Every Third Thought Read online

  From art, music, and travel, it’s a short step to books. Max is an avid reader. For the Parkinson’s patient, literary expressions of the mind and the body in extremis can be therapeutic. In The Year of Magical Thinking, Joan Didion writes that ‘Grief turns out to be a place none of us know until we reach it.’ The same might equally be said of ill-health, and it’s a consoling thought.

  The end-of-life literature of recent years – The Black Mirror by Raymond Tallis; The Work of the Dead by Thomas W. Laqueur – suggests that not only will some patients turn to language, but also that language can speak across time and space. Such pain-conscious titles are ones that some patients would never be without.

  ‘Words have a longevity I do not,’ is how Paul Kalanithi puts it in When Breath Becomes Air. Max and I start to discuss some of our favourite reading from the library of chronic infirmity: Susan Sontag: Illness as Metaphor (1978), a series of essays written while she was being treated for breast cancer; Jean-Dominique Bauby’s astonishing monologue The Diving Bell and the Butterfly (1997); Harold Brodkey’s neglected AIDS memoir This Wild Darkness: The Story of My Death (1997); Gillian Rose’s pocket masterpiece Love’s Work (1995). For the Parkinson’s sufferer, moreover, there is also Michael J. Fox’s Lucky Man (2002).

  It is a suggestive irony that prose rarely pulses with such life as when it grapples with mortality, either in fact or fiction. It’s as if we cannot face life’s greatest mystery any other way. Some of these graveside testaments seem to speak all the more eloquently because they are whispered from the mysterious antechamber to death. Perhaps the unconscious reasoning behind our fascination with such books is that – we think – we may learn something from words uttered in extremis. Our conversation, circling round, has reverted to the endgame. Now I have another question: would Max, in extremis, accept palliative care for his Parkinson’s?

  ‘A hospice?’ he queries. This seems like an unwelcome suggestion. ‘Of course I’d consider it, though I’d hope it doesn’t come to that.’ He pauses in thought. ‘In that case, I suppose you have to think about your loved ones. It’s all very well saying that you want to live out your days at home, surrounded by your family, but that could be an awful burden on other people. You have to balance your wishes against what’s being imposed on your family.’

  Going one step beyond a hospice, I wonder if he supports assisted dying? Max takes that question in his stride. ‘I’m a great believer in people having the right to choose how and when they die, though I’m not sure I’d have the courage to go that route myself. I imagine that, informally, there’s still an awful lot of euthanasia.’

  Max looks out of the window. From his smile, I guess he’s about to indulge a flight of fancy. ‘I would love to be like Socrates, and sit on my terrace with a glass of champagne before saying goodbye.’ The smile becomes wry. ‘I did actually google “hemlock” to see if I could make some at home, but I’m not enough of a botanist.’ He chuckles. ‘Apparently, it’s horribly bitter.’ He returns to our theme. ‘People have the right to choose their own ending.’

  *

  Max is pragmatic about existential matters. On one occasion, referring to his late wife, he observed, very matter-of-fact: ‘We act as if death is unusual, when in fact everyone you look at has been touched by it, in one way or another.’

  I notice that he seems determined not to be intimidated by mortality. ‘I want to work to the end,’ he remarks, ‘staying as engaged as I can.’ He seems happily focused on living in the present moment, the here-and-now, and is debating whether to learn French or Spanish (he already knows Latin). This, he adds, ‘is something I’ve wanted to do all my life.’ He admits that he’s aware of a time-limit to his ‘third age’ ambitions, but does not repine. ‘I suppose one does tally up these signs of decline, but I don’t feel unhappy about that. I’m resigned to my situation, and hopeful that there’s still some life worth living.’

  I ask him, if he could make a deal with Fate, how many more ‘good’ years he would settle for?

  ‘Ten.’ Max’s answer is swift and decisive. ‘If I made it to eighty, I’d feel I’d done OK. If I fall short of eighty, I’d say, “That’s the cards.” I’d rather die a little sooner, than have a long, lingering illness. I think I’d be unlucky not to hit seventy-five, but who knows?’

