Only a man with stage IV cancer himself could, with impunity, skewer the sickly sentimentality of the late Randy Pausch’s The Last Lecture (2008). Pausch, a professor of computer science at Carnegie Mellon University, was diagnosed with terminal pancreatic cancer and became an Internet sensation after his lecture was posted on YouTube. The lecture, delivered to a standing ovation at his university, was entitled ‘Really Achieving Your Childhood Dreams’. Pausch also treated his audience to a demonstration of his press-up technique. Hitchens was unmoved: ‘It ought to be an offence to be excruciating and unfunny in circumstances where your audience is almost morally obliged to enthuse.’
The late philosopher Sidney Hook was Hitchens’s anti-Pausch. Hook, taken seriously ill in old age, ‘began to reflect on the paradox that... he was able to avail himself of a historically unprecedented level of care, while at the same time being exposed to a degree of suffering that previous generations might not have been able to afford’. Hook, suffering from heart failure and a stroke, asked his doctor ‘to discontinue all life-supporting services or show me how to do it’. His doctor denied this request, and Hook survived.
Hook’s essay, ‘In Defense of Voluntary Euthanasia’, is the perfect antidote to Randy Pausch: ‘Having lived a full and relatively happy life, I would cheerfully accept the chance to be reborn, but certainly not to be reborn again as an infirm octogenarian.’ Hook coined the phrase ‘mattress graves of pain’ to describe the suffering of stroke victims, and concluded his piece with a quotation from the Roman Stoic Seneca: ‘the wise man will live as long as he ought, not as long as he can’.
But Hitchens did not adopt Hook’s non-interventionist stance. It could be argued that his approach to his cancer treatment was at odds with much that he previously professed to believe (or not believe) in. In God Is Not Great he coined the withering phrase ‘the tawdriness of the miraculous’. He summarized the views of David Hume approvingly:
A miracle is a disturbance or interruption in the expected and established course of things. This could involve anything from the sun rising in the west to an animal suddenly bursting into the recitation of verse. Very well, then, free will also involves decision. If you seem to witness such a thing, there are two possibilities. The first is that the laws of nature have been suspended (in your favour). The second is that you are under a misapprehension, or suffering from a delusion.
He followed this up with Ambrose Bierce’s definition of ‘prayer’: ‘a petition that the laws of nature be suspended in favour of the petitioner; himself confessedly unworthy’. His friends and his doctors might wish to remind themselves of what Hitchens wrote, in good health, in God Is Not Great: ‘Those who offer false consolation are false friends.’ In his memoir, Hitch-22, he was scathing of such wishful thinking: ‘I try to deny myself any illusions or delusions, and I think that this perhaps entitles me to try and deny the same to others, at least as long as they refuse to keep their fantasies to themselves.’
When Hitchens died at the MD Anderson Cancer Center in Houston, Texas, his wife was clearly not prepared: ‘The end was unexpected.’ In Mortality, she describes how Hitchens, still intubated after a bronchoscopy, and therefore unable to speak, scribbled notes for her, such as: ‘I’m staying here [in Houston] until I’m cured. And then I’m taking our families on a vacation to Bermuda.’ Interviewed on Australian television after his death, she said:
...it was not clear to his doctors or to us that he was dying. His very radical state-of-the art medical treatments had proved quite successful and the cancer was in abeyance... the oncologist said he was in the one per cent of people who would have been alive then and we hoped that he would either go into a long remission or certainly have quite a bit more time. He caught a very, very virulent pneumonia...
Asked by her interviewer whether Hitchens considered at that time ‘it might be the moment to let go?’, Blue answered: ‘No, not at all, actually, because he’d been given such a prognosis. When they did the follow-up scan basically it was black; no cancer was showing...’
Inevitably, I will be accused of tastelessness in my analysis of Christopher Hitchens’s cancer story. To that charge, I would say this: Hitchens made a career out of dissecting the inconsistencies of his opponents’ arguments, and might have made similar observations to mine, had the story been about somebody else. He believed passionately in the freedom to offend people. We should be wary, however, of mocking beliefs which we do not share. One man’s delusion and folly is another’s ‘radical, childlike hope’. As news of Hitchens’s cancer diagnosis first became widely known, evangelical Christians speculated on the Internet about whether or not his illness would lead to a religious conversion. In Mortality, Hitchens scoffed at the notion. But in his time of ‘living dyingly’, he did find a kind of faith. This was not a return to the Anglicanism of his upbringing, or the Judaism of his mother’s family. Hitchens, the arch-mocker, the debunker of myth, found solace and consolation in the contemporary rites of genetics and oncology.
