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à la mort. Cependant, la formation en Primum Non oncologie met l’accent sur le traitement du cancer et fait très peu de Nocere: place à la relation d’aide en prépa- Reflections of a ration à la mort. Des médecins tels Bahá’í Oncologist que l’écrivain Atul Gawande veulent ramener le sujet de la mort dans la about Treating the conversation entre le médecin et Dying Patient le patient. De plus, bon nombre de religions, dont la foi bahá’íe, peuvent aider à examiner comment les mé- AARON ALIZADEH decins perçoivent et abordent le sujet de la mort. Dans le présent article, je Dedicated to Carley Elle Allison traite de mon expérience personnelle en tant qu’oncologue et en tant que July 18 1995 - March 31 2015 bahá’í en ce qui concerne le sujet de la mort. Abstract Medical oncology is a subspecialty of Resumen internal medicine that focuses on the Oncología médica es una subespecialidad treatment of cancer. Cancer is the sec- de la medicina interna que se encarga en el ond leading cause of mortality in the U.S. tratamiento del cáncer. El cáncer es la se- Therefore death is a frequent subject for gunda causa de mortalidad en los Estados oncologists. However, oncology train- Unidos. Por lo tanto la muerte es un tema ing emphasizes cancer therapy with little frecuente para los oncólogos. Sin embargo, guidance on counseling in preparation for la formación oncológica enfatiza el trata- death. Physicians such as the writer Atul miento del cáncer con poca orientación en Gawande are working to bring back the la preparación para la muerte. Médicos, topic of death into the physician-patient como el escritor Atul Gawande están tra- conversation. Furthermore, many reli- bajando para traer de vuelta el tema de la gions, including the Bahá’í Faith, can help muerte en la conversación entre el médico to address how death is perceived and dis- y el paciente. Además, muchas religiones, cussed by physicians. The purpose of this incluyendo la Fe bahá’í, pueden ayudar a article is to review my personal experience hacer frente a cómo la muerte es percibida as an oncologist and as a Bahá’í, as it re- y discutida por los médicos. El propósito lates to the topic of death. de este artículo es de revisar mi experien- cia personal como oncólogo y como bahá’í Resumé relacionando el tema de la muerte. L’oncologie médicale est une sous-spécialité de la médecine interne I sit across from my patient (we’ll call axée sur le traitement du cancer, qui him Mr. Smith) in an 8x8 ft. exam est la deuxième principale cause de mortalité aux ÉtatsUnis. Les onco- room. We have previously reviewed the logues sont donc souvent confrontés fact that his pancreatic cancer appears 66 The Journal of Bahá’í Studies 25.3 2015 incurable with the presence of liver commonplace. Patients whom I saw and bone metastases. His demeanor is regularly in clinic regularly would calm, even serene. He speaks eagerly stop showing up. The transition could as if I am his confidant, the only per- be sudden and unexpected, making it son to grasp the precious news that he difficult to believe they had actually will soon die. died. It soon dawned on me that the He quickly divulges that he does practice of oncology took place on not fear death, but he is afraid of pain. the “ceiling” of this world—a portal When he pauses I try to reassure that between the physical world and death. we have good medicine to alleviate As an oncologist, was I to serve as a pain. I also begin to introduce chemo- spiritual gatekeeper of sorts. therapy options, but he waves me si- According to the American Can- lent. He has made up his mind to start cer Society, the five-year survival rate hospice care. He wants to spend his re- for all types of cancer in the U.S. is maining time with loved ones in peace. approximately 68%, a substantial in- No chemo side effects, no long waits in crease from the 49% of the mid 1970s. doctors’ offices, no vein punctures, CT Yet in my experience (and I suspect scans, IV drips. None of that. Just pure most other oncologists feel similar- time at home and with the people he ly), death and the practice of oncolo- loves. He expresses sadness and mild gy remain inseparable. Death hovers guilt about leaving them, but he also subconsciously in the conversations makes it clear that he is ready for this. we have with our patients, wheth- The subtle joy in his tone surprises er in the discussion of the causes of me. I leave the room feeling a little let cancer, the treatment, the side effects, down by his decision, yet his serenity the prognosis, the surveillance, the in- lingers. heritance pattern. Death is a silent yet I decided to sub-specialize in oncol- omnipresent backdrop. Its beckoning ogy during the third and final year of remains fixed in my mind as I tend to my general internal medicine residen- my patients. Death comes for all. It cy. I was enticed by