Different deaths: “I wanted to express how very simple death and burial are, just as easy as the falling of an autumn leaf”—but not always

“I have left out some details—I wanted to express by those ruins that the peasants have been paid to rest for centuries among the very fields in which they toiled when they were alive. I wanted to express how very simple death and burial are, just as easy as the falling of an autumn leaf—nothing but a bit of earth turned over, a small wooden cross. Where the grass of the churchyard ends, over the little wall, the fields around it form a last line against the horizon—like the horizon of a sea. And now the ruins tell me how faith and religion moulder away, no matter how firmly grounded they are—but that the lives and deaths of the peasants are always the same. Steadily sprouting and withering like the grass and the little flowers that grow in the churchyard there.” Vincent Van Gogh, 1885

“At 3.30 in the morning, I am woken by a doctor on the phone. He says my mother [who is 82, frail, and has made clear in an advanced directive that she doesn’t want invasive treatment at the end of life] has developed sepsis and a galloping infection in the ulcer. They are going to operate and she may well die. I am confused, I say that she has advance medical decisions against interventions of this sort. Oh well, says the doctor, we’re working with her, and she’s happy with this. She’s very bright, very alert. And he puts the phone down. I imagine my mother, docile and smiling as she always is in fear. I remember how she agreed to go to the operation that wasn’t hers, was rolled along the corridor, bright and smiling for the doctor. I imagine her infected leg. I imagine her waking up to find it gone…. And now she has been put on a ventilator, for her operation, and when I call the ICU they say she is stuck on it, she can’t breathe on her own. They don’t know if she will ever come off it, but if she does, they say, she will live a very limited life in a nursing home….[My brother] sneaked himself and my father on to what he thought was the palliative ward only to find my mother breathing with just an oxygen mask, conscious, but off her head.” [She died a few days later in hospital.] Kate Clancy, Guardian, 2021 https://www.theguardian.com/news/2021/apr/06/letting-go-my-battle-to-help-my-parents-die-a-good-death

Old men can shrivel to nothing more than a compilation of stories

The first day I arrived to work at the BMJ in 1979 I wore a suit. I hardly ever wore one thereafter, but the suit showed my nervousness. As I attended meetings, cocktail parties, and dinners I was deeply grateful to any older person who gave me time, rescued me from being stranded and awkward. One of these people I had subsequently to fire, a greater embarrassment to me than him, but one of those kind souls that I remember clearly was Dr John Havard, and unintentionally he taught me something about aging that is now affecting me.

Havard was the secretary of the BMA, the highest official in the catacomb of the BMA, when I was a lowly assistant editor. Patrician through and through (or so it seemed to me), he had trained in law as well as medicine, sprinted at near-Olympic standard, written an influential book on undetected murders, revitalised the BMA, played a prominent part in Britain requiring seat-belts to be worn in cars, and campaigned against boxing. The elected doctors at the BMA, I came to realise, resented his power, intelligence, and patrician manner, and when he retired they replaced him a dolt.

Like all of us, he had his failings, which are hinted at in the short sentence in his BMJ obituary: “He also had a son with Diana Northcott.” https://www.bmj.com/content/340/bmj.c3218 Readers are not told who she was, but we know she was not one of his two wives. The wicked but probably true story about him at the BMJ was that he married his mistress to be able to introduce her as his wife to the Prince of Wales in the year that the Price was the president of the BMA.

The BMJ obituary also notes that “he had few friends but many admirers.” Perhaps that’s why he was so generous in talking to me. The way that he talked to me is how, I fear, I now talk to many people. I would say something and rather like a shilling into a juke box (look it up if you don’t know what that is) some word would provoke not a song a story from his past. He had no other conversation. These were rehearsed monologues not a dialogue. They were good stories, but after a while I realised that I’d heard them all before. I was too lowly, timid, and polite to say so and would listen to the stories again and again. As my stature rose and he aged, I tried to avoid him—despite my gratitude for his kindness.

The same, I fear, is now happening to me. My head is filled with stories, some of them true, all of them distorted. In conversation—particularly, I worry, with young people—the person says something that triggers a story, just as happened with Havard, and off I go. Sometimes, I inquire, “Have I told you this before?” but I am, I suspect, telling the same people the same stories again and again.