SUSAN SONTAG:
REFILLING THE POISON CHALICE
Susan Sontag (1933–2004), the American essayist, critic and novelist, did not go gently into that good night. She had – rather miraculously – survived advanced breast cancer in the 1970s, then uterine sarcoma in the 1990s, before finally succumbing to myelodysplastic syndrome (MDS), a type of bone marrow cancer. She had written about sickness in Illness as Metaphor and AIDS and Its Metaphors. Swimming in a Sea of Death (2008), the memoir written by her son David Rieff, begins with the diagnosis of MDS. Sontag and her son visit ‘Dr A’ in his office to receive the bad news:
MDS, he explained, slowly and deliberately, as if he had a family of village idiots sitting in front of him, was a particularly lethal form of blood cancer. [I felt for Dr A: ‘slowly and deliberately’ is how we’re taught to impart bad news, regardless of whether the interlocutor is a famous author, or, indeed, a village idiot.]... ‘So what you’re telling me,’ she finally said, with a poignant deliberation that makes me gasp even remembering it, ‘is that in fact there is nothing to be done.’ After a pause, she added, ‘Nothing I can do.’ Dr A did not answer directly, but his silence was, as the cliché goes, eloquent.
Sontag was not willing to accept this prognosis. After all, hadn’t she confounded her doctors back in the 1970s, when she had advanced breast cancer? She had initially undergone radical surgery in New York, and then tracked down a French breast cancer specialist, who prescribed a novel form of immunotherapy. Whether this immunotherapy cured Sontag or not is unclear; this form of treatment did not later go on to become standard therapy for breast cancer, so it seems unlikely. At any rate, her astounding good fortune instilled in Sontag an unshakeable faith in scientific medicine. The experience also gave her a sense of her own invincibility, a sense that must have grown stronger when she overcame cancer for a second time in the 1990s: ‘If you were supposed to die, and you live, in defiance of practically all the experts’ predictions and against all the odds, how can you not attach some meaning to what has occurred?’ But for all her attachment to science, Sontag had some flaky Reichian beliefs about the aetiology of cancer: ‘I’m responsible for my cancer. I lived as a coward, repressing my desire, my rage.’
When she was diagnosed with MDS, Sontag read everything about the condition she could lay her hands on: ‘Her apartment became a kind of research unit...’ Rieff saw this frantic search for information for what it was: ‘magical thinking disguised as practical research’. Although Sontag’s book Illness as Metaphor had ended with a plea to ditch the military metaphors of the struggle with disease and to ‘give such images back to the warmakers’, Rieff writes: ‘You did not give in to cancer, you fought it, and if you fought hard enough and, above all, intelligently enough, there was a chance that you could win.’ Sontag, although uninterested in sport, became obsessed with the cyclist Lance Armstrong. He, more than any famous cancer victim, had championed the concept of ‘fighting’ it.
This being Amer
ica, Sontag moved on from the hapless Dr A to the infinitely more encouraging Dr Stephen Nimer at Memorial Sloan-Kettering, the famous New York cancer hospital. Nimer handled the Difficult Conversation with aplomb:
...when pressed Stephen Nimer would be very frank with my mother about just how terrible her MDS was. It is true that he never allowed himself to be drawn out on whether he personally thought my mother would survive or not (though she repeatedly tried to get him to do so, and asked me to ask him on a number of occasions as well). Instead, he would reframe the question, and in doing so, or so it seemed to me, let the hope back in... it was Nimer himself who determined this outcome. Somehow, whether it was through sheer force of personality, long experience, or psychological acuity, or some combination of all of these, Stephen Nimer managed to make the question ‘unaskable’ on some deep level.