the burgeoning has already and will continue to call field of molecular science, along with for my loved ones. It will call for me. the gravitas of treating cancer. Oncol- Yet, despite its centrality in the field ogy offered me an opportunity to prac- of oncology, death is seldom discussed tice medicine with serious diagnoses openly. If so, it is often mentioned in a and weighty decision-making. But I hushed, quick voice, a dirty five-letter was not yet fully aware that death was word—the less articulated, the better. the ultimate source of the gravitas. Siddhartha Mukherjee’s The Em- In my previous three years of in- peror of All Maladies describes itself ternal medicine clinic, very few, if any, as a “biography of cancer.” Its bril- of my patients died. Once I started liance lies in its ability to portray man- my oncology fellowship, death became kind’s long struggle with the dreaded Primum Non Nocere 67 disease. Mukherjee chronicles the his- and able to endure this grievous price? tory of humanity’s experience with Having lost many battles, I am ever cancer, starting in 1000 BCE with the aware of the strength and elusiveness Persian queen Ahoshta’s breast tumor. of my foe. I witness the physical and He portrays mankind’s evolution in emotional devastation that cancer studying, understanding, and treating causes on a daily basis. My skills as an cancer over the last three thousand oncologist are honed on treatment of years, and the book culminates with cancer, so the greatest challenge, for modern-day oncology and the devel- me, is when and how to tell a patient to opment of “targeted therapy”—the stop fighting. When Mr. Smith decides so-called “smart bomb” medicine. to forego treatment for his cancer, it A central focus of the book is Pres- is difficult for me not to experience ident Nixon’s “War on Cancer,” which disappointment, even when I clearly started with the National Cancer Act recognize the wisdom, and even the of 1971, the political history of which heroism, of his decision. is discussed in detail. The “war on can- Several months after my discussion cer” becomes not only a central theme with Mr. Smith, I meet Mr. Jones, who but also a metaphor throughout the has advanced colon cancer. He too book. Mukherjee makes it clear that has multiple liver metastases, but he we are at war with cancer on multiple is only fifty-four years old—twenty levels: cellular, personal, familial, and, years younger than Mr. Smith—and ultimately, social. The main theater of is already on his third line of therapy this war is the oncologist’s office. since the initial diagnosis some sixteen From their early days of training, months earlier. oncologists adopt the “war on can- We avoid mentioning the obvious, cer” mindset. They study how to fight that his cancer is rather resistant to cancer and defeat it. Like a general, chemotherapy. I am keenly aware that a good oncologist is always thinking once the current regimen stops work- about outcomes: What strategy will ing, there will only be one additional I devise when the current therapy FDA-approved chemo regimen I can stops working? What will be the third offer. This is in the forefront of my line of defense, fourth line? Perhaps mind throughout our consultation, but a clinical trial with novel therapies I sense that he does not want to discuss will make the difference in this case. his prognosis. Here is where I cannot Chemotherapy’s potential for toxicity be merely a clinician, I must somehow is factored into the decision-making. develop the skills, the instincts and in- But while the physician may view the tuition of a spiritual counsellor. None dreaded side effects as unavoidable—a of this was taught to me in my medi- collateral attrition to achieve the goals cal training. at hand: reduction in tumor size, re- Ever optimistic, Mr. Jones makes mission, cure—is the patient willing repeated references to how well he is 68 The Journal of Bahá’í Studies 25.3 2015 tolerating the chemo. When we dis- steadfastly society seems bent on cuss the neuropathy (nerve pain) he denying the obvious fact that no has developed because of the chemo, exercise regimen, however inge- he emphasizes the point that it does niously devised, no amount of not limit him on the tennis court. He vitamins or potions or lotions can does admit to new episodes of right- long deter the inevitable onset side abdominal pain—not coinciden- of our own aging and eventual tally, precisely the same location of death. Yes, however much we his liver metastases—but he dismisses may wish to avoid discussing it, the symptom, attributing it to a mus- aging, dying, death, and whatever cle “tweak” sustained during a recent happens afterward are as much a tennis match. I don’t want to worry part of our own lives as any other him, but I feel obliged to inquire a bit important periods or events—our further about the nature of his pain. wonderful