Is this how we fade away? Slowly but surely, just as a cancer advances, we are invaded by our stories. The present becomes uninteresting or just too painful. The stories become more mythic than real, and perhaps, as we dement, they become locked in our heads. We shrivel away until we are nothing more than a compilation of stories.

Am I a pisseur de copie?

I’ve greatly enjoyed Muriel Spark’s satire on the publishing world, A Far Cry From Kensington, but I’m left haunted by the idea that I might be a pisseur de copie.

The book is spare, waspish, fast-paced, funny, and a joy to read, especially after a volume of Proust. Spark like Proust is observing the strange but endlessly fascinating ways of humans—but in a very different style.

Mrs Hawkins, the narrator, works briefly for three publishers: one is on his way to jail for fraud; another is an upper-class idiot; and the third are a gay American couple prone to dramatic fights. Spark has some sympathy for all of them.

Very lightly Spark offers advice on writing scattered throughout the book. I’ve already posted her advice on how to write a novel, https://richardswsmith.wordpress.com/2021/05/31/muriel-sparks-concise-and-excellent-advice-on-how-to-write-a-novel/ but here are other nuggets.

“That Loy [Spark?] style of ferreting out facts and juxtaposing them with inventions.”

“A novelist doesn’t really have to undergo every experience, a glimpse is enough.’”

“‘When you are editing copy, Mrs Hawkins, what sort of things do you look for?’ said Howard Send. ‘Exclamation marks and italics used for emphasis,’ I said. ‘And I take them out.’”

But what Spark hates most is a pisseur de copie, and the villain in the book is one. She writes: “I forget which of the French symbolist writers of the late nineteenth century denounced a hack writer as a urinator of journalistic copy in the phrase ‘pisseur de copie’, but the description remained in my mind, and I attached it to a great many of the writers who hung around or wanted to meet Martin York [the fraudulent publisher].” She forgets which French symbolist writer came up with the term because she’s invented it herself.

Once you know the phrase pisseur de copie you read them everywhere. Most of those obliged to make a living by spewing (pissing?) out columns every few days might be called pisseurs de copie. But am I one? I fear I am. I’m not financially obliged to write something every day, but some beast inside me encourages me to do so—and I enjoy it. It’s my hobby. I don’t suffer as I think a non-pisseur, a proper writer, must. My only excuse is that my pissing is not printed and sent to hundreds of thousands of people; rather it’s projected onto a screen where people can ignore it—and 99.99999999% of the world does. Good for them.

Other quotes I took from the book:

They [the Poles] greatly enriched London with their new and alien life. Like other groups of war refugees, they brought their courage with them; it was no mean offering.

People love coincidence, destiny, a lucky chance.

‘They’, which meant they, the Government, they, the Americans, they, the Irish, and many other theys; which left a very small world of ‘us.’

The sadness of these last gatherings of personal effects, the siftings and sortings and parcelling-up, is more inexpressible than the funeral, where at least there is a fixed rite, there are words, the coffin has a shape and the grave a certain depth, and even the sorrow of the mourners has some silent eloquence if only conveyed and formally interpreted by their standing still. But the grief which is latent in relics like Wanda’s pair of worn shoes has no equivalent at all.

I had always associated people of crusader-like left-wing leanings with grim faces and glum rectitude, with plans and statistics, and coming home from night schools at the London School of Economics, in the rain, sucking acid drops.

It is a good thing to go to Paris for a few days if you have had a lot of trouble, and that is my advice to everyone except Parisians.

The opioid crisis, the Sacklers, and the role played by doctors

The half a million and still rising deaths from opioid overdoses in the US together with increasing numbers in other countries is surely medicine’s biggest failure. I tried to think what might match it. The mass incarceration and abuse of the mentally ill over centuries? The infection of patients with hepatitis B and HIV? The deaths and suffering that result from 10% of all patients admitted to hospital suffering an adverse event and 1% dying? The torturing of the dying? The many unnecessary operations? The widespread overtreatment? Healthcare’s considerable contribution to ecological disaster and climate change? Ivan Illich would say the destruction of cultural mechanisms for responding to the suffering, pain, death, and grief that are part of being human, but the burgeoning epidemic of deaths from opioids must rank high.

