Let Me Die! Help Me!

The right to die has found its voice. Past generations heard little of that claim, the cri de coueur of our day.

I imagine we never wanted to die so much as we do now. In previous times when life was short, brutish and mean we struggled to stay alive. But now Medicine has taken over. Deaths are prevented, delayed and deformed. Few families in advanced societies have been spared the grotesque spectacle of a loved one subjected to medically prolonged dying.

Because we enjoy better health we live longer lives. Because we reach old age we accumulate the mutations that overwhelm our defences. Cancer results. The cancer epidemic is the trophy won for us by medical advances. And so Medicine sets out to fight its ugly daughter. We cut out tumours, we poison them with chemotherapy, we shrink them with X-Rays, we outwit them with genetically engineered antibodies. Many are the gains, great are the costs.

Eventually dying happens.

Death frightened me when I was younger. Now I can see death as a sometimes friend. John Keats nursed his brother through the long death of tuberculosis. Then Keats himself became tubercular. He knew what lay in wait for him: cachexia then death. The terminus he contemplated was like late–stage cancer, the body self-starved, the mind too aware, the complexion ghastly pale, the skin empty, disfigured:

                                                The weariness, the fever, and the fret 

                                                Here, where men sit and hear each other groan; 

                                                Where palsy shakes a few, sad, last gray hairs, 

                                                Where youth grows pale, and spectre-thin, and dies; 

                                                Where but to think is to be full of sorrow 

                                                And leaden-eyed despairs –

 

 

Keats wrote dreams of an easy death (in his Ode to a Nightingale):

                                                           Darkling I listen; and, for many a time 

                                                           I have been half in love with easeful Death, 

                                                           Call’d him soft names in many a mused rhyme, 

                                                           To take into the air my quiet breath; 

                                                            Now more than ever seems it rich to die, 

                                                           To cease upon the midnight with no pain, 

                                                           While thou art pouring forth thy soul abroad 

                                                           In such an ecstasy! 

                                                           Still wouldst thou sing, and I have ears in vain— 

                                                           To thy high requiem become a sod. 

 

When recently I posted ON EUTHANASIA I anticipated readers might react strongly. I was right: most who responded – on–line and off-line – experienced my thoughts as a wound. I learned how a doctor is expected to relieve all suffering. A doctor is a trusted friend. Once the doctor denies his patient her right, she feels he has betrayed her. The wounded person’s gaze is not directed here to the doctor as a moral agent, not as a person entitled to moral autonomy, simply as one who could help, who now, abruptly, at this last critical and defining moment, acts selfishly.

I wrote that changing a law does not necessarily serve wisdom. The reality here is no conceivable law can resolve all of the problems of our competing needs and values. We need relief. We need a doctor who respects our autonomy. We need a doctor who will not sit in lofty judgement.  We need a doctor who will protect life and now we need one who will take life. And we need to know he’ll protect when he should and take when we seek it. The forgotten need is that of the doctor to reconcile those parts of his work. Putting it a different way, if the doctor, in trying be all those things, violates her own being, inevitably she disintegrates. She must give away her integrity. And then all lose.

I read the responses. I felt them, the tremor of the soul that prompted brave, naked, passionate disclosure of self.  My mind went back to deaths I have known, deaths I have conducted. I recalled the baby who aspirated meconium in the birth canal. The baby’s chest heaved as it worked to ventilate lungs clogged with a material of the texture of bitumen. We ventilated him, he did not improve, he did not die. He would not die. Morning after morning I entered NICU and there he was, his skin marbled, his chest rising and falling in obedience to our machine. His life felt like a reproach. We had turned on the machine. I learned then that the decision to bring in the technology is more onerous than to withhold, to wait.

I recalled the first person to ask for my mercy. That person was my mother, the one who had given me life. Mum would have been sixty, I thirty. ‘Darling’, she said, ‘I have high blood pressure, I have high cholesterol; one day I’ll have a stroke. When that happens, I want you to slip me a mickey.’

I understood Mum’s reference to ‘a mickey finn’ – a lethal draught.

‘Mum, NO!’ – was my instinctive response, which I quickly softened with promises to read favourite literature to her.

Twenty or more years later Mum duly suffered stroke after stroke, the final one devastating. My son and I carried her up the stairs one day and I asked her whether she recalled our conversation. She did, clearly. I asked Mum whether she regretted my failure to ‘slip her a mickey’. Mum’s blithe response did not surprise me. Whichever way she might have responded would not prove any argument, would be particular, not general, would not resolve the next sufferer’s dilemma.

I sat with the heat and the passion and the pain of this debate. Having little faith in lawmakers to solve the problems of human existence and oblivion, I searched for some useful fragment to proffer. I recalled those numerous patients who had made written Advance Care Directives. For the simple doctor these expressions of your wishes are a godsend. I read them and I am ruled by your refusals. Some decline ventilation, some explicitly forbid ICU, some decline antibiotics or feeding by tube. Many directives are less specific: ‘Do nothing more than keep me comfortable.’ ‘Let me die with dignity.’ These last call for my deepest self-search. They challenge me to imagine what  comprises and what violates your dignity. They draw my mind into the unknowable tomorrow. But these directives too are helpful. Your opaque request demands my vision of your humanity. It’s a big ask and it’s a fair one. My parents asked of their children that we allow them to die with dignity. We did our best and we saw Mum and Dad pass more or less peacefully from us with our honest best. It’s a big ask but I feel equal to it.