teenage years, acquir- Again he dismisses it, so I move on. ing a driver’s license, achieving We conclude the visit by agreeing to various levels of higher educa- order a CT scan to assess how the can- tion, getting married, having chil- cer is responding to the current chemo dren, and so forth. (Hayes xiii) regimen. For reassurance (his or mine?), I re- Hatcher also quotes the forward of view the one treatment regimen that Elisabeth Kubler-Ross’s book Death: still remains. I also point out that an The Final Stage of Growth: “Death is a experimental research protocol might subject that is evaded, ignored, and de- be worth looking into. Implacably up- nied by our youth-worshipping, prog- beat, he responds favorably, and tells ress-oriented society. It is almost as if me he will contact the National Cancer we have taken on death as just anoth- Institute. At no time do I mention the er disease to be conquered” (Hatcher word “hospice.” At no time is the word xii-xiii). “death” mentioned in our discourse. Oncologists can become convenient Such an encounter is more typical than allies in our society’s quest to live for- my earlier one with Mr. Smith. ever. Ironically, it is this same drive Professor John S. Hatcher’s intro- for immortality that is the hallmark duction to Life, Death and Immortality: of the cancer cell. When cancer cells The Journey of the Soul describes our are given the correct balance of nu- society’s current attitude toward death trients, they will multiply ceaselessly. and our basic denial of its existence: Thus, the drive for immortality in the physical world ultimately equates with [O]ur culture has descended ever the ethos of death. Conversely the further into its moribund obses- body’s physical death (or “transition” sion with youthfulness, appear- and “change” in terminology appro- ance, and hedonism. Ever more priate to a religious or philosophical Primum Non Nocere 69 perspective) paradoxically defines in an associative relationship with the what it means to be alive, to transition, soul, which is gradually introduced to or, to cast aside this mortal frame to spiritual concepts through an indirect, emerge immortal in our true spiritual or metaphorical, relationship with the form. In this light an underlying spir- spiritual realm. The soul is our es- itual message begins to develop clari- sential self: spiritual, non-composite, ty. Perhaps mortality is not meant to and eternal. The body functions as a be feared. Perhaps acceptance of our vehicle for the soul’s willful sojourn inevitable death is, in fact, a route to- toward an understanding of God; a ward a new mode of life, a better life. journey that encompasses the period Most of the world’s faiths empha- of one’s physical life, whether that life size the point that death is not an end be but a few hours or ninety years: to our existence but rather a portal through which we are transported to Thus, it is apparent that the soul, a reality that, while indescribable and even as the body, has its own in- unfathomable, is glorious and total- dividuality. But if the body un- ly felicitous. And yet, we might well dergoes a change, the spirit need ponder how so many of the world’s not be touched. When you break diverse faiths can reach such a similar a glass on which the sun shines, conclusion, if it were not a reflection the glass is broken, but the sun of a deeper metaphysical reality that still shines! If a cage containing society does not yet understand. a bird is destroyed, the bird is un- While I find it comforting and in- harmed! If a lamp is broken, the spiring that so many of the world’s flame can still burn bright! great religions offer congruous vi- (‘Abdu’l-Bahá, Paris Talks 65–66) sions of an existence beyond the physical world, I myself am a follower of As a Bahá’í oncologist, I hold the the Bahá’í Faith, so it is from the texts belief that the soul is eternal and that of this religion that I wish to share this essential human reality exists be- some examples about how a spiritual yond the death of the body. It is the perspective can have a major impact soul that constitutes an individual’s on the work of every oncologist in the true identity—as opposed to the tem- life/death decisions they must make poral body, which ultimately ceases on a daily basis. to function and, finally, decomposes. The Bahá’í Faith posits that hu- The prophet and founder of the Bahá’í man reality is essentially spiritual in Faith, Bahá’u’lláh, affirms the mysteri- nature, driven by the power of the ous and eternal nature of the soul: soul. It further asserts that the human temple—the body—is created to serve The human soul is exalted above an important, but ultimately founda- all egress and regress. It is still, tional, purpose. The body functions and yet it soareth; it moveth, and 70 The Journal of Bahá’í Studies 25.3 2015

