from medical student, through professional and powerful neurosurgeon, to helpless terminally ill patient. He died, aged just 37 years old. I wept with and for him. I am unsurprised that esteemed figures like Atul Gawande and Abraham Verghese have endorsed this book so comprehensively; all are giants among men when it comes to deep psychological truths about human beings.

As a schoolboy and undergraduate Paul Kalanathi read prolifically.  Literature, he came to see, ‘not only illuminated another’s experience, it provided the richest material for moral reflection’. Through reading and studying philosophy and neuroscience and ethics he pursued his goal relentlessly: ‘to seek a deeper understanding of a life of the mind.’  But he was all too conscious that his thinking didn’t sit comfortably in an English Department, and he simply couldn’t find the answers to where biology, morality, literature and philosophy intersected, or what makes life meaningful even in the face of suffering and death and decay. He craved direct real-life experience. And so it was that he embarked on a career in medicine, as so many men in his family had done before him.

His humanity and compassion pervade the accounts of various experiences along the way, bringing him eventually to specialise in neurosurgery. As he says: ‘While all doctors treat diseases, neurosurgeons work in the crucible of identity: every operation on the brain is, by necessity, a manipulation of the substance of our selves’. At critical junctures the question is not simply whether to live or die, but more than that, what makes life meaningful enough to go on living? I should have liked many more of his illuminating experiences, but their brevity served to spell out the pressure he was under, the limited time he had left in this world to record his thoughts.

Neurosurgery is a fiercely demanding discipline with its commitment ‘not only to one’s own excellence but to another’s identity’. As he says: ‘We [have] assumed an onerous yoke, that of mortal responsibility. Our patients’ lives and identities may be in our hands, yet death always wins. Even if you are perfect, the world isn’t. The secret is to know that the deck is stacked, that you will lose, that your hands or judgment will slip, and yet still struggle to win for your patients. You can’t ever reach perfection …’ The burden of this ‘unforgiving call to perfection’ was driven home ferociously when a friend and colleague jumped off of a high roof, killing himself, following the death of one of his patients.

But shining through all the high-powered knife-edge clinical precision is this particular doctor’s empathy and kindness. He learned that ‘the physician’s duty is not to stave off death or return patients to their old lives, but to take into our arms a patient and his family whose lives have disintegrated and work until they can stand back up and face, and make sense of, their own existence’. He understood …
That  ‘a tureen of tragedy was best allotted by the spoonful‘.
That traumatised patients’ relatives wouldn’t retain devastating details in one fell swoop.
That it was irresponsible to be more precise in prognoses than you could be accurate.
That holding a patient’s hand becomes a mode of communication.
That there is more than mere biological life at stake; identity matters. ‘The call to protect life – and not merely life but another’s identity; it is perhaps not too much to say another’s soul – was obvious in its sacredness.’

Then came the devastating diagnosis of his own metastatic Grade IV cancer, and everything changed. He had ‘traversed a line from doctor to patient, from actor to acted upon, from subject to direct object’.

When Kalanithi began suffering pain in his back – pain so severe he could only curl up on the floor screaming – he rationalised away the symptoms. After all, healthy men in their thirties simply didn’t get lethal cancers, did they? Finding he was already terminally ill with extensive metastases required immense adjustments, far more disorientating and dislocating than he ever imagined. And once again he turned to literature to try to make sense of the questions raging through his mind – Solzhenitsyn, Tolstoy, Woolf, Kafka, Hemingway, Frost, memoirs of cancer patients – ‘anything by anyone who had ever written about mortality … searching for a vocabulary with which to make sense of death, to find a way to begin defining myself and inching forward again’. It was literature that brought him back to life during this time.

‘Death may be a one-time event, but living with terminal illness is a process.’

‘One chapter of my life seemed to have ended; perhaps the whole book was closing. Instead of being the pastoral figure aiding a life transition, I found myself the sheep, lost and confused. Severe illness wasn’t life-altering, it was life-shattering … My life had been building potential, potential that would now go unrealized. I had planned to do so much, and I had come close. I was physically debilitated, my imagined future and my personal identity collapsed, and I faced the same existential quandaries my patients faced … Death, so familiar to me in my work, was now paying a personal visit. Here we were, finally face-to-face, and yet nothing about it seemed recognizable. Standing at the crossroads where I should have been able to see and follow the footprints of the countless patients I had treated over the years, I saw instead only a blank, a harsh, vacant, gleaming white desert, as if a sandstorm had erased all trace of familiarity.’ And the ground was to buckle and roil again and again as the disease progressed and the patient adjusted to his new reality.