So that’s my first suggestion: COMPOSE YOUR THOUGHTS, EXPRESS YOUR WISHES, WRITE THEM DOWN, GIVE THEM TO YOUR DOCTORS (IN THE PLURAL), TO YOUR LOVED ONES, TO YOUR LAWYER.

No guarantees.

The second idea came to me as I wondered about by own expertise in the matter of ending life by intent. I must do it unerringly. You don’t want to wake up mute and paralysed after I have botched it. Your family doesn’t want to see you struggle or convulse or vomit then inhale, gag and gasp. I’d need training. Then it came to me: the legalized euthanaser must be trained, supervised and certified. You’d want him to know the relevant law, the protocols. The euthanaser might benefit from ethical training. I am sure the practitioner will need pastoral support and peer supervision. He’ll need to be able to recognise and resist the opportunist heir-designate who wants Aunt Nancy knocked off before her care costs consume too much of the inheritance. (I had to do this once.)

So here’s my second suggestion, this to the lawmakers: A PERSON MUST BE LICENSED TO END LIFE. THE LICENSE WILL ASSURE THE COMMUNITY AND PROFESSIONAL PEERS THAT THE PRACTITIONER IS TRAINED, COMPETENT, HONEST AND WILLING. That final adjective might save many patients from the painful disappointment of denial of help by a doctor not prepared to end a life. (That doctor might be me.) You might or might not be able to respect the difficulty of a doctor who feels torn between your need and his vanity/arrogance/integrity/different sense of defining mission, but you need not suffer a humiliating rebuff in your extremity of need.

As I wrote earlier, a change of law cannot resolve everything.

Striped Socks

In late 1969 the new doctor emerges half-baked from his progressive medical school. After graduation he spends three years in residence in major hospitals. He emerges from that great womb and enters family practice, feeling underdone still. But he blazes into his new work in a rural general with a few guiding verities. He will not create distance from his patients. He will not wear a white coat. He will wear bright socks, a signal to the young that he too is – was – is young. He will not hold himself aloof. He will not frighten children.

 

 

He starts his work and his feet are rainbows. When he treats children he sits next to them on the floor. Instinct rather than ideology guides the new doctor: he needs to be close; he wants to do away with barriers.

 

 

On his very first day, the ninth of April, 1972, the new doctor delivers a baby, a little girl. He becomes a long-term friend of the new mother. Every April ninth he remembers and often contacts the ‘baby’ – long after she grows, graduates, becomes a musicologist, a linguist, a creator of Aboriginal dictionaries.

 

 

He keeps changing his colourful socks but he does not change his ways. So long as his patients are, for the most part, young, the thin membrane that separates doctor from patient suffices for safety; the blurring of the professional and the human nurtures both the doctor and the doctored.

 

 

A young mother passes terrifying nights seated by her firstborn, watching him, willing his breathing as he gasps his inbreaths and wheezes his outbreaths. She brings the child to the new doctor. His concern comforts her. In time the boy’s asthma improves. The doctor meets and treats all three of that young woman’s children. He is drawn to the three, the thin boys gangling, the coal-eyed little girl, a faun. The children do not fear him. These too he befriends.

 

 

A few years pass and the young parents bring Grandfather to the doctor. The young family have taken the old man and Grandmother in to their home, thoroughly alarmed by the pneumonia he narrowly survived during the previous winter. Sixty years previously that man survived gassing in the trenches. His lungs are ruined, he might not get through another winter. Would the young doctor resume his care? He does, and further friendships grow.

 

 

Grandfather survives a dozen more winters in cheerful semi-invalidism, dying eventually in his late eighties. Grandmother, born in December 1899, lives to see three centuries and two millennia, living beyond all arithmetic probability, dying eventually, aged 104.

 

 

 

The father of the asthmatic boy likes to run. He’s a graduate in Architecture, a landscape artist who turns to teaching maths. He teaches at a school fifteen kilometres distant. Sometimes he runs those fifteen kms, up and down hills, across a couple of creeks to the school in the valley. The teacher shows his doctor friend the secrets and joys of running sandy country tracks. Up hills they run, sharing vistas of white, off-white, pale grey, deep grey, their breath white in the frosty mornings. Summer sees the two up and running before the heat strikes. Sweat-born raptures bind them in close friendship. The doctor showers and dresses for work in the en-suite bathroom of the aged matriarch. He tiptoes past the old lady lying asleep in her bedroom, greeting her after she has awakened. 

 

 

 

Years pass. Decades pass. All are older now. The Medical Board sends letter after letter to doctors, warning them to keep proper distance from patients. The Medical Board has never had the pleasure of being a country doctor. The doctor wears his garish socks still, unconsciously. He knows by now the byways of health, the pathways along which he and patients alike, stumble; ways that lead slowly or rapidly towards the universal destination. He knows his own vulnerability to the pain of others, the sorrows that seep through a thin membrane; and the power of hope to seep osmotically back. He knows too the cases where hopes of cure are cruel illusion. He seeks in these cases to be a guide, to keep company with his patient his friend. That a friend not pass, lost or alone, into finality.  