yet it is still. It is, in itself, a testi- of prognosis and death, how does one mony that beareth witness to the balance the necessity for truthfulness existence of a world that is con- with desire to maintain hopefulness? tingent, as well as to the reality And what if I am wrong, and sudden- of a world that hath neither be- ly an unexpected remission occurs or ginning nor end. (Gleanings 161) a treatment begins to take hold, and death is not as close as I had estimated? The Bahá’í Writings are replete with In spite of the sobering statistic multiple descriptions of the next that cancer is the second leading cause world. In these passages the spiritual of death in the United States (Ameri- world is described in beautiful detail can Cancer Society), according to data and its reality is exalted. Bahá’u’lláh from the Center for Disease Control observes: “I have made death a mes- the majority of people who are di- senger of joy to thee. Wherefore dost agnosed with cancer do not die from thou grieve?” (Arabic Hidden Words their disease (FastStats). Many people n. 32) are cured of their cancers, and only Similarly, ‘Abdu’l-Bahá, the son of a small percentage of patients in the Bahá’u’lláh and His successor as head oncology office have a stage IV or in- of the Bahá’í Faith, describes the next curable disease. world as “the kingdom of lights” The topic of death, therefore, man- where we will be “acquainted with all ifests itself in two different but inter- mysteries, and will seek the bounty of connected settings. The first involves witnessing the reality of every great people who have potentially curable soul” (730). disease or who have completed their Although my beliefs give me great cancer therapy and are now in remis- comfort and enable me to see mor- sion. The second setting occurs when tality in a spiritual light, the topic of a person has incurable, “terminal” death remains fraught with complex- cancer. ity in my daily practice of oncology. In the first scenario, when a person When and how does an oncologist dis- presents with a cancer that is poten- cuss the topic of death? We are never tially curable, the expectation is that trained to do this, even though it may the person will survive their disease be one of the most important conver- rather than succumb to it. Neverthe- sations we can have with our patients. less, a diagnosis of cancer is often re- Whether or not the profession is ready ceived as a shock and also as a stigma. to approach this critical absence in our Consequently, questions immediately training, how do I personally decide arise in the patient’s mind: Why has when to begin this discussion? Ear- this happened to me? Is this something ly in the illness? Later on? How do I have brought upon myself ? Have I I gauge the effect my comments will not taken sufficient care of my body? have on the patient? In the discussion Have I not eaten the right foods? Did Primum Non Nocere 71

I unnecessarily or carelessly expose that all human beings succumb to the myself to some toxin? Why? Why? inevitability of death, this epiphany Why? can create “new” opportunities for a Another crucial part of this label person to live more thoroughly, more of being a “cancer patient” is that this thoughtfully, more focused. It can urge may well be a person’s first real awak- us to re-prioritize important matters ening to the fact that they are mortal in our life. When viewed in this con- and will eventually die. Doubtless, this text, the prospect of our demise (or initial brush with death likely contrib- transition) can become a constructive utes to the stigma so often associated rather than destructive force. with a cancer diagnosis. Despite our Despite the positive benefit that ac- society’s denial of death, subcon- knowledging death might bring, the sciously one is constantly aware of its topic is infrequently discussed in an inevitability (Yalom). Similarly, can- open manner in oncologic care. More cer’s inexorable growth pattern and likely it is carefully avoided. Instead, our perception of it as a foreign invad- the discussion focuses on treatment er within us, evokes a deeper psycho- details—the side effects and symp- logical threat than most other chronic toms, the imaging tests, the lab tests, diseases. It is the physical ailment that and so on. But like background noise, most closely embodies the process of the subject of death is almost always death itself, hence earning the moni- there during the office visit, and its ker “the emperor of all maladies” (qtd. theme reverberates for both physician in Mukherjee xviii). and patient alike, whether or not they Along with the existential threat choose to acknowledge its strains. posed by a diagnosis of cancer comes Psychotherapist Irvin Yalom ob- the opportunity to change one’s life for serves that death “whirs continuous- the better. People often report that a ly beneath the membrane of life and diagnosis of cancer brings them a new exerts