  When, in conversation, he refers to ‘Fate’ again, I find myself moved by the way Max’s ‘cards’ have fallen lately, and find it impossible not to allude to the irrational workings of an imagined God.

  ‘I don’t know what that means,’ he replies. ‘I’m not especially irreligious, but I don’t believe there’s a God up there who gives a fuck about me or my life. I mean . . . God isn’t going to intervene to cure me. There is no cure for Parkinson’s.’

  We pause here, as if to acknowledge this brutal and unreconcilable truth, the reality of Max’s everyday existence. In a way that I’ve come to see as typical of the man, Max defaults to optimism again. ‘Of course,’ he says, ‘I will actively seek to delay its progress.’

  For a few moments, another silence falls into the room, as we gather our thoughts. Out of nowhere, Max says: ‘I feel that the real battle with this thing is yet to come.’ Another pause: there’s an awful lot unspoken about Max’s situation which is, I am quite sure, exactly the way he wants it to be. Just to have had this conversation feels like a small victory in his so-called ‘battle’.

  So there he is, a veteran, setting out on a long campaign in hostile territory he cannot reconnoitre. On this journey, he will go it alone. That’s who he is, a man of courage and gritty determination. I wonder: does he believe in the ‘good death’ and the art of dying, ars moriendi?

  ‘I think I do.’ Max perks up at the classical allusion; he has always been interested in the Romans. ‘You’ve given me a very good idea. I’ll make it a project. I mean “the End” is staring me in the face now. For decades of your life you can push it to the back of your mind. But now I think about it every day.’

  13

  THE GOOD DEATH

  ‘The growing good of the world is partly dependent on unhistoric acts; and that things are not so ill with you and me as they might have been, is half owing to the number who lived faithfully a hidden life, and rest in unvisited tombs.’

  George Eliot, Middlemarch

  Later, I discovered that I had wrongly assumed ars moriendi to have a classical, Graeco-Roman origin. On closer examination, it turns out to have been a phenomenon from the Middle Ages that may have evolved in response to the horrors of medieval medicine. The original, so-called ‘long version’, entitled Tractatus artis bene moriendi, composed in 1415 by an anonymous Dominican friar, was widely translated, and became much read in England, where the idea of ‘the good death’ filtered into literature.

  As a popular title, Tractatus artis bene moriendi was also among the first books printed with movable type, and became circulated in nearly one hundred editions before 1500. This ‘long version’ survives in about three hundred manuscript versions.

  Ars moriendi divides into six parts: the first chapter explains that dying has a good side, and serves to console the terminally ill that death is not something to fear. The second chapter outlines the five temptations – lack of faith, despair, impatience, spiritual pride and avarice – that beset the dying, and how to avoid them.

  The next chapter identifies the seven questions to ask a dying man, along with the consolation available to him through the redemptive powers of the Saviour’s love. This is followed by a chapter expressing the need to imitate Christ’s life. The fifth chapter addresses the friends and family, and outlines the general rules of behaviour at the deathbed. Finally, the sixth includes appropriate prayers to be said for the dying.

  Miguel de Cervantes and William Shakespeare both expressed clear views about good ways of going. In the prologue to his final novel, Los trabajos de Persiles y Sigismunda, Cervantes likens the impending end of his life to reaching the end of the road after travelling with friends ol
d and new, whom he wishes he could go on conversing with. Shakespeare’s understanding of death is polyvalent and all-encompassing. In Measure for Measure, the Duke of Vienna, disguised as a friar, instructs:

  Be absolute for death. Either death or life

  Shall thereby be the sweeter . . . .

  So too, in Hamlet, the student prince articulates a mature and extraordinary mood of resignation:

  We defy augury. There’s a special providence in the fall of a sparrow. If it be now, ’tis not to come. If it be not to come, it will be now. If it be not now, yet it will come—the readiness is all. Since no man of aught he leaves knows, what is’t to leave betimes? Let be.

  The lives and deaths of many characters in the Persiles also bear out the view that those who live well come to a good end, and those who don’t, don’t. This was a common attitude. In The Art of Dying Well, the Italian Jesuit Robert Bellarmine, a contemporary of Shakespeare and Cervantes, declares, ‘True, therefore, is the sentence, “He who lives well, dies well;” and, “He who lives ill, dies ill.”’ This is a sentiment whose afterlife still lingers, leaving questions hanging in the air like gun-smoke after a shooting.