 

 

 

The running friend becomes unexpectedly breathless. Time passes and he cannot catch his breath. Tests show a shadow on a lung. Other tests reveal a tumour in the bowel. The years of torment begin. Surgery, chemotherapy, surgery again, scans and biopsies that show a third disorder, a serious chronic lung inflammation, nemesis now of three male generations. The teacher painter architect runner friend – what word can encapsulate a human person? – must take strong steroid medicines to stay alive, to breathe.

 

 

 

The breathing man works on a new painting. He paints a square-rigged ship negotiating a strait. He paints the ship then repaints it. His work reaches no finality. He shows the work to his doctor friend, who comes – as he used to in the running days – for breakfast. That’s a sound in New Zealand, a fiord really. It’s called ‘Doubtful Sound.’ Captain Cook came to the entrance, felt uncertain whether he’d get ‘The Endeavour’ out if he were to enter. He felt doubtful and he named the place for his doubt.

 

 

 

The painting shows a tall ship heeling before a strong wind. Its bow points bravely into the wind. The wind bears it towards the reef that guards the mouth of the sound. The rocks are a maw, open, baleful. The sails are close rigged. This is a ship under strain. Relieving that strain is a smaller boat whose heaving oarsmen pull the larger one towards safety. The doctor looks at the picture doubtfully. He was raised on boats. He’s negotiated dangerous narrows, but he had a motor to see him through.

 

 

 

That small boat, that’s a whaler. I used to row boats like that as a boy, on the Thames. In earlier times the master of a square rigger would launch the whaler to sound depths, but also, to help the mother vessel in places where the going was tight. When he felt doubt that he’d make it through.

 

 

 

The cortisone voice crackles, phrases punctuated by breathing pauses. The creator looks at his unfinishing work. Artful brushstrokes of blue, of greys, of white, create waves, wake, bow-wave. The ship holds its own. In all the stresses and forces it has not reached finality.

Empty, Empty and Desolate the Sea

I can’t see Manny anywhere. I stand and fret in St Kilda Road. The spring gale blows a clatter of discarded plastic drink cups along the great boulevard. The cups fly and land and take flight again, baffling the redshirted volunteers who try to arrest them. In all the great sweep of road it is only the volunteers who run, no others: the marathon field has swept past me as I keep my watch and ward, as I wait and wait for Manny.
 

It is eight thirty-five. The marathon runners have passed, the half-marathoners too. Where is Manny? We’d arranged to meet at seven thirty. When we saw each other a week ago Manny told me he could run only two hundred metres without breathlessness. I was treating him for the respiratory infection that he’s prone to: whether it’s his cancer therapy or the cancer itself or a recurrence of pneumonia, he’s been unable to train. ‘Until the other day’, he says hopefully, ‘I did 10K on the treadmill.’ Then he concedes, ‘I had to walk and jog.’

 

Last night Manny sent a message: I’m hoping miracles do happen. This will be my thirty-ninth Melbourne Marathon. I am determined to start. I don’t want to embarrass myself. I hope I make it to the five kilometre mark. I’ll meet you there around seven-thirty I hope.

 

I have been watching since seven-fifteen, searching faces, peering into the throngs for sight of Manny’s familiar features, his labouring body. The road has been full, but empty, empty and desolate. So Manny has been defeated at last. After running thirty-eight successive Melbourne marathons, one of only eight people who have started and completed every one, Manny has admitted defeat. And it is not the event that has defeated him, but his illness. The wind howls in my ears, dust flails my face. I am almost relieved that Manny does not have to run into the gale.

 

I turn for home then look back over my shoulder. At the extreme of sight two figures are dimly seen. Their bodies are shapes, undefined. They seem to move: are they moving towards me or away? I wait. Yes, two figures, moving slowly, making slow progress in my direction down St Kilda Road. Can this be Manny and another, a support person? I wait my turn to become the next in Manny’s chain of supportive escorts. The figures approach, they gain definition. They move comfortably, they laugh and wave. They are young, female, they are not Manny.

 

Sombrely I jog back, keeping pace now with some lagging half-marathoners. Sloggers, these, a sub-sub-sub elite, united in dour resolution. These runners have the Manny spirit, the spirit that brought him through and home in the last two full Melbourne Marathons.

 

Back home I try to call Manny. No luck. I call his devoted son – all his relatives love and cherish him: no answer. I leave an anxious message. Restless, I await news. Day ends without word. I send an email.

Finally the following arrives: With help from my wonderful family I did the impossible and finished the thirty-ninth Melbourne Marathon.

I did the Cliffy Young shuffle and someone was with me all the way to help me along. I’m feeling very sore and tired.

I’m sorry I missed you. Hopefully we can run together next year.