a vast influence on experience view of life, of their relationships, and and conduct” (146). The discussion of their priorities. This transforma- of one type of treatment over anoth- tive effect is largely the result of the er, the timing of therapy (should we patient becoming aware that death is start now, or later?), the frequency of a reality and that it may not be just a imaging tests, the plan for surveillance remote possibility, a mere abstraction measures—all these particulars are forever in the future. measured against a silent but implicit In this same context, Mukherjee concern about cancer recurrence and quotes American poet Jason Shinder’s death. This is the silent but palpable remark: “Cancer is a tremendous op- tension present during even some of portunity to have your face pressed the most routine oncology visits. right up against the glass of your What of the second setting in mortality” (Mukherjee 398). Given which the patient has stage IV 72 The Journal of Bahá’í Studies 25.3 2015 incurable cancer? Even in these cir- The cancer continues to grow, and cumstances the anticipation of death she eventually dies from the disease is not discussed as frequently as one nine months after the diagnosis. Ga- would imagine. This is particularly wande notes that her death comes only true in the beginning phase of the days before she was to begin a new, diagnosis. There might be an initial experimental therapy. She dies while (and often vague) discussion about es- in the hospital and never receives the timated survival statistics during one benefit of hospice care at home. On the of the early oncology visits, but there- contrary, she and her family remain in after the subject is frequently dropped, full “battle mode,” as Gawande puts it, or even meticulously avoided. Instead, up to the last day. She narrowly escapes the majority of the conversations fo- being placed on a ventilator when her cus on symptoms, side effects, imaging mother, recognizing the futility of the results, treatment options, strategies, situation, decides to forego extreme and statistics. lifesaving measures. This somewhat predictable routine Gawande interviews Dr. Paul Mar- is not unlike embarking on a road coux, the Harvard oncologist who trip. In the beginning, we give little cared for Sara Monopoli. Marcoux is thought to time, rather, our thoughts well aware of the data that third-line are occupied, with the details of the chemotherapy for lung cancer is rarely journey. We comment on the scenery, successful in prolonging life. However, discuss when to stop for a meal, or in “taking measure of the room” he remark on how smooth or rough the quickly realizes what most oncologists road is. It is not until we near the des- often face: “a patient and family un- tination that our mind begins to focus ready to confront the reality of their on the journey’s end, that inevitable disease” (165). He goes on to say that destination. Suddenly, we can no lon- “the signal he got from Sara and her ger avoid being attentive to what lies family was that they wished to talk directly before us. only about the next treatment options. In his book Being Mortal, surgeon They did not want to talk about dying” Atul Gawande calls attention to our (165). Thus, instead of mentioning his society’s ill-preparedness for mortal- concern that little time was left, and ity. Gawande discusses the case of a trying to discover the basic wishes of thirty-four-year-old woman named this young woman and mother, Mar- Sara Monopoli with newly diagnosed coux reviews experimental treatment stage IV lung cancer. The diagnosis options. Gawande points out that doc- arrives when she is in the late stages tors worry about sounding “overly of pregnancy with her first child. Af- pessimistic” and that discussing death ter the delivery, she embarks on multi- is “enormously fraught,” particularly ple rounds of various therapies, but all in the circumstance of a young parent to no avail. with a newborn child. Primum Non Nocere 73

Gawande also visits his own in- the priority was her lung cancer, volvement in Sara Monopoli’s case. I said. Let’s not hold up the treat- During her evaluation for lung cancer, ment for that. We could monitor she was coincidentally diagnosed with the thyroid cancer for now and a thyroid tumor that had been discov- plan surgery in a few months. ered by a CT scan. While this was … I saw her every six weeks and likely a slow-growing tumor with fa- noted her physical decline from vorable prognosis, it was still a cancer, one visit to the next. Yet, even in and it was Gawande’s job to discuss a wheelchair, Sara would always the surgical options: arrive smiling. … She’d find small things to laugh about. … She Sitting in my clinic, Sara did not was ready to try anything, and seem discouraged by the discovery I found myself focusing on the of this second cancer. She seemed news about experimental