  The patient, more than the reader, will be tormented to find that these are questions without answers. Both patient and reader will, inevitably, find themselves in a quasi-spiritual fix. For the writer, at least, there can be a bigger dividend. Words can heal wounds. The consolation that books can offer lies in their courage and their defiance. The exercise of thought, imagination, and creativity can provide real solace. Put words on the page, and you leave a mark behind. But in the process of putting black on white, you might have the sneaking suspicion that you are writing on sand.

  Paradoxically, it is from works of the imagination, especially fiction and poems, that we derive the most wisdom about Prospero’s ‘third thought’. After that anonymous Tractatus, post-classical consolatory death literature flourished until the seventeenth century. Other works in the English tradition include The Waye of Dying Well and The Sick Mannes Salve, culminating in 1650 with Holy Living and Holy Dying.

  Elsewhere, we find Russian writers doing things that others never dare even to contemplate. Tolstoy’s novella The Death of Ivan Ilych makes another kind of bleak commentary on ‘the good death’ that’s the equal of Shakespeare and Cervantes. A profound and beautiful meditation on an individual’s passing, Ivan Ilych is scarcely a hundred pages, but it reverberates like a much bigger book.

  *

  This long short story (ninety-eight pages in Aylmer Maude’s translation) begins when a certain Pyotr Ivanovich goes to visit Ilych’s widow, who describes how Ivan her husband had just died in agony. ‘He screamed unceasingly, not for minutes but for hours.’ Tolstoy uses this conversation to establish the terror of death, and also ‘the customary reflection’ of those who are left behind that ‘it could not and should not’ happen to them. From this stark opening, Tolstoy moves to tell the reader that Ivan Ilych’s life, which is narrated in the simplest terms, had been ‘most simple and most ordinary, and therefore most terrible’. After a momentary career disappointment in middle age, this unexceptional provincial magistrate gets a new job in a new town, finds a new house, starts to redecorate it, and is perfectly happy.

  Then this happens.

  Ilych is up a step-ladder, helping his interior decorator with some new curtains, when he slips and should have fallen badly, but manages to save himself. ‘It’s a good thing I’m a bit of an athlete,’ he says. ‘Another man might have been killed. I merely knocked myself, just here. It hurts when it’s touched, but it’s passing off already – only a bruise.’ However, despite protestations of well-being, something is not quite right. ‘It could not be called ill health’, says Tolstoy, with another twist of the narrative screw, ‘if Ivan Ilych sometimes said that he had a queer taste in his mouth and felt some discomfort in his left side.’

  Eventually, Ivan Ilych goes to see ‘a celebrated doctor’ and gets drawn into a fog of euphemistic evasion. Tolstoy’s account of this consultation is a triumph of irony:

  From the doctor’s summing-up, Ivan Ilych concluded that things were bad, but that for the doctor, and perhaps for everybody else, it was a matter of indifference, though for him it was bad.

  As his condition worsens, it gets ‘rendered worse by the fact that he [Ilych] read medical books and consulted doctors.’ At the beginning of Chapter VI, Tolstoy moves to the existential crisis at the heart of the book, summarising Ivan Ilych’s situation in two brilliant sentences:

  Ivan Ilych saw that he was dying, and he was in continual despair. In the depth of his heart he knew he was dying, but not only was he not accustomed to the thought, he simply did not and could not grasp it.

  In this crisis, he finds no solace from friends or family, and his worldly desires have faded. All he wants now is the comfort of his loved ones. But they can’t understand this, or relate to his suffering. The only person, close to Ilych, who instinctively responds to his master’s despair, is Gerasim, his salt-of-the-earth personal servant. Ilych sees that ‘no one felt for him, because no one even wished to grasp his position. Only Gerasim recognized it and pitied him. And so Ilych felt at ease only with him.’ The inevitable end to the story is as bleak as anything Tolstoy ever wrote. ‘What does it mean?’ asks Ilych. ‘Why? Why must I die in agony?’