‘Next year’. Two years ago Manny’s cancer doctor warned him against running: You fractured a cancerous rib just by coughing. You might have cancer in any of your bones. You can’t afford to run. But Manny did run. In 2016 with the same warning echoing, he asked his GP what he thought; this GP said, I’ll run at your side. And that was our plan again this year. But I missed him.
I missed him but Manny ran. He shuffled through the spring gales and he completed the full forty-two kilometres, plus the final terrible two hundred metres. And I missed witnessing one of the great athletic feats, one of the triumphs of the spirit over the flesh.

 

Next year, Manny, next year.

 

THE MCG STANDS EMPTY, THE SOLE RUNNER, LIKE PHEIDIPIDES OF OLD, ENTERS ALONE

The Delinquent Chromosome and the Marathon Runner 

Most of us have no intercourse with our forty-six chromosomes. They perform their work honourably in intracellular obscurity and we leave them alone. Not so for my friend Manny Karageorgiou: his Chromosomes Numbers 13 and 14 have conspired to mutate. This mutiny came to light late in 2013 when he broke a rib without trying. He simply breathed or coughed or heaved a carton and the rib quietly cracked.
 

What Manny has tried to do – what he has managed to do every year for 37 years – is to run the 42.195 kilometres of the Melbourne Marathon. Manny is one of a tiny and diminishing band of brothers to achieve this feat. This, their 38th year, they number only eight.

 

When Manny’s rib cracked he consulted his doctor. In their shared innocence, patient and doctor initially believed they were dealing with a painful area in Manny’s chest, a mere nuisance, an impediment to running: and Manny had a marathon to run. The Marathon would call him. Come October Manny would obey the call and run. Always the Melbourne Marathon, always and only Melbourne. Athens too, has called Manny. Deep in his Greek heart’s core he hears that call. He feels aeonic tremors, he hears echoes across time of Pheidipides at Marathon field. Manny feels, he hears and he yearns to join the runners in Athens; but year after year that marathon clashes with Melbourne’s.

 

Manny could not run both. Melbourne held him: captive of his love for the Melbourne, of his obligation to its history, of his loyalty to his old comrades, Manny stopped his ears to Athens in October, he turned his back on the Aegean and, busted rib and all, he ran Melbourne. That was last year. For a period of time between the fracturing of the rib and that Sunday in October, my colleagues filled Manny’s body with poisons – thalidomide, dexamethasone, bortezomib – in their attempts to put down the chromosomal mutiny. The short term for that poisoning is high-dose chemotherapy. 

 

When I wrote of Manny’s marathon in 2014, runners from around the world responded in awed respect of the man who’d run thirty-seven Melbournes, and who’d prepared and run it this time with a diseased rib and a poisoned body.

 

All that was in 2014. Since then Manny has undergone autologous haemopoietic stem-cell transplantation. The chemical savagery of this procedure – doctors have to poison every blood-producing cell in his body – can cure or kill. It did not kill Manny. But the mutiny grumbles on, bones everywhere are eroded, they await their moment of innocent impact or small tumble. One crack and a marathon runner will have run his last.

 

Manny’s haemato-oncologist, a compassionate and scholarly man, forbids running. He knows too well Manny’s disease. My guess is he has never run a marathon, is innocent of the joy, has never known the intensity of that blood-filled, tear-filled passage through space and time to self-realisation. For his part, Manny knows little about his proliferating mast cells, rogue daughters of his body’s revolution; he knows less of the osteoclasts punching holes in his bones; and nothing of the dysregulation of an oncogene translocated to his perfidious chromosome 14. But Manny knows enough. He understands the doctors do not speak of cure, he accepts the unending medication, he understands the risks of running. But he takes the occasional light run.

 

I haven’t asked Manny, ‘Do you run to live?’ I sense that the occasional light run is the answer that Manny’s mind or body drives him to. When Manny asks this family doctor, ‘Do you think I can run the marathon again this year?’ – the question I hear is: ‘Am I permitted to live before I die?’ And who am I – captive of my own marathon dreaming – to deny Manny? I decide I will run Melbourne at Manny’s side.

 

   

***

 

 

Lining up at the rear of the field of seven thousand dreamers before the Start, Manny implores me for the seven thousandth time: ‘Promise you’ll leave me behind once I’m too slow for you, Howard. I don’t want you to sacrifice your time for me.’ Manny never dreams he’s honouring me. But even before the gun sounds, runners reading the rear of Manny’s shirt salute him: ‘Legend!’ – they cry – ’Thirty-five Melbourne Marathons! Amazing!’ They clap him on the back, not realising Manny’s shirt sells him short by two marathons. Manny does not correct them. The same people spill glory and goodwill onto me in my Spartan’s shirt: ‘Go Spartan!’

 

A beautiful morning for running. Beneath low cloud a light breeze cheers and cools us as we snake along boulevards and run spirals through Melbourne’s parklands. Manny’s prudent pace suits me. I search for bodily pains to fret about. Nothing: silence from the supposed stress fracture in my left foot, nothing from the torn right calf muscle that I have rested from four weeks. The opposite calf sends alarms, but these are false. Pheidipides Goldenberg has no complaints.