thera- determined. She’d read about the pies for her lung cancer. After one good outcomes from thyroid can- of her chemotherapies seemed to cer treatment. So she was geared shrink the thyroid cancer slightly, up, eager to discuss when to op- I even raised with her the possi- erate. And I found myself swept bility that an experimental ther- along by her optimism. Suppose I apy could work against both her was wrong, I wondered, and she cancers, which was sheer fantasy. proved to be that miracle patient Discussing a fantasy was easier— who survived metastatic lung less emotional, less explosive, less cancer? How could I let her thy- prone to misunderstanding— roid cancer go untreated? (168) than discussing what was happen- ing before my eyes. (168–69) At no point did Gawande mention to Sara that the lung cancer progno- Sara Monopoli’s case presents an sis was so grievous as to negate any extreme example of the challenges threat of an indolent localized thyroid oncologists face in discussing prog- cancer. In essence, her surgical evalua- nosis with a patient who has terminal tion with Gawande for thyroid cancer illness. A mother’s bond of love with was a waste of the short time allotted her newborn child is one of the stron- to this dying woman. In discussing her gest forces of attraction in this world. prognosis he states, Her attachment to this physical world is therefore understood and justified. My solution was to avoid the The thought of being separated from subject altogether. I told Sara that her child would certainly cause tre- there was relatively good news mendous distress. Her physicians im- about her thyroid cancer—it was mediately sense this and understand- slow growing and treatable. But ably become complicit in her desire to 74 The Journal of Bahá’í Studies 25.3 2015 avoid mentioning what so desperately childhood, as it will greatly aid needs to be said. in its elimination. Whatever de- Oncologists are not being negligent creaseth fear increaseth courage. in their reticence. There is legitimate (Epistle 32) concern that discussing prognosis in frank terms might introduce psycho- In his chapter about heroism, logical trauma, and that the emotional Hatcher asks if true heroism—or distress might detract from a possible courage—is being unafraid in the face therapeutic benefit. According to Dr. of danger, or if it is, instead, the will Daniel Rayson in the Journal of Clin- to act despite experiencing fear. Per- ical Oncology, many patients with ter- haps the answer lies in Bahá’u’lláh’s minal cancer prevent themselves from assertion that the knowledge of the experiencing traumatizing thoughts eternality of our essentially spiritual of death by not acknowledging that self and, thus, our continuity beyond death could be near (4371–72). this life, can play a major role in re- So it is that this scenario with a ducing fear. Such assurance emanates patient with terminal stage IV cancer from a belief that the body is a tem- plays out repeatedly in oncology offic- porary vehicle for the development of es, including my own. In most cases our soul; that this mortal life, while the patient is older—since cancer is important, is primarily a period of more commonly a result of aging and preparation for our birth into the spir- cellular senescence—but the refusal itual realm, just as our gestation in the to accept one’s mortality at any age is womb is preparation for being able to axiomatic in our contemporary society function in this life. Hatcher mentions where the mantra of TV commercials that many people do not have faith in assures us that there is a pill or treat- an afterlife, and yet these people can ment for every malady, even death also reduce their fear of death. This itself. often occurs when we endanger our Both Hatcher and Gawande discuss lives for a worthy cause, knowing that the importance of courage among our objective in this life is to undergo people who approach their mortal- psychic/emotional/spiritual growth. ity. Hatcher refers to Bahá’u’lláh’s A beautiful example of courage teaching about the elimination of fear and heroism in the face of death is the through knowledge: documentary film Death by Joy. The movie begins with the preparation of In the treasuries of the knowl- the Bahá’í funeral of a woman named edge of God there lieth concealed Mary. Instead of the funeral home a knowledge which, when applied, staff, Mary’s two daughters loving- will largely, though not wholly ly apply rose water to their mother’s eliminate fear. This knowledge, body and wrap her in a fine white however, should be taught from shroud. The movie then goes back in Primum Non Nocere 75 time to approximately one month ear- true hero, a teacher of courage and of lier, when Mary receives a diagnosis Bahá’u’lláh’s precept that knowledge of incurable glioblastoma multiforme, reduces fear. the most aggressive form of brain The main hero in