Book Review.
What can we do but keep on breathing in and out, modest and willing, and in our places? – Mary Oliver
Recently, the international news thread has been all about the militant Taliban violently taking over Afghanistan and the Republican controlled state of Texas signing an abortion law prohibiting abortions after 6 weeks post-conception. What is the possible connection? Why wall-to-wall newsprint coverage? Perhaps touching our painful, fearful matters of life after death!
My early university days are recalled from the vast labyrinthines of my deep memory. Professor Trefor Jenkins, in 1980, introduced me to ‘hard’ medical ethics when I was a science student at the old Medical School.
Two major themes were extensively debated emerging at the extremes poles of life: around birth issues and dying; specifically abortion (preventing life) and euthanasia (shortening life), respectively.
Jenkins, a gentle kind Welshman, a father figure to me, was also my genetics teacher, who successfully planted the life long seed of curiosity, urging me to explore the grammar and language of life: The vast encyclopaedia of DNA, chromosomes, and genes - his kind gift keeps on giving.
The story of inheritance is not nearly complete as biotechnology, specifically gene therapy, marches on and arrogantly infiltrates itself into the space of the great existential questions of the consequences of reordering the letters of DNA and ‘… playing God.’
I am particularly captivated by the infinite ability and the relentless drive of organisms (from viruses to humans) to reproduce their species by passing on their genes from generation to generation. Embedded in the DNA are specific proteins that ironically drive the need to survive and replicate - from the invisible bacteria to the giant whale (remarkable that the will to live lies embedded in gene producing proteins!)
Professor Jenkins, the quintessential moral man, was also a key player in activating the disciplinary trial of the medical doctors who were complicit in the murder of the influential anti-apartheid activist, Steve Biko, by state security agents: death by neglect.
What spun out of this extraordinary tale of political inspired murder was the other side of the coin of death by neglect: euthanasia, whereby doctors withhold treatment in dying patients, or actively bring death forward in time by fatally suppressing breathing by prescribing high doses of opioids - pain killers, for example.
Over ample cups of coffee, spread across a couple of years, we discussed the meaning of life, the purpose of death, of premeditated murder, of planned suicide, of soldiers licensed to kill, of indiscriminate pogroms, of genocide, of femicide, of cannabilism, the minds of serial killers (nature or nurture?), of crimes against humanity. There were lighter moments, for sure.
Active euthanasia and elective abortions both interfere with the life project. Euthanasia shortens life; abortion prevents it from ever happening. There is the inevitable slippery slope syndrome - Eugenics, the dark shadow of genetics, is driven by the hideous ideology of selecting and eliminating the ‘ugly genetic stains’, the perceived impurities that prevent the formation of the perfect race.
The aim of the eugenic masters was to stop the transmission of their perverse construct of dirty genes passing from generation to generation. It began in the United States in the 1920s but was soon dropped because of massive backlash from civil society, especially around sterilisation of the severely mentally ill.
The Nazis picked up the mantle, and there was absolutely no friction on their slippery path. They wittingly tumbled into free fall. Anyone who did not fit the ubermensch ideal of the Aryan race were exterminated by the millions - Jews, gypsies, homosexuals, socialists, communists, the psychotics, and the mentally retarded. ‘Wipe them off the genetic map’ was their refrain.
The science of genetics weaponised and flipped into mad darkness - the race to the bottom of human perversity was won. Mass euthanasia on industrial scale by gassing, starvation and execution in the death camps of the ‘other.’ Beware the slippery slope!
Professor Phillip Tobias taught a fabulous annual course in embryology - the anatomical changes a foetus undergoes from the time of conception - unification of a single sperm from the father and single ovum from the mother - until birth, nine months later. And where things can go horribly wrong. The continuous miracle is that most of the time everything turns out just fine.
A highlight of his MasterClass. Approximately 18 days after conception the embryonic heart is formed and begins pumping. Probably the mother is not yet even aware she is pregnant!
I clearly remember asking the world renowned palaeontologist when life began? He, of course, was devoted to the science of answering the other question: when did our species, the humanoids, as we know it, begin? Not the specific individual, but homo sapiens, sapiens - the life form that can think about thinking. He did not answer, perhaps intuitively, allowing me mental space to find my own answer.
And I, a true blooded sapien, have been thinking ever since about the origins of the beginning of an individual human life: does life of an individual start at conception when the sperm-ovum dyad starts to divide; or when the embryological heart is formed or detectable by a technological monitor?
Or when the foetus can be supported outside the womb (at approximately 22 weeks)? Or, according to Jewish custom, at forty days, when the soul is implanted? Or at birth after the first natural breath? Or when the kids are out the house and the dog is dead? Who decides? When did your life journey begin?
Evolving reproductive rights in liberal democracies started to complicate matters - the rights of the owner of the womb who nourishes the growing foetus: the biological woman or more recently, surrogate mothers? The originator of the DNA or the renter of the womb? And the what are the reasonable rights and obligations of the supplier of half the genes: dad?
Millions of written and shouted words try answer these complex questions. Political and gender wars are viciously fought over the derivatives of these moral conundrums, and Supreme Courts agonise their consciences and still deliberate - Wade vs Roe et al. Texas lawmakers are stirring the abortion pot, again. The battles rages on. Whose body is it anyway?
So where do I position myself?
(Disclaimer: There are clear medical indications for active abortion and passive euthanasia - however, the slippery slope is ever present, backed by incontrovertible historical precedents, and that moral decline needs to be central in our awareness space when making the tough decisions.)