Patrick Radden Keefe tells an important part of the story of the epidemic in his magnificent book, Empire of Pain: The Secret History of the Sackler Dynasty, a family saga that reads like a great novel, reminding me of Thomas Mann’s Buddenbrooks and Elizabeth Jane Howard’s Cazelet Chronicles. The book convincingly makes the case for the greed of the Sackler family being the main driver of the epidemic, and from the beginning of the book you are fascinated to know if the family will get the punishment it deserves. The answer is essentially no legally but yes in terms of reputation. No Sackler has been to prison, and they still have their billions—but their name is disgraced and removed from art galleries, museums, and universities.

At the end of his book Keefe acknowledges that blame for the crisis could also be made against other pharmaceutical companies, the Food and Drug Administration, “the doctors who wrote prescriptions, the wholesalers that distributed the opioids, and the pharmacies that filled the prescriptions.” There are other books to be written about the role of these different players, and I look forward particularly to reading the one of the role of doctors and the whole medical establishment. Some of the elements of that book can be extracted from Keefe’s book, and that’s what I want to do in this blog. But first I want to summarise the role of the Sacklers and their drug company Purdue.

The family saga begins with the three Sackler brothers Arthur, Mortimer, and Raymond, who were born in Brooklyn between 1913 and 1920. The family, particularly Arthur, had the entrepreneurial energy and drive of immigrants, and all three sons overcame poverty to graduate as doctors.

Arthur, who died in 1987 before the opioid epidemic began, was in many ways brilliant and invented much of the pharmaceutical marketing that has become so familiar: glossy rather than sober advertising; drug representatives performance managed to sell; hiring doctors to promote drugs (key opinion leaders or KOLs in the jargon); dubious scientific studies that exaggerate the problem, downplay side effects, and advocate new conditions for which the drugs will work; free-trips for doctors; conferences featuring well-paid speakers; medical newspapers filled with promotional material; incestuous relationships with regulators; and databases that identify high-prescribing doctors. His achievements earned him a place in the Medical Advertising Hall of Fame.

The Sackler brothers owned a medical advertising company (and secretly its main competitor), a medical newspaper, and a database company. They used this formidable marketing capacity to power the sales of Librium then Valium, asserting that the drugs were effective in a huge range of conditions, had no side effects, and were not addictive. It was their success in peddling these minor tranquillisers that made them the millions that they began to give to museums, art galleries, and universities, always insisting that their family name was attached. From the beginning they were adept, in contrast, at separating the family name from their ever-proliferating companies.

The logical next step was for the family to buy a pharmaceutical company, which they did in 1952. Purdue Pharma was a sleepy company selling laxatives, but the Sacklers longed to create a company with a “blockbuster,” a drug that makes billions. Eventually they came up with the idea of a controlled-release opioid: MS Contin containing morphine was released in1984 and Oxycontin containing the more powerful  oxycodone in 1996. They Sacklers argued that these controlled-release formulations were not addictive because there were no peaks and troughs, the cause, they argued, of addiction. Fewer than 1% of those taking the drugs became addicted, and those who did become addicted did so because they were prone to addiction not because the drugs themselves were addictive.  This, as Keefe points out, is the same argument as that used by the gun lobby—the people not the guns (or drugs) are the problem.

Purdue Pharma used all the tactics developed by Arthur to market the drugs, including publishing studies on the high prevalence of chronic pain and targeting deprived communities where the prevalence was especially high. Somehow the Sacklers and the many leading doctors who worked with them managed to shift medical thinking in the US to regard opioids as essentially non-addictive and suitable for treating non-malignant pain. That was a remarkable achievement and, as far as I can tell, has not happened in Britain. The result of the marketing was a rapid rise in prescriptions soon followed by a rapid rise in deaths that resulted from both use and abuse of the drugs and addicted people moving to illegal opioids.

Much of Keefe’s book is devoted to the proliferation of legal cases against the company and eventually the family. The family has always refused to accept that they have done anything wrong and have used high-charging lawyers and political connections to avoid justice. None of the family would talk to Keefe when he was writing his book, and they tried to stop the book.