Gawande’s book cancer. Being Mortal is clearly his father, At- Recognizing the finality of her dis- maram Gawande, who is also a phy- ease, Mary decides to forego radiation sician. His story about the diagnosis, and chemo—with their potential to treatment, and outcome of a spinal prolong survival by several months— tumor provides the framework for the in order to focus her limited remaining book. The senior Dr. Gawande devel- time on her loved ones. What ensues is ops a shooting pain in his arm. Imag- a month-long celebration in her home ing studies show a tumor within his with her family and dear friends as spinal cord. Several expert neurosur- constant visitors. gical opinions ensue and surgical re- Mary’s body gradually fails, but, moval of the tumor is considered. Ga- amazingly, we witness no sadness or wande Sr. ultimately decides against tears. Rather, the house is filled with surgery because of uncertainty about music, delicious food, laughter, love, the treatment’s chances of success. and invigorating energy. At one point, Over the course of time, the tu- our hero Mary admits that she could mor grows, and Gawande Sr., who fret about her physical death, but she is a urologist, gradually loses use of chooses not to, so she can concentrate his arm and retires from surgery two her energy on what matters most to and a half years after the diagnosis. her—love. Recognizing the spiritual He then survives two and a half more purpose of her life, she allows herself years during which he invests himself to be filmed in order to demonstrate, wholeheartedly in philanthropic activ- through her own acceptance of her ity. Finally as the tumor continues to fate, that death need not be feared. She grow, he opts for a course of radiation opts to approach her death with seren- to the tumor, but it does more harm ity as an example for others, to teach than good. He ultimately loses use of that this natural transition is an inte- his legs, and when the quality of his gral part of each of our lives. life diminishes further, he starts hos- One of the movie’s highlights oc- pice care. curs when Mary starts to have dreams Gawande’s father is awakened by of a realm of lights, which she in- his own mortality. After the diagno- terprets as glimpses of the spiritual sis, he chooses to live his life more world she is destined to enter soon. deliberately. His thoughts, actions, She describes her visions with rapture and decision-making become keener. and conviction. As a viewer, I found One might say that he becomes more it impossible not to share in her joy, “alive” than he had ever been, perhaps and for me Mary ultimately becomes a because he realizes that we all have a 76 The Journal of Bahá’í Studies 25.3 2015 death sentence. Gawande describes his been about perseverance; never father’s experience in this fashion: to accept limitations that stood in my wa y. As an adult watching Only now did I begin to rec- him in his final years, I also saw ognize how understanding the how to come to terms with lim- finality of one’s time could be a its that couldn’t simply be wished gift. After my father was given his away. When to shift from push- diagnosis, he’d initially continued ing against limits to making the daily life as he always had—his best of them is not often readily clinical work, his charity projects, apparent. But it is clear that there his thrice-weekly tennis games— are times when the cost of push- but the sudden knowledge of the ing exceeds its value. Helping my fragility of his life narrowed his father through the struggle to de- focus and altered his desires. (209) fine that moment was simultane- ously among the most painful and Detachment from extraneous, the most privileged experiences worldly matters and focus on issues of my life. (262) of greater import is a profoundly spiritual realization. Bahá’u’lláh reveals The experience of watching and as- in one of the Hidden Words, “O My sisting his father through terminal Servant! Free thyself from the fetters illness becomes a profound lesson for of this world, and loose thy soul from Gawande. He comes to understand the prison of self. Seize thy chance, for that his role as a physician is not only it will come to thee no more” (Arabic to treat and cure, but also to help in- n. 40). dividuals and our society as a whole As in Hatcher’s evaluation of death, on the journey from birth to death: “I Gawande’s book on mortality also at- never expected that among the most tempts to define courage and heroism. meaningful experiences I’d have as a After acceptance of our mortality, how doctor—and, really, as a human be- do we summon the strength to face it? ing—would come from helping others Strength grows out of courage just deal with what medicine cannot do as as knowledge can generate and foster well as what it can.” (260). courage. In reference to Socrates rea- Physicians can work to facilitate soning in