 

Running half a pace behind Manny I take him in, not as the indoor person I have known, but Manny as runner. His build is not classic Kenyan: Manny is constructed of old materials, a series of chunks assembled one on top of the second. Impressive that he has lugged this unpromising torso through thirty-seven marathons. Projecting below that torso are the legs which are Manny’s secret. Beautifully muscled, elegantly defined beneath skin shining with vitality and sweat, Manny’s legs look decades younger than he as they pump smoothly, rising, descending, devouring distance.

 

Approaching the thirteen kilometre mark, Manny grinds on steadily, shouting out greetings to figures who come into view and earshot, his comrades, these, fellow members of the hallowed eight. To a man they look old. And calm. The marathon is their familiar foe. It holds no terrors, no surprises for them. Not for the first time, I recall Tennyson’s Ulysses as he looks upon his comrades:

 

 

Souls that have toil’d, and wrought, and thought with me –

That ever with a frolic welcome took

The thunder and the sunshine…

You and I are old;

Old age hath yet his honour and his toil;

Death closes all; but something ere the end,

Some work of noble note, may yet be done…   

 

 

With a cry of a different temper, Manny swerves, his voice joyous. He mounts the kerb, sweeps a good-looking woman into his arms, kisses her face, her hair. She pushes him away a little, looks at him searchingly. Satisfied, she smiles: ‘You look good, darling, you look wonderful. You’re running smoothly.’ The good-looking woman is Manny’s wife Demetra. She plenishes us both with cola and kisses, promising to find us again ten kilometres down the route. Manny releases his wife, takes a step, turns back, grabs Demetra again, crying into her hair, ‘I love you, darling’, and sets off again. I look down and try to deal with a lump that has risen in my throat.

 

Heading out toward the beach now we are bathed by sun and cooled by the breeze. Aaah, blessed day. The first Kenyan, having turned and now heading homeward, glides past us on air. Shouts of wonder rise from all throats as runners and spectators alike react to this shock of the beautiful. 

 

‘That’s my street there, Howard, Number 141. Please join me and my family at any time from 3.00. Bring your wife. Please.’ I want to join Manny and his family. If I finish in time I’ll certainly be there. Until now, Manny has spoken little while I have spoken more. A quieter person, he places one foot before another, repeatedly, steadily, and runs inwardly. I ask from time to time, ‘How are you going, Manny?’ ‘Not great. Not as good as last year.’ Not feeling great but not complaining either. As we swing out along the beach road and past Café Racer, a bunch of bystanders suddenly flows onto the road in our path and Manny’s face relaxes and falls into a wide smile. Hugs, handshakes, claps on Manny’s back, kisses on Manny’s face from two toothsome young women, and Manny keeps smiling and keeps on running. The interlopers pump sunshine up Manny’s arse and run alongside him. For the best part of an hour we run with the posse and through all that time Manny is smiling.
We come to the turn and the posse whoops and cheers as Manny turns for home. Manny is brother to one, uncle to a couple, second cousin to a few more, godfather to another. The kissing females are godson’s girlfriend and her girlfriend. The brother is shorter than Manny, genial, younger, rounder and pretty fit. He stays the distance for the full hour as do godson and one of the kissers. Others, out of shape or out of condition, fade away and re-join us later. Finally, with farewells, more clasps and shakes and blessings the mob falls away. ‘See you at my place, darling!’ ‘See you after three, Manny!’ The mob loves Manny and he them. Afterwards he tells me, ‘They’re here to meet me every year. Every year at the same spot. They never fail.’ A little later Manny says, ‘Dem and I are taking the whole family to Athens next year…it won’t be at marathon time of course.’

Increasingly I relish Manny’s invitation to join him and the family. These people run to the beat of a familiar drum.

  Back on the road, unescorted by Manny’s family, I have a question: ‘Manny, are you Manuel or Emmanuel?’

‘Manuel. They call me Manny. Also Manoli.’ 

Manny, Manoli – these affectionate diminutives are the aural furnishings of a life. Cushioned at every mention of his name, the man lives his life in relation, in connection, not alone, never – so long as these names are heard – alone. Back on the road, the solid road, returning from my abstractions, back with Manny-the-person I notice him struggling wordlessly. What silent erosion within his skeleton, what deposition of para-proteins in his kidneys, what mischief in his marrow, hampers this champion? Conversely (and most striking), how remarkable the redemptive effect of the loving presence of Manny’s family!

 

 

Around the corner and into Fitzroy Street where the crowds thicken and the cheering is a roaring without end, we allow ourselves a fifty-metre walk up the ugly little hillock placed here for the torment of the tiring runner. I reckon we’ve run better than two thirds of our 42.195 kilometres. Manny bursts into joyous shouting: ‘My baby! My baby!’ Emerging from the midst of the thronging cheerers is the adoring Demetra, bearing encouragement and affection and more Coke. And a baby! – their first grandchild. Manny cradles the pink bundle, adores her like a Magus. To me Demetra passes chocolate! I’m dubious about this; I’ve never eaten chocolate in the middle of a run. Will I like it? Will it like me? Too late – it’s melting in my sweaty paw. Now it’s inside me, followed by a bottle of Coke. Supercharged with caffeine and sugar and fluid I am invincible. In Demetra’s arms, holding his pink grandbaby, Manny looks the same, but once around the corner and out of sight, he looks and feels utterly vincible.