  In the twentieth century, Sigmund Freud, faced with the complexity of dying, was at once humane, sensible, and profound. ‘We must’, writes Freud, ‘make friends with the necessity of dying’. Death, he instructed, is ‘the aim of all life. Everyone owes nature a death.’ Freud’s own death is one of the subjects in Katie Roiphe’s investigation of ‘great writers at the end’, The Violet Hour.

  Freud had fled to London, from Nazi-occupied Vienna, in September 1939, suffering from an excruciating cancer of the jaw, for which he had undergone some brutal radiation treatment whose final outcome was a hole in his cheek plugged by a prosthesis he called The Monster. ‘My world is again what it was before,’ he wrote to a friend, ‘a little island of pain floating in a sea of indifference.’ Nevertheless, he refused to take any painkiller other than aspirin. ‘I prefer to think in torment than not to be able to think clearly,’ he said.

  An exile, at home in Maresfield Gardens, Freud could rest outdoors on a chaise longue, to enjoy the fading warmth of the autumn sun. Psychologically, he was prepared for the end by the dreadful losses of his middle years. In 1920, when his daughter Sophie died of influenza, Freud had written, ‘For us there is little to say. After all, we know that death belongs to life, that it is unavoidable and comes when it wants.’ In another essay, he wrote, ‘If you would endure life, be prepared for death.’ Again, in Beyond the Pleasure Principle, also published in 1920, Freud had begun to explore our irrational longing for oblivion, beautifully described by Roiphe as ‘the mysterious attraction of undoing oneself’.

  The fierce dialectic of life and death persists throughout Freud’s work. Famously, he recognizes humanity’s profound cognitive dissonance: ‘in the unconscious every one of us is convinced of his own immortality.’ This is, in other words, an existential conflict we cannot escape. With such thoughts uppermost in my mind, I went to see one of Freud’s biographers, the psychoanalyst and writer Adam Phillips.

  14

  THE NECESSITY OF DYING

  ‘Death destroys a man: the idea of Death saves him.’

  E. M. Forster, Howards End

  A visit to Adam Phillips is an intriguing negotiation, and possibly a quest, or even a voyage into the unknown. I’ve been going to Phillips’ office (formerly his flat) near Portobello Road for about thirty years, but I find it hard to imagine what it must be like to meet him for the first time, still more to have a consultation.

  On the appointed day, and at the appointed time, you arrive at Phillips’ address. You check your notes. At first, second, and even third glance, it seems highly improbable, even impossible, that this battered off-white door could open a stairway t
o one of the most sought-after psychoanalytic consulting rooms in London. But it does, and once you press the buzzer marked PHILLIPS, you find yourself climbing, past heaps of junk mail, and dusty household debris, three flights up one of the grottiest staircases in the civilized world.

  Today, having reached the top floor, and pausing to look down into the street from the window of the book-cluttered study where Phillips holds consultations with his patients, and does much of his writing, I have no idea how this session will go. We are going to discuss Prospero’s ‘third thought’ as friends, but with the hope, on my side, that I shall acquire some insights into the predicament of humanity in these closing years. After my conversations with Kate, Carol and Max, and my encounters with Professor Lees and Henry Marsh, there’s much to explore and digest. But I’m optimistic: a conversation with Phillips is always consoling, and sometimes inspiring. Besides, he’s my old friend, and we share plenty of history.

  The sixty-two-year-old man who sits opposite me in a small wooden chair by the window, overlooking his street’s white stucco, has sometimes, in younger days, had an uncanny resemblance to Bob Dylan, though I must say he is ageing rather better than the author of ‘Tangled Up in Blue’. At first, the writer and psychotherapist steers my enquiries towards conversation by looking away, scarcely meeting my gaze, perhaps because he understands that (if I did not know him better) I might become disconcerted by the awkwardness of his wandering right eye, a childhood trait. He is dressed like a post-graduate in dark corduroy trousers, loafers and a warm brown shirt. On some mornings, he could seem like an inhabitant of Middle Earth; you might also mistake him for a university professor, or even a poet. Somewhere, he has said that he reads psychoanalysis like poetry.