Plato’s Laches, Gawande de- rather than interfere with the “dying fines courage as “strength in the face of role” at the end of life. This role, Ga- knowledge of what is to be feared or wande points out, is crucial in one’s hoped” (232). For Gawande, his father life as well as in the lives of those left exemplifies such courage: behind. It provides the opportunity to establish one’s legacy, make peace When I was a child, the les- with God, connect with loved ones, sons my father taught me had and ensure that the patients’ stories Primum Non Nocere 77 end “on their own terms.” At its core, letting the current take us. As the Being Mortal is a manifesto for our so- sun burned away the mist, it be- ciety to start to address forthrightly gan warming our bones. Then we and intelligently the topic of our own gave a signal to the boatman, and mortality: he picked up his oars. We headed back toward the shore. Our most cruel failure in how we treat the sick and the aged is In a beautiful metaphor, Gawande the failure to recognize that they acknowledges the physician’s role as have priorities beyond merely spiritual gatekeeper or boatman. The being safe and living longer; that concept of the Bodhisattva is also the chance to shape one’s story is applicable: an individual who attains essential to sustaining meaning in Nirvana only to return to the mortal life; that we have the opportunity world that they might help others. to refashion our institutions, our Obviously, no physician can assume culture, and our conversations in that all people will share a belief in an ways that transform the possibili- afterlife or even the reality of the soul, ties for the last chapters of every- but the spiritual message remains true one’s lives. (Gawande 243) regardless of one’s perspective. It is possible to accept death in a positive The book concludes as Gawande fashion because death is a natural and visits the Ganges with his father’s inevitable function of being alive. ashes. He paddles out early one morn- Mindfulness about our mortality can ing into the mist of the river. He re- actually improve the quality of our cites prayers in a ceremony to enable lives. Bahá’u’lláh, and the Prophets of his father’s spirit to achieve Nirvana, all the great religions of the world, and this process allows him to see the emphasizes this point: life in this phys- collective mortality that connects us ical world is shorter than our minds through the generations. The author would like to accept. is transformed through the experience of his father’s death. Raised a O Son of Being! Bring thyself Hindu, Gawande expressly denies a to account each day ere thou art conviction in religion. Nevertheless, summoned to a reckoning; for an awareness of the ancient cycle of death, unheralded, shall come birth and death creates a vision be- upon thee and thou shall be called yond the self and toward something to give account for thy deeds. much vaster. It is in this vein that the (Arabic Hidden Words n. 31) final chapter of Being Mortal ends:

After spreading my father’s ashes, we floated silently for a while, 78 The Journal of Bahá’í Studies 25.3 2015

CONCLUSION its splendor. Why does thou veil thyself therefrom? (Arabic Hid- My belief as a Bahá’í and my work as den Words 32) an oncologist require the recognition that death is a natural and integral part The field of oncology is inextricably of life. Not only as individuals, but as linked to discussions of human mor- a society, we are constantly exhorted tality. Medical Bodhisattvas of sorts, to refrain from acknowledging our oncologists, through exposure to the mortality or from discussing it openly. inevitability and necessity of death, But if we accede to this tendency we can strive more fully to succor their do so at a cost both to ourselves and patients, to connect with them spiritu- to the body politic. Gawande would ally and to reduce their suffering. rightfully suggest that those costs are immense. Furthermore, our lives are charac- terized by processes of change—as soon as we are born, we journey toward death, at least insofar as our mortal lives are concerned. It is my own belief that our essential reality does not stop with the cessation of our physical bodies. But regardless of whether one believes in an afterlife, we can all strive to remain mindful of mortality on a regular basis in order that we may maximize the potential of our individual lives. Finally, my job as an oncologist mirrors my duty as a Bahá’í which is to serve people—first to do no harm, and then to assist one another as, in time, we all prepare to leave the shore of this world. So it is that after each case, I had best reflect on Bahá’u’lláh’s teaching:

O Son of the Supreme! I have made death a messenger of joy to thee. Wherefore dost thou grieve? I made the light to shed on thee Primum Non Nocere 79

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