 

 

Around the corner now and into St Kilda Road, the broad thoroughfare closed to traffic in honour of us marathoners. The sun shines, the day has warmed, everyone who is not running enjoys the balm. Runners enjoy the painful raising of knees, the heavy hurt in the thighs, the weight of weary, weary bodies that started running almost four hours ago. The 32 – kilometre sign tells us there are only ten kilometres to go. Only ten kilometres to go feels to a runner as welcome as only ten more years might sound to a prisoner serving life. The experienced runner knows the second half of a marathon starts at 32K.

 

 

We plod in the sunshine. The field has thinned as faster runners leave us behind and others – the broken, the breaking, the bleeding, those limping – fall behind us. Here to one side of us, runs Eeyore, a young woman from England. She runs smoothly ahead then stops, bends forward in apparent pain, and breaks into a slow walk, and soon she is at our side again. Eeyore replies to my clinical enquiries morosely. I encourage her, I pump sunbeams, I tell her she should be proud. I should shut up and allow her to enjoy her misery. Eeyore and Manny and Pheidipides keep company intermittently until the final few hundred metres. Just ahead and to our left runs an aged, arcuate Japanese runner. His age might be anywhere from fifty to seventy. He clings to a line, a crack visible in the road’s surface where one layer of tarmac meets its neighbour. Dourly, silently, mute to my greetings, his spine twisted into a boomerang convex to the left, Japan runs the lines. His speed is no better than ours but I bet he could run all the way to Hokkaido without stopping.

 

 

A soft sound issues from the female who runs half a pace ahead on our right. The slight sound recurs – the grunt of a person in pain? – pulls me close. No not a grunt, it’s a moaning, the woman’s lament for her suffering self, her threnody sung for self-comfort. She’s about forty, shapeless, pale, a moving emblem of tortured humanity. The moment brings me back to the Olympic Marathon (I think it was at Barcelona) where a Swiss or French runner, whose name I seem to recall was Dominique Something approached the Finish. No-one who witnessed the sight of this tall, thin woman, faltering and staggering in her final lap of the stadium will forget her in her extremity. The brutally hot day, the merciless steeps of Monjuic in the approach to the stadium, the criminal timing of the event in such heat had all but undone her. She lumbered into view, slowed, stooped, seemed to recover herself and advanced. Time and again she seemed at the point of falling. Officials were seen to move toward her, then to retreat. Appalled viewers on screen and in flesh begged wordlessly for it to end, but Dominique stumbled on. Twenty, thirty metres from the Finish she fell. Officials came to her aid and in so doing ended her chance of completing the Olympic Marathon. It is Dominique whom I hear now as this woman moans.

 

 

It is no disrespect to acknowledge that we belong to the dregs of the marathon world: among the select who run marathons, possibly the most resolute and vigorous of people, our sub-group group is the most enfeebled. And all the more honour to us who persist. On we go, pausing for drink every three kilometres, enjoying the excuse to walk twenty, thirty metres. Then up again with weary legs, up and back into the slow steady tread that our heartbeats allow us, that is all our breaths and our body salts and our fluid reserves and our moral reserves can support. We walk, we pause to walk thirty guilt-free walking paces, then on again we run, and on. Manny and I negotiate small contracts: we’ll run without stop to the top of this short rise, then we can coast down the farther side; we’ll run and not stop until we reach the next drink stop, then we’ll reward ourselves with cool fluids and a splash of water; we’ll run now and will not stop until we reach the MCG, and then…

 

 

We enter the great stadium side by side. The huge grandstands tower about and above. We insects crawl the margins below. At my left Manny says, ‘It’s magnificent, isn’t it?’ It is, it is indeed. We swing our arms, pumping our reluctant thighs into action, we raise our heads, then hoist ourselves onto our toes for the final 150 metres. Two aging men, one with an intact skeleton, the second much ravaged, swing around the bend. We pass the bent man from Japan: his face, transmogrified, is a rising sun; and Manny and I are sprinting, and sprinting we fall across the Line.

 

  

  

POSTSCRIPT: I have written elsewhere of my inadvertent double entry (and double payment) in this year’s Melbourne Marathon. I duly wore two bibs – each with its distinct number – and with them, both electronic timing chips. I had speculated that Pheidipides Goldenberg might record a finish in both last and second-last places. If you google Melbourne Marathon Results 2015 you will see how closely I anticipated the result. And you’ll find, ahead of me by one second, Manny, Manuel, Manoli Karageorgiou. 

  

Writing as Healing

The mother of identical twin boys sent me this story by Ranjava Srivastava.

 

“Losing my twin baby boys for ever changed the way I treat my patients.

I will never know the kind of doctor I would have become without the searing experience of being a patient, but I like to think my loss wasn’t in vain.

‘My obstetrician’s tears stunned me but also provided immediate comfort. They normalised the mad grief that had begun to set inside me.’
Around this time 10 years ago, I was poised to start my first job as an oncologist when personal tragedy visited in a way that would forever change the way I would practice medicine.