Nimer referred Sontag to the Fred Hutchinson Cancer Research Center in Seattle, for a bone marrow transplant, despite knowing − as he must have done − that the chances of success were very slim: ‘And they were going ahead with treatment, presumably in the belief that it was not futile, and that she was not wrong to hope.’ Rieff quotes a brochure on MDS, which suggests that his mother was not suitable for this treatment: ‘In the very small proportion of patients who are under 50 years of age with a severe form of myelodysplastic syndrome, intensive radiation and/or chemotherapy followed by allogenic stem cell transplantation can be considered.’ Sontag was seventy-one, and not, by any objective criterion, a good candidate for this treatment. Nimer (as quoted by Rieff) clearly believed that it was worth trying, even if the likelihood of a cure was remote: ‘Susan told me from the outset that she wanted me to do everything she could to save her life, and so we could go straight into a discussion about what she wanted [my italics] and what the plan would be.’ After the publication of Rieff’s memoir, it emerged that Sontag’s medical insurance had refused to pay for the transplant, and that she had to pay a deposit of $250,000 on admission to the Seattle hospital.
When she arrived at the Fred Hutchinson Cancer Research Center, ‘its clinical research director, Fred Appelbaum, dropped by to remind my mother of the poor survival statistics... she was devastated. That evening, still completely devastated, she kept repeating, “Why would he tell me such a thing?”’ Rieff gives us the simple answer: ‘I remembered having read somewhere that the Hutch had been taken to court, accused by the relatives of some patients whose loved ones had not survived their transplants of not having warned them of how small their chances of survival had really been.’ In that single sentence, we have the double-bind of modern oncology: if the doctor does not carry out the futile treatment, he is heartless and has condemned his patient to hopelessness and death; if he does carry out the treatment, the surviving relatives will sue him for failing to be realistic with the Loved One. In fact, it’s a triple bind: if he does carry out the futile treatment, and he is realistic with the patient, she is ‘devastated’.
The transplant inevitably failed; when told, Sontag screamed: ‘But this means I’m going to die!’ She went back to New York to the relentlessly upbeat Dr Nimer. Rieff, who clearly detested Dr A (‘I prefer not to name him’), whom he describes as fat, overbearing and patronizing, positively hero-worships Nimer: ‘But for Nimer, the essence of being a doctor was doing everything possible for his patients, even if it meant trying experimental therapies where the chances of success were not high.’
Sontag’s condition steadily deteriorated, but she refused to accept that she was dying, and her son felt unable to be frank with her: ‘What conversations I had with her about her prognosis soon became almost lawyerly exercises.’ Sontag had what I would call a ‘wild’ death: ‘there was nothing easy about my mother’s death, except, literally, her last few hours. It was hard, and it was slow – sometimes the days of her dying seemed to me actually to be taking place in slow motion – and in the process it was not only my mother who was stripped of her dignity.’
Rieff felt keenly and bitterly his failure to engage with his mother and the fact of her dying: ‘I am anything but certain that I did the right thing, and in my bleaker moments, wonder if in fact I might not have made things worse for her by endlessly refilling that poisoned chalice of hope.’ I think he is hard on himself – he never had a chance. Sontag herself steadfastly refused to even contemplate her mortality. At one point, after yet another delusional talk with his mother about all the things she would do after the bone marrow transplant cured her, Rieff finally collapsed: ‘I finally broke down, I wept. But my stupefaction was almost as great as my grief. I kept thinking, “she really does not know what is happening to her. She still believes that she is going to survive.”’ After Sontag’s death, Nimer contacted Rieff by email, almost in the guise of a grieving relative: ‘I think about Susan all the time. We have to do better.’ Although Rieff finally begins to harbour some niggling doubts, nothing can shake his faith in Nimer as a ‘great doctor’, such is the force of Nimer’s personality, more ‘physician-shaman’ than ‘physician-scientist’. I wonder how Sean O’Mahony would have handled Susan Sontag.
Rieff buried his mother in Montparnasse, in Paris. In 2006, two years after Sontag’s death, her former lover, the photographer Annie Leibovitz, put on an exhibition of her work over the previous fifteen years at the Brooklyn Museum. The collection included two photographs of Sontag: one taken when she was in Seattle for her transplant, where she looks bloated and clearly very ill, the second after her death, taken in a back room of the Frank E. Campbell Funeral Chapel in New York. Rieff was appalled, and called the photographs ‘carnival images of celebrity death’.