Initially, as the tumours shrank, he set his sights on returning to the operating theatre – not the recumbent form on the receiving end of invasive treatment, but the upright one wielding a scalpel. Which he did. Even though exhausted beyond measure, only overcoming the nausea and pain by iron will, he persisted, and gradually his strength and stamina improved, alongside his fluency and technique. He began taking full responsibility for his patients, working longer hours, and despite his physical problems, started to enjoy the job once again, finding true meaning in this demanding work.

The birth of a daughter, Elizabeth Acadia, brought him a sense of joy and satisfaction hitherto unknown. But when she was only five months old, at Christmas time, the cancer began to resist all forms of treatment, and Paul made the decision to devote any energy he could summons to complete his book. Decline at this stage was unexpectedly rapid, and Cady was just eight months old when Paul died in a hospital bed 200 yards from where she was born.

Poignantly, his wife, Lucy, also a doctor, appended the Epilogue to When Breath Becomes Air – a searingly painful account of his last hours and a family’s grief. In 2013, she revealed, Paul had emailed his best friend to tell him about his terminal cancer: ‘The good news is that I’ve already outlived two Brontë sisters, Keats and Stephen Crane. The bad news is that I haven’t written anything.’ He had set his sights on rectifying this omission. When Breath Becomes Air became a new way for him to help others, a contribution only he could make; at once a moving personal story, a statement about death, and an inspiration to all who read it.

This is what courage sounds like.

Ironically, I read this book on the day when one of my granddaughters sat an exam for assessing her potential for entry to medical school. One day I might give her my copy of Paul Kalanithi’s book, but it’s too raw, too harrowing, too honest about the price doctors pay, to expose her to at this stage.

 

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‘Perfection’? or ‘Good enough’?

A couple of weeks ago I happened to catch a bus into the town centre already crowded with students from a science faculty outside the city boundary. There was a healthy buzz of conversation everywhere but the voice of the girl behind me dominated because she was speaking loudly into her mobile (as people tend to do).

She appeared to be agonising over some end-of-term exams they were taking and suddenly said: ‘Why am I putting myself through all this stress? I could have been an artist! … No, I’m too much of a perfectionist to be an artist.’

Hello? You think creative people don’t suffer stress? Aren’t perfectionists? Why, only this week I was reading about an author, Madeline Miller, who took ten years to write her first novel, five of them spent writing and rewriting the first few chapters over 50 times! She describes herself as an ‘incorrigible perfectionist’.

It was Voltaire who allegedly first penned the famous aphorism: perfect is the enemy of the good, although other well known writers and philosophers have come to a similar conclusion.

We all have to achieve a balance between our ideals and our realities, don’t we? I first really absorbed the concept of ‘good enough’ when I was a researcher looking into parenting issues. I remember in 1988 quoting in my PhD thesis, the British pediatrician and psychoanalyst Donald Winnicott who coined the phrase ‘good enough’ mothers way back in 1953.

And all through my academic life I had a post-it on my screen: Perfection is always one more draft away. Theses, journal articles, books, conference presentations – there came a point with everything, when I had to say, ‘Stop! It will do’. No merit in constantly striving for perfection and never letting anything try its luck in the real world.

It hadn’t occurred to me until that student’s conversation impinged on my brain in the bus, that here I am, right now, in my fictional world, worrying away once again at what constitutes good enough parenting.

My protagonist is a new mother, a perfectionist, a brilliant academic, stressed by the demands of a fretful baby who simply hasn’t read the manual! And when bad things start happening to the infant, the professionals responsible for safeguarding have to decide where the line can and should be drawn between the ideal and the realistic. Get it wrong and a baby’s life might be in jeopardy as well as a mother’s mental health. We’ve all seen the vilification of social workers and community health professionals when a child is horrendously abused and dies in real life; the press have a field day.