I had returned from my Fulbright year at the University of Chicago, blessed with only the joys and none of the irritations of being pregnant with twins. Landing in Melbourne, I went for a routine ultrasound as a beaming, expectant parent. I came out a grieving patient. The twins were dying in utero, unsuspectedly and unobtrusively, from some rare condition that I had never heard of. Two days later, I was induced into labour to deliver the two little boys whom we would never see grow. Then I went home.

If all this sounds a little detached it is because 10 years later I still have no words to describe the total bewilderment, the depth of sorrow and the intensity of loss that I experienced during those days. Some days, I really thought my heart would break into pieces. Ten years later, the din of happy children fills our house. But what I have found myself frequently reflecting on is how the behaviour of my doctors in those days profoundly altered the way in which I would treat my patients.

An experienced obstetrician was performing my ultrasound that morning. Everything was going well and we chatted away about my new job until he frowned. Then he grimaced, pushed and prodded with the probe, and rushed out before I could utter a word. He then took me into his office and offered me his comfortable seat. Not too many pregnant women need a consultation at a routine ultrasound.

“I am afraid I have bad news,” he said before sketching a picture to describe the extent of the trouble. I thought for a fleeting moment that my medical brain would kick in and I would present him with sophisticated questions to test his assertion that the twins were gravely ill. But of course, I was like every other patient, simultaneously bursting with questions while rendered mute by shock.

I was well aware that doctors sometimes sidestepped the truth, usually with the intent of protecting the patient. I knew he could easily get away with not telling me any more until he had more information but I also knew that he knew. I read it in his face and I desperately wanted him to tell me.

I asked the only question that mattered.

“Will they die?” 

“Yes,” he said, simply holding my gaze until his tears started.

As I took in the framed photos of children around his office he probably wished he could hide them all away.

“I don’t know what to say,” he murmured, his eyes still wet. 

Until then, in 13 years of medical training, I had never seen a doctor cry. I had participated in every drama that life in bustling public hospitals offers but never once had I seen a doctor cry.

My obstetrician’s tears stunned me but also provided immediate comfort. They normalised the mad grief that had begun to set inside me. Yes, the doctor’s expression said, this is truly awful and I feel sad too.

“You are sure?”

“There is a faint chance that one lives but if you ask me, things look bad. You know I will do everything I can to confirm this,” he said.

The obstetrician had told the unflinching truth and in doing so almost surgically displaced uncertainty with the knowledge that I needed to prepare myself for what lay ahead. I had test after test that day, each specialist confirming the worst. I think I coped better because the first doctor had told the truth.

Two other notable things happened that week. Among the wishes that flowed, another doctor wrote me an atypical condolence note. His letter began with the various tragedies that had taken place that week, some on home soil and others involving complete strangers. “I ask myself why,” he wrote, “and of course there is no answer to why anyone must suffer.”

Until then, everyone had commiserated only at my loss – and I was enormously grateful – but here was someone gently reminding me that in life we are all visited by tragedy. All the support and love in the world won’t make you immune to misfortune, he was saying, but it will help ease the pain.

Finally, there was the grieving. I lost count of the pamphlets that were left at our door to attend support groups, counselling sessions and bereavement seminars but we were resolutely having none of it. My midwife called me out of the blue – it was a moving exchange that taught me how deeply nurses are affected too. But I didn’t need counselling, I needed time. I valued the offers but I knew that my catharsis lay in writing. I wrote myself out of suffocating grief, which eventually turned to deep sadness and then a hollow pain, which eventually receded enough to allow me to take up my job as a brand new oncologist. How I would interpret the needs of my patients was fundamentally altered now that I had been one myself.

Cancer patients are very particular about how much truth they want to know and when. I don’t decide for them but if they ask me I always tell the truth. A wife brings in her husband and his horrendous scans trigger a gasp of astonishment among even the non-oncologists.

“Doctor, will he die from this?” she asks me.

“I am afraid so,” I answer gently, “but I will do everything in my power to keep him well for as long as I can.” 

It is the only truthful promise I can make and although she is distressed she returns to thank me for giving her clarity. Sometimes honesty backfires, when the patient or family later say they wanted to talk but not really hear bad news. I find these encounters particularly upsetting but they are rare and I don’t let them sway me from telling the truth.

Oncology is emotionally charged and I have never been afraid of admitting this to the very people who imbue my work with emotion. I don’t cry easily in front of patients but I have had my share of tears and tissues in clinic and contrary to my fears, this has been an odd source of comfort to patients. In his Christmas card, a widower wrote that when my voice broke at the news that his wife had died he felt consoled that the world shared his heartbreak.

It can be tricky but I try to put my patients’ grief into perspective without being insensitive. It’s extraordinary how many of them really appreciate knowing that I, and others, have seen thousands of people who are frightened, sad, philosophical, resigned, angry, brave and puzzled, sometimes all together, just like them. It doesn’t diminish their own suffering but helps them peek into the library of human experiences that are catalogued by oncologists. It prompts many patients to say that they are lucky to feel as well as they do despite a life-threatening illness, which is a positive and helpful way of viewing the world.