JOSEPHINE HART:
‘MEDIEVAL, DEGRADING AND INEFFECTIVE’
Josephine Hart (1942–2011) began life in the distinctly unglamorous environs of Mullingar, County Westmeath. She had a traumatic childhood: by the time she was seventeen, three of her siblings were dead. She moved to London, toyed with acting, and ended up in magazine publishing. A first marriage ended in divorce, but in her second, to advertising multi-millionaire and Tory peer Maurice Saatchi, she had found her soulmate. Her first novel, Damage (1991) was a bestseller and was adapted into a successful film. She organized fashionable poetry readings with recitations by famous actors, produced plays, and was a prominent figure on the London literary scene. She enjoyed the lifestyle that came with her second marriage. In person, she came across as intense and a little scary.
In 2010, Hart was diagnosed with a rare type of pelvic cancer, primary peritoneal carcinoma. She died in 2011. Her husband has spoken frequently and eloquently of his grief, and has gone into semi-permanent mourning. He visits his wife’s grave every day, where he eats his breakfast and talks to her. Geoffrey Gorer would have approved. Saatchi has described her cancer treatment as ‘medieval, degrading and ineffective’. Clearly not used to being thwarted, Saatchi has declared his own war on cancer. (A previous declaration of war on cancer by Richard Nixon was not notably successful.) Saatchi proposed a private members’ Bill, the Medical Innovation Bill, in the House of Lords in 2013, with the intention of giving doctors the freedom to treat cancer patients with ‘cutting-edge’ and ‘revolutionary’ treatments, without the fear of litigation. Clearly, Saatchi has been motivated by witnessing the horrors of his wife’s illness and death, but I detect also a whiff of pique: before his wife’s cancer, I imagine that he solved most problems with his money and influence. Cancer, however, was unimpressed by Maurice Saatchi. He was interviewed in 2013 by Elizabeth Grice of the Daily Telegraph:
In desperation, Saatchi trawled the Internet for news of hopeful discoveries. The future of cancer science seemed to lie in mapping the cancer genome and providing less toxic therapies. ‘Why couldn’t Josephine Hart have the future of science?’ He approached Harvard Medical School with details of her case. They analysed his wife’s tumour and sent back a thick report with a covering letter that said: ‘The good news is that your wife’s tumour is non-mutational.’ Her own doctors were unimpressed. �
��Isn’t this genetic profiling very important?’ Saatchi asked. He was told: ‘It’s irrelevant.’ That was the tipping point; the moment he knew he would eventually have to challenge the adherence to standard practice.
The man who once ran the biggest advertising agency in the world, who is credited with helping bring Margaret Thatcher to power in 1979, made his intentions clear: ‘I intend to cure cancer, you see. I mean to do it. I expect to do it.’ Saatchi was not previously very exercised about cancer: Silk Cut (a brand of cigarette) was one of Saatchi & Saatchi’s biggest accounts.
It is not clear to me how this change in legislation would ‘cure’ cancer. Although Saatchi’s PR campaign was slick and influential, informed opinion, including the Royal Colleges (Physicians, Surgeons and General Practitioners) and the British Medical Association, saw no need for such legislation. More than one hundred oncologists wrote to The Times opposing the Medical Innovation Bill: ‘We are concerned that rather than promoting responsible scientific innovation in the treatment of cancer, the Medical Innovation Bill will actually encourage irresponsible experimentation producing nothing more than anecdotal “evidence”, at the potential expense of causing serious harm and suffering to patients.’ Saatchi was furious, and raged in the Guardian: ‘The 100 doctors who wrote to The Times rubbishing my medical innovation bill are the authentic voice of complacency... How I pity their patients.’ In January 2015, the influential cancer journal The Lancet Oncology devoted an editorial to the Bill. In it, Saatchi’s personal credentials (‘an unelected individual with no professional medical or scientific training’) were loftily dismissed, and the authors went on to explain that doctors are already able to innovate outside clinical trials: ‘There are many ways in which doctors can access drugs that are in early-stage clinical trials but not yet widely available. However, provision of these agents on a desperate whim, in an unmonitored environment, could lead to patient harm.’ The Bill, concluded the editorial, ‘strikes at the heart of evidence-based medicine’.
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