I’m also somewhat preoccupied with the point at which the current novel itself is good enough to publish; it’s far from that point at the moment. Indeed I’ve scribbled several possible new opening sentences just over Christmas – the brain doesn’t recognise official holidays! And I know it won’t ever be perfect; they never are. It just has to be good enough to satisfy the reader that it’s a tale well told and worth writing. And believe me, young-angst-ridden-student-scientist, artists most certainly are perfectionists too!

 

 

 

 

 

 

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Sleeplessness and productivity

Moving mighty wardrobes …Wardrobes

… craning the neck to mitre corners on ceilings …Mitred corners

… up and down stairs with forty years worth of accumulated detritus possessions … none of these things are kind to muscles and joints already suffering wear and tear and the ravages of arthritis. So small wonder that sleep has been rather elusive during the latest stages of big renovations chez nous.

But hey ho! the old brain is safely protected in its rigid bony cage, and it’s been busily plotting the next book (well, two actually if you count the children’s annual Christmas production) in the darkness of long nights of wakefulness.

The scenes are vivid: a young woman wandering up and down the aisles of the chemists shop, reading labels and safety warnings … back at home titrating doses … cradling baby as he gulps down the milk … watching him sink deeper and deeper into unconsciousness … removing all traces …

Lying there with the video scrolling in my head, it’s so real and the sense of dread so acute, aches and pains simply vanish. And as soon as it’s a decent hour, I’m up committing the scenarios to the computer. OK, I may be knackered by the evening but I’m fired up on the adrenaline – progress with the house AND the books! Silver linings and all that jazz.

But hang on a minute …

Lying in bed: constructs perfect plot

Standing in shower: constructs perfect characters

Hanging out washing: constructs perfect setting

Sitting in front of screen: where did perfection go?!

Hey ho! Perfection is dozens of drafts away.

I’ve been toying with the idea of releasing some tempting little titbits closer to publication to whet the appetite. So I was intrigued to learn that Ian Rankin (or his publisher more likely) has just revealed the first line of his new Rebus novel – his 21st publication – Rather be the Devil, due out on 3rd November.

Rebus placed his knife and fork on the empty plate, then leaned back in his chair, studying the other diners in the restaurant.
‘Someone was murdered here, you know,’ he announced.

Would this tempt you to buy the book?

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Perfection

Did you follow the Glasgow 2014 Commonwealth Games, I wonder? I dipped in and out, marvelling all the while at the stunning abilities of these top athletes – their skill and stamina and flexibility and sportsmanship.

The real highlight for me, though, was the diving in Edinburgh. Watching Tom Daley somersaulting from the highest board, executing perfect twists and turns, entering the water so cleanly that the surface was barely disturbed, left me breathless (and anxious!). And the 14 year old Matthew Dixon; how did he feel perching on the very edge of that board 10 metres up the very first time he tried it? How did his mother feel with his hurtling brain so close to that unforgiving concrete? My heart was in my mouth, never mind hers! (Even the more experienced Daley says: ‘When you look down, your knees go weak, your legs turn to jelly and it’s terrifying.’) And then there’s the synchronised diving. How two people can execute identical moves simultaneously during that brief and rapid descent, is beyond my comprehension. This is surely a kind of perfection writ large.

Perfection, ahhh – that brings me to this week’s story of the baby born to a Thai surrogate mother, who has allegedly been abandoned by his would-be parents because he isn’t perfect. Baby Gammy has Downs Syndrome and other co-morbidities. Of course, we don’t know the minds of any of these characters; we only know what the media tell us, and some sources cast serious doubts on the authenticity of this account and the credentials of those most concerned. Double TroubleBut picture the scenario from the point of view of the commissioning couple: instead of a beautiful healthy child to bring up and launch into the world, the prospect of a short and difficult life for their baby, and the grief of losing him. This wasn’t what they signed up for. The story is that they have elected instead to take Gammy’s healthy girl twin, and to leave the damaged baby behind. (They themselves are variously reported to have asked for Gammy to be aborted, or to have said they were only offered the one, or to have been informed that Gammy had only a day to live and his mother wanted him to be buried in Thailand.) So what of the surrogate mother? The papers report that she has rejected all offers from other couples to adopt her son and intends keeping him and loving him for as long as she has him. Apparently thousands of well-wishers around the world have begun donating money online to enable this impoverished woman to do just that. Whatever the truth really is, this difficult story has highlighted some of the many ethical issues associated with surrogacy. I’ve had an ongoing interest in this topic ever since I researched it for my novel, Double Trouble, but what do you think of the rights and wrongs of this case?