All three of the Sackler brothers were doctors, and several of the later generations also trained as doctors, although few of them saw patients. They had great respect for the medical profession, and Arthur was comfortable with the doublethink that allowed him to see the success of his marketing and at the same time argue that “doctors were unimpeachable. It was laughable, he asserted, to suggest that a physician might be seduced by a glossy layout in a medical journal in the same manner that a housewife might be swayed by a slick ad in a magazine.” (Such sexism was, of course, normal at the time.) Yet, as Keefe quotes: “The doctor is feted and courted by drug companies with the ardor of a spring love affair…The industry covets his soul and his prescription pad because he is in a unique economic position; he tells the consumer what to buy.”

The epidemic of opioid deaths could never have happened without doctors prescribing the drugs in large amounts. Some doctors were clearly culpable in that they ran “pill mills,” where they prescribed huge quantities of drugs to anybody, knowing that many of the drugs would find their way onto the black market. Many of those doctors went to prison, but just as gambling companies make much of their profits from addicted gamblers so Purdue made much of its profits from these “pill mills” and from the “high-prescribing” doctors, who weren’t doing anything illegal but were not practicing good medicine. These doctors were known as “whales” to the salespeople.

Crucially important in stoking the opioid epidemic were the leading doctors who promoted MS Contin and Oxycontin. Purdue funded many such doctors, and often they spoke to other doctors in expensive resorts where the attending doctors had all their expenses paid. One doctor Russell Portenoy, a neurologist who was called “the King of Pain,” argued (not incorrectly) that the medical establishment had not taken pain seriously. Opioids were, he said, a “gift from nature” and he coauthored an influential paper that highlighted “the possibility of long-term pain relief from opioid therapy, without the development of . . . serious adverse effects, including drug abuse.” He also spoke at conference at the University of Toronto organised by Purdue where many doctors preached the benefits of treatment and downplayed the risk of addiction.

David Haddox, a pain doctor, was employed by Purdue and a strong advocate of the wider use of MS Contin and Oxycontin. He advanced the argument that problems arose not from the drugs but from the patients: “If I gave you a stalk of celery and you ate that, it would be healthy. But if you put it in a blender and tried to shoot it into your veins, it would not be good.” Haddox developed the concept of “pseudo-addiction,” which “seems similar to addiction, but is due to unrelieved pain.” The treatment he advocated was to increase the dose of opioid.

The New England of Journal features in this sorry saga. It carried many of the ads for Librium and Valium produced by Arthur’s company and was making “more than $2 million a year” in the late 60s (about $15m in 2021) from advertising, most of it from drug companies. Much more troublesome is a seven-line letter published in the journal in 1980 headed “Addiction Rare in Patients Treated with Narcotics.” https://www.nejm.org/doi/10.1056/nejm198001103020221 The letter was used extensively by the drug reps of Purdue, and their sales materials summarised the study as saying “a survey of more than 11 000 opioid-using patients, taken over several years, found only four cases of documented addiction.” They drugs reps must as well have quoted the last sentence of the letter, which reads: “We conclude that despite widespread use of narcotic drugs in hospitals, the development of addiction is rare in medical patients with no history of addiction.” This plays to the idea popular with the Sacklers that the only people who become addicted are those who are prone to addiction.

The New England Journal of Medicine has come under pressure to retract the letter but has not done so. Instead, it has attached to the letter: “‘Editor’s Note’ (added May 31, 2017): For reasons of public health, readers should be aware that this letter has been ‘heavily and uncritically cited’ as evidence that addiction is rare with opioid therapy. Leung et al. describe its history.” The letter by Leung et al analyses 608 citations of the letter and shows that most (72%) cited it as evidence that addiction was rare in patients treated with opioids. The authors also analysed the citations over time and classified them as affirmative (supporting the conclusion that addiction is rare), negative, or other. The citations peaked in 1996, the year Oxycontin was launched, and were almost all positive with no negative citations. Indeed, there were no negative citations until 1999, when there was one.

Affirmative, negative, and other citations of NEJM letter suggesting that addiction to opioids is rare

I’m sure that the editors of the journal published the letter in good faith, but a combination of the prestige of the journal, its high circulation among American doctors, and particularly the extensive use of the letter by the drug reps of Purdue must have played a prominent part in the change of attitude towards opioids among the medical establishment.