I am a firm believer that life of an individual human begins at conception - as soon as cell division starts - and ends with the last breath. That is the complete life cycle and any interference raises serious moral dilemmas. I chose a career in medicine to be a participant in prolonging the quality of life of every patient. After 36 years since graduation my motivation has not dimmed, but my perspective of the complexity of the context of every patient is much broader and realistic, more nuanced and less judgemental. I think!
An example of a medical moral dilemma.
Dr Paul Kalanithi wrote a phenomenal autobiographical book in 2016: When Breath Becomes Air. His medical career was taking off, well on the way to graduating as a world class neurosurgeon, but the mysteries of life throws up the unexpected when least expected. Left field is full of surprises.
In his mid thirties Dr Paul started to cough incessantly, feeling exhausted and losing weight. He thought it was symptoms of burnout. Not to be. Within a short space of time he was diagnosed with stage 4 metastatic lung cancer, untreatable, even though he was neither a smoker nor was there a family history of cancer.
He married Lucy, a fellow physician, a few years prior to diagnosis. They were childless, planning to have children, once they both qualified as specialists.
He ultimately wrote the book between the fatal diagnosis and ultimate death. A riveting book that left me tearful about the unfairness of fate, but intellectually satisfied by grappling with the most refined questions of a life, well examined.
Kallanithi may have been a great surgeon treating hundreds, but his prose is magnificent touching many millions of readers.
Back to the story. Before starting chemotherapy, and to protect the integrity of his chromosomes, his sperm were frozen, and in due course, whilst undergoing life prolonging treatment a surprising, unexpected decision. Paul and Lucy immediately wanted to start a family, faced by the certainty of his death within two years.
After sober deliberation with family and ethical experts, they went the in-vitro ‘petri dish’ way: one sperm of Paul’s impregnating his wife’s ovum, and then the blastocyst successfully implanted into Lucy’s uterus, and nine months later a beautiful little girl was born, his only child he would ever know.
When Cady was 8 months old, Paul died peacefully, surrounded by family, with him holding his daughter shortly before his last breath, tightly bound in his frail arms; tubes, drips and oxygen mask, notwithstanding. His will to reproduce life, to propagate his genes, knew no bounds.
He knew Cady for a very short time, and probably his daughter will never remember those months of connection. However, his genes continue their journey, through his daughter, even though he died as a young man, knowing that she would never know her dad. Would I have similarly decided if I were in his shoes? Not sure but unlikely. Life and death, when breath turns to air.
Images of the Taliban, guns and hand grenades slung across their chests, marching unimpeded into Kabul, keep me aware of the the fragility of life, that there are always those who glorify death. Scenes of refugees holding onto the wheels of massive aircraft airlifting the lucky ones are heart wrenching as they fell inevitably to their deaths. Suicide bombers killing themselves and innocent bystanders; repeats of 9/11 - the Americans retaliating by more killing - the death cycle continues. No sanctity for life.
News of the Taliban and Texan abortion law pushed COVID-19 off the front pages for a few days. But the global virus is back, simply wanting to find a host to replicate and pass on its selfish genes, not caring at all of its path of human destruction. And it transforms into multiple variants if immunisation is tracking ahead in the race of life over death.
Who knows how this deadly viral era will end, but when history of the early 2020s is canonised surely one immortal captured image will be the dystopian sight of patients on ventilators, surrounded by medical personal in protective gear. The artificial, external breathing machine keeping the comatose patient alive is paradoxical in a world where terrorists or eugeneticists or radical euthanasists want to deliberately shorten life of others.
The deep uncertainty of covid 19 is it’s senseless brutal, murderous attack on the respiratory system of human beings - the life long miracle of transforming air into breath and back to air which we share with all sentient beings.
From inhaling oxygen that reaches every cell, and exhaling the waste, carbon dioxide - to produce and transmit energy, to grow, to survive - this is the magic of respiration, the physiology of life. Every cellular mechanism needs oxygen, even the ovum and the sperm, and the ovum-sperm complex, to continue the life process, to facilitate life on earth.
Paul Kalanithi’s airways were attacked by mutated out-of-control cancer killer cells; Covid also takes out the lungs - so do bullets and bombs, cigarettes and asbestos.
The lessons we need to learn, embed, and teach, are:
- Without the element of air there is no breath, no life.
- Without respiration, air cannot convert to breath.
- And perhaps understand that God may just be the breath within the breath - the most delicate, the most fragile, the most magisterial of all ideas.
Links.
1). When Breath Becomes Air
https://en.m.wikipedia.org/wiki/When_Breath_Becomes_Air
Dr Jonathan D MochPsychiatrist,Founder and Director, MINDFULNESS IN ACTION.
Website
www.jdmoch.com ( email address to send private comments)
(26). Letter From An African Psychiatrist
Another thought provoking and beautifully crafted read. Thank you. What a joy to wake up to your letters and what a privilege to journey through your incredible mind, for a bit. When I was old enough to comprehend that there is death and that the ten commandments say thou shalt not kill, it was very simple for me, you don't kill. It was black and white. I like simple. So I stopped eating animal, as a young child and the medical profession railed against me and insisted my parents feed me animal and I had no choice. I was sent mixed messages and this confused my pure view of the world, and that's when I started to witness that life is not black and white, but it would take me decades to just resign myself to the shades of grey. Where does one draw the line? Thou shalt not kill. Yet there are rules for how to kill an animal. The only way I can find peace with it all is to accept that this life, this world, this earth, this solar system is but a drop in the ocean, a tiny fraction of what there is to life. We are only, on what some term as this prison planet, experiencing not even the tip of the iceberg. This is not utopia, it never will be. It's a phase.