The Behaviour of MothsIt was entirely by chance that this week I read The Behaviour of Moths by Poppy Adams – which was given to me by friends who came to stay a couple of weeks ago – and found that it also includes a surrogate pregnancy. It’s a most unusual story and it wasn’t until P126 that I began to understand why they chose it for me; and not until P155 that all really became clear. After that I was glued to it. I don’t want to spoil the dramatic tension for you, so I’ll simply say that it tells the story of two sisters brought up by eccentric parents in a rambling Dorset mansion. The elder girl, Virginia/Ginny, becomes apprentice to her semi-detached father who is a reputable and dedicated lepidopterist. Together they hunt and study every kind of moth they can find, conducting experiments on them, researching their behaviours, amassing a formidable laboratory and collection.

The story begins with Ginny watching from the first floor for the arrival of her ‘little sister’, Vivien/Vivi, returning after decades of absence. Through the lens of Ginny’s peculiar take on life, it recounts each day of one week in their lives when they meet, as old women, one last time. Slowly, gradually, subtly, we piece together their experiences, feelings and differences as they re-live their childhood, and try to resolve the legacy of the past and the accumulated burden of their emotions. And yet … well, how much of this can we really believe? From the time Vivi falls out of the bell-tower and is nearly killed, it’s like a collapsing column of dominoes, each one nudging the next towards an inexorable conclusion. The Behaviour of Moths is a haunting tale, and I’d love to have a one-to-one chat with the author about her thinking, especially about the character Ginny; I’m not at all sure I have understood her correctly.

But to return to the topic of perfection, at one point in the book, Arthur, a troubled young father says: ‘You can’t choose your children. You can’t take the best ones, the ones that survive, the ones that are born the right colour. If you decide to have that child you must take it, whatever happens. You must claim him.’  When things go wrong, the surrogate mother concludes, ‘If it survived it was hers; if it died, it was for me to mourn.’

Uncanny, huh? It could have been written with the Thai family, and the Australian commissioning couple, and baby Gammy in 2014, in mind. And yet this was published in 2008. And is fictitious.

Speaking of perfection … the lilies in our garden are blooming in profusion right now. We have massive banks of them in the house and still a proliferation in the flower beds. Now there’s perfection of a different order, huh?

White lily

Yellow lily

Spotted lily

Red lily

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Aiming for perfection

Well, what an amazing beginning to the year 2010!

Temperatures up here have sunk to minus thirteen – minus sixteen a bit further north. It’s snowed every day except one for three weeks now. We’ve slipped and slithered to a few events – the ones that weren’t cancelled – but the roads have been deadly.

But it’s stunningly beautiful. I keep reaching for the camera …

… with due care, of course. Don’t want to fall and break that expensive lens … or both my arms … and end up totally helpless … like someone in the advanced stages of dementia … like my character, Doris Mannering, in Remember Remember … Fanciful? Yes. But then aren’t all creative writers? Imagining yourself into a person or place is what it’s all about.

And I’ve been doing a lot of imagining this week. It’s the big edit. ‘Be severe,’ said my editor. And ‘kill the baby’ (which in common parlance means, erase the bits you love best). I’ve been severe all right! Twenty-eight thousand words have been cut. That’s more words than many a dissertation. And every one of those twenty-eight thousand words has been thought up, written down, read several times and now deleted. For ever. Weird way of filling your time, huh? But fortunately for me I’m sufficiently distant from the original draft for it not to be too painful. There’s something to be said for publishers’ delays after all!

I finished this mammoth stint at 10.30 last night and sent it off to my editor. But then, in the night … you know about my subconscious mind … I had an idea … As the saying on my old computer had it: Perfection is always one more draft away. And because we’re never satisfied, we go on … and write another novel … and another … always hoping … this time …

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