Doctors unlike pharmaceutical companies tend to get a positive press: they are the “good guys.” But the catastrophe that has struck the US could not have happened without doctors prescribing the opioids and prominent doctors and journals promoting them.

Doctors and the health care system have probably not matched SARS-CoV-2 with the deaths and suffering they have caused, but if we were to add to the deaths and suffering caused by the opioid crisis the others caused by doctors and the health care system that I listed in the first paragraph they might come close. And the harm from SARS-CoV-2 will eventually dwindle away whereas the harm from doctors and health care continues.

What is “inspiration”? Nietzsche nails it

This is Nietzsche’s account of the inspiration he felt when writing “Also Sprach Zarathustra,” which he wrote in 10-day bursts over a year. Have you ever felt anything like this? I’ve felt a very dilute version.

“Has any one at the end of the nineteenth century any distinct notion of what poets of a stronger age understood by the word inspiration? If not, I will describe it.

If one had the smallest vestige of superstition in one, it would hardly be possible to set aside completely the idea that one is the mere incarnation, mouthpiece or medium of an almighty power. The idea of revelation in the sense that something becomes suddenly visible and audible with indescribable certainty and accuracy, which profoundly convulses and upsets one—describes simply the matter of fact. One hears—one does not seek; one takes—one does not ask who gives: a thought suddenly flashes up like lightning, it comes with necessity, unhesitatingly—I have never had any choice in the matter.

There is an ecstasy such that the immense strain of it is sometimes relaxed by a flood of tears, along with which one’s steps either rush or involuntarily lag, alternately. There is the feeling that one is completely out of hand, with the very distinct consciousness of an endless number of fine thrills and quiverings to the very toes;—there is a depth of happiness in which the painfullest and gloomiest do not operate as antitheses, but as conditioned, as demanded in the sense of necessary shades of colour in such an overflow of light.

There is an instinct for rhythmic relations which embraces wide areas of forms (length, the need of a wide-embracing rhythm, is almost the measure of the force of an inspiration, a sort of counterpart to its pressure and tension).

Everything happens quite involuntarily, as if in a tempestuous outburst of freedom, of absoluteness, of power and divinity. The involuntariness of the figures and similes is the most remarkable thing; one loses all perception of what constitutes the figure and what constitutes the simile; everything seems to present itself as the readiest, the correctest and the simplest means of expression.”

Muriel Spark’s concise and excellent advice on how to write a novel

I read this excellent advice on how to write a novel in Muriel Spark’s “A Far Cry From Kensington,” her satire on the world of publishing. I’ve seen the book described as her masterpiece, and it certainly has the wit, colour, pace, and brevity that I associate with the best Spark novels.

“You are writing a letter to a friend,’ was the sort of thing I used to say. ‘And this is a dear and close friend, real – or better – invented in your mind like a fixation. Write privately, not publicly; without fear or timidity, right to the end of the letter, as if it was never going to be published, so that your true friend will read it over and over, and then want more enchanting letters from you. Now, you are not writing about the relationship between your friend and yourself; you take that for granted. You are only confiding an experience that you think only he will enjoy reading. What you have to say will come out more spontaneously and honestly than if you are thinking of numerous readers. Before starting the letter rehearse in your mind what you are going to tell; something interesting, your story. But don’t rehearse too much, the story will develop as you go along, especially if you write to a special friend, man or woman, to make them smile or laugh or cry, or anything you like so long as you know it will interest. Remember not to think of the reading public, it will put you off.”

Oddly, I’ve been giving the same advice to people for years about how to write something much less grand than a novel—a blog perhaps.

But, adds Spark later in her book to write a novel you need concentration-and for that you need a cat:

So I passed him [the Brigadier] some very good advice, that if you want to concentrate deeply on some problem, and especially some piece of writing or paper-work, you should acquire a cat. Alone with the cat in the room where you work, I explained, the cat will invariably get up on your desk and settle placidly under the desk-lamp. The light from a lamp, I explained, gives a cat great satisfaction. The cat will settle down and be serene, with a serenity that passes all understanding. And the tranquillity of the cat will gradually come to affect you, sitting there at your desk, so that all the excitable qualities that impede your concentration compose themselves and give your mind back the self-command it has lost. You need not watch the cat all the time. Its presence alone is enough. The effect of a cat on your concentration is remarkable, very mysterious.