I will never know what kind of a doctor I might have become without the searing experience of being a patient. The twins would have been 10 soon. As I usher the next patient into my room to deliver bad news, I like to think that my loss was not entirely in vain.” 

……… 

I read this story with alarm. It made me feel anxious because I have and love a pair of identical twin boys. I felt involved because, like the writer’s doctor, I am a doctor who cries; and like the writer, Dr Srivastava, I am a doctor who writes. Finally we two are products of the same medical school (Monash) – Dr Srivastava graduated at the top of her class, in the present century, I graduated at the opposite end of my class, in antiquity (1969).

A final point of commonality was her reassuring remark that ten years after her doctor wept her home is full of the noise of happy living children.

I found the piece helpful. Dr Srivastava identifies and untangles the strands of her experiences with surgical deftness. Her doctor weeps, her colleagues show support and care and empathy and she heals. As a trained observer, the writer dissects her experience of grief, lays out its anatomy and reflects upon its organs and parts.

Like the writer, I find relief and understanding in the act of writing. I suspect that a part of this relief results from word search. The writer is obliged to seek the precise word for the experience. In my case this forces me to test and taste a number of words. Perhaps a dozen words might work more or less passably, but the acts of searching, of choosing, of trialling, help me to clarify what my feelings were not quite like. I mean I discover what I mean. Perhaps this functions as a working through, a self-conversation, something between analysis of an experience and re-imagining it. In my case too, the pleasure of words is an aesthetic joy that comforts me.

Medicine is a pursuit conducted with the living in the shadow of death. It is a pursuit packed with anxious questions: what is wrong with me, will I die, what can be done, will it hurt, how much, how will I know the answers, when will I know? This crying doctor feels the patient’s fear and his own and has to know the border that divides the two. My fears are for the patient, of the patient, of failure, of failing a person of flesh and feeling. My fears include the terror that strikes me when I see my patient slipping away, the knowledge of my mortal inadequacy.

The writer who lost her twins precisely names the elements in her emotional experience. With remarkable poise she traces the costs and the benefits of the loss. So coherent are her reflections I could feel myself learning as I read. I learned about her life and her work, how the two are not the same but never severable. I learned more of how a doctor feels, who she is, who I am.

Alone and Palely Loitering

You walk past them at lunchtimes and at smoko, you see them sheltering under eaves in foul weather, you see them in their outcast clusters, you see them and you avert your gaze for fear your concern will offend.

They are many, these persons of all ages, members of an underclass. If they were to unite as voters they’d overthrow governments. If they were to become radicalised we’d tremble in our beds. But no, they do nought to us and all to themselves. These human persons harvest leaves and dry them and chop the dried leaves finely then wrap the product in a cylinder of paper. Carefully, accurately, with practised fingers, they burn the leaves, then hungrily, deeply inhale.

Alone in the animal kingdom these sentient creatures do not flee from smoke.

I see them, I see my friends, who meet my gaze and smile in confession – and I am sorry to see – in embarrassment.

A long time ago my father in law was dismayed when advised by his tobacconist (yes, he saw a specialist, no mere candy vendor) that Chesterfields would no longer be imported to Australia. The tobacconist asked: ‘How many do you smoke a day?’

My father in law told him.

The tobacconist responded: ‘You are a very special customer; we’ll make sure you stay supplied.’

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The very special customer became too breathless to read a bedtime story to his grandchildren. Soon he developed a cough. Suspecting cancer he stopped smoking.

Not long after, the very special customer died of his disease and my children lost their very special grandfather.

Manufacturer Phillip Morris continues to accommodate its special customers. My friends huddle and shelter while I shudder. And I direct my superannuation to alternative investments.

Manny the Marathon Man

Manny Karageorgiou ran 42.2 kilometres yesterday, racing his oldest foe. At 58 years, Manny is the youngest of the Glorious Ten who have competed in and completed every single Melbourne Marathon. ‘Forty two kilometres’ – it rolls off the eye easily, but it’s a long way to travel on foot. My car gets tired over that distance.

Manny ran with the most reluctant consent of his oncologist. He delayed his stem cell transplant so he could keep faith with the Ten. This GP consented more readily despite the rib that fractured as it filled with tumour, despite the remaining bones waiting for fracture in the merest trip, bones brittle and chalky from the medicines and radiation. The GP consented; who could say ‘no’ to that beautiful face, a child’s face, appealing, smiling through the pain and fear, gentle, mild even before the cancer, tenderer than ever since the rib broke, as Manny sought to comfort his fearful wife and his children.

They came around, the family. They ran the late kilometres with him, the bitter second half of the marathon, they ran, a caravanserai of love and hope and tearful joy, along the endless steppes of St Kilda Road. Manny’s son ran the whole distance at his side. Pana, as Manny calls him is a strapping footballer, vigorous and fearless. Afterwards he would say, ‘I don’t know how anyone could run another marathon after experiencing the pain of the first.’ But Manny has run the Melbourne Marathons thirty seven times. He has outrun the Reaper. So far.

Why does he run?

He runs for faith, he runs for pride, he runs to be humbled, he runs for the self-glory of mortifying his flesh. He runs because he lives. He runs for all of us.

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