The cat unfortunately does not guarantee a good book.

The Brigadier listened with deep interest as he ate, his glaring eyes turning back and forth between me and his plate. Then he said, ‘Good. Right. I’ll go out and get a cat.’ (I must tell you here that three years later the Brigadier sent me a copy of his war memoirs, published by Mackintosh & Tooley. On the jacket cover was a picture of himself at his desk with a large alley-cat sitting inscrutably beside the lamp. He had inscribed it ‘To Mrs Hawkins, without whose friendly advice these memoirs would never have been written – and thanks for introducing me to Grumpy.’ The book itself was exceedingly dull. But I had advised him only that a cat helps concentration, not that the cat writes the book for you.)

What is our relation with “reality”? Evolving ideas: from Thales to Schopenhauer

I sit here in my “reality,” my fingers on the keyboard, the screen flickering in front of me, music playing, and my breakfast digesting inside me, but is this the only “reality.” I could have, of course, imagined all this: everything that seems to be “real” might come from inside my head. I know as well that there is complicated—albeit incomplete—quantum mechanics that can “explain” this “reality” in a way that I cannot. Is the “reality” “explained” by quantum mechanics more “real” than my “reality?” The introduction by R J Hollingdale to Arthur Schopenhauer’s Essays and Aphorisms provides a brief and splendid account of the history of our attempts to explain “reality” and its relationship to us.

Thales in the sixth century BCE said that everything is “really” water. Hollingdale interprets Thales as meaning: “The world of diversity is an apparent world; in reality the world is one.” There is a “real” world and an “apparent” world, and much of philosophy (and physics) is devoted to finding the relation between them.

There is the world of nature–the sun rising every day, us being born and dying—and the world of thought and imagination. Hollingdale writes: “The world of thought and imagination is incredibly dynamic; it is continually expanding and changing and adding to itself new shapes and colours. The living occupy the world of nature, but the world of thought is also inhabited by the dead, and especially by the ‘mighty dead’, the founders and ancestors; indeed in this world they are no longer dead, they live on, they appear in dreams and waking dreams, they are immortal – and shall we too not be immortal, in that other world?” (Hints here of heaven.)

For Heraclitus ceaseless change was “real” and unity and permanence “apparent.” Parmenides thought the opposite: change is illusion and “reality” motionless, unchanging. For Democritus (and for us today in many ways) solidity is illusion and “reality” indivisible atoms.

Plato expounded the famous idea of people sitting in a cave with the light behind them watching shadows on the wall. We are those people, and the shadows are our “reality,” but the real reality is the light behind us (God?).

Bertrand Russell though the Catholic Church a combination of Jewish history, Greek theology/philosophy, and Roman law. After Plato, writes Hollingdale, “ the history of Christianity is the history of a progressively widening gap between the two worlds, until in its final form Christianity means duality: the duality of Church and State, Pope and Emperor, this world and the next, the City of God and the Earthly City, God and his creation, the individual souls of men and the Holy Spirit ‘in whom we are all one’ – all ultimately forms of that primeval duality of the world in the eyes and the world in the mind.”

Modern philosophy begins after what Hollingdale colourfully calls the “metaphysical debauch” of the Middle Ages with Descartes proposing that the world is divided into “thinking substance” or soul and “extended substance” or matter. One is not more “real” than the other.

Spinoza said that soul and matter are not substances. Rather there is only God. “Everything is ‘really’ God, but God has an infinite number of modes of being, two of which are soul and matter. These are the only two that we humans know, but they are one underlying substance, God.

Locke, like Descartes, concluded that the world is what it seems to be: a material thing and a mental thing. He added that mind can know only the mental thing, which opened the way for Berkeley to go the whole hog and say that everything is mind. There is no world beyond our minds.

Hume asserts that our mind consists of ‘impressions’ and ‘ideas’. Impressions are our perception of the physical world; ideas are images of impressions, formed in thinking and reasoning. We can know something only if we have received an impression: what we haven’t perceived we can’t know. Our knowledge of the world is fragmentary, and our reasoning powers are illusory.

Kant was greatly bothered by the bleakness of Hume’s philosophy and set about creating something more comfortable. He divided the mind into the thinking part and the perceiving part. The perceiving part of the mind receives impressions from the senses that Kant called particulars. The thinking part of the mind develops concepts. Kant envisages three types of concepts: a posteriori (abstracted from sense perception and applied to it); a priori (applicable to sense perception but not abstracted from it), and a third type called Ideas, which are concepts that are neither abstracted from sense perception nor applicable to it. The a priori concepts of science and other forms of knowledge are “categories,” of which there are 12. The concept that “every event has a cause” is a category. The imposition of categories on perceptions of sense in time and space is how we think. An object that doesn’t fit with the categories cannot exist for a human observer.

There is a world out there, which Kant calls “the thing in itself,” that comprises both objects that cannot exist for humans and objects that are perceived through the categories, which Kant calls phenomena. “The ultimate conclusion,” writes Hollingdale, “is that there are two worlds: the ‘real’ world (the thing in itself) and the ‘apparent’ world (the world of phenomena).”

This is where Schopenhauer starts, and he interprets Kant as having concluded the same as Berkeley—that “the world as it is perceived is a creation of the intellect which perceives it.” Schopenhauer starts his great work The World as Will and Idea, with “The world is my idea.” There must be an “I” to perceive the world and our knowledge of “I” is different from our knowledge of the world, which is my idea: knowledge of oneself is knowledge of immediate reality. This knowledge of ourselves is “will.” ‘My body and my will are one’. My body is the phenomenal form of my will, my will is the noumenal form of my body: my body is ‘appearance’, my will ‘thing in itself’.” This is true of all bodies, including animals and stones. The difference is that humans are aware of the will and the idea. Otherwise, we are the same: “the will in the stone and the will in me is the same will.”

For Schopenhauer “the ‘world as idea’ is the outer, physical world, the realm of time, space and causation, ‘appearance’, Kant’s phenomenal world; the ‘world as will’ is the inner, subjective world, not subject to the forms of space and time, a unity, ‘reality’, Kant’s noumenal world or thing in itself.”

No doubt this “game” of trying to know the world, ourselves, “reality,” and the connections among these things/objects/ideas/phenomena continues and will continue—without resolution and often returning to where we started. What fun. As Eliot wrote: “We shall not cease from exploration, and the end of all our exploring will be to arrive where we started and know the place for the first time.”

Six reasons for reading Proust

It took me 40 years to read Marcel Proust’s In Search of Lost Time the first time, and now I have started again. Why? A friend who is an accomplished novelist and poet and teaches creative writing has never read it. I think she’s right not to do so: I fear that she would find it overwritten, narcissistic twaddle, and I couldn’t bear that. As I read my way through the first volume, Swann’s Way, I wondered if I might be able to find a way to convince her that she should read Proust.

She might read it—and she’s aware of this—because many writers think it the greatest novel of the 20th century, greater than Ulysses. But is that any reason in itself to plough your way through 4000 pages? I know of people who rate the book so highly they read nothing else, starting again at the beginning when they reach the end. There is something metaphysical about endlessly reading a book that is about capturing the past: your past would be reading the book. To reread endlessly the same book seems crazy, and I think that I must have imagined, rather than known, the person who never reads anything else. I don’t think that you should read a book simply because it is rated highly by many, but it seems to me that it should tempt you to try.

What are better reasons for reading Proust? The first answer is that he is trying—and ultimately failing, as we all fail—to capture the past. We are interested in our pasts, not least because our past has made us what we are. Our past is filed with treasures and horrors, both of which fascinate us: the full value of the treasures can never be recovered, but as compensation the horrors can be examined with most of the horror extracted as the forensic pathologist examines the dismembered corpse. (You see how reading Proust affects how you write yourself.)

Here are examples from this first volume of Proust describing the joy, impossibility, and difficulties of trying to capture the past and the present:

“And so it is with our own past. It is a labour in vain to attempt to recapture it: all the efforts of our intellect must prove futile. The past is hidden somewhere outside the realm, beyond the reach of intellect, in some material object (in the sensation which that material object will give us) which we do not suspect. And as for that object, it depends on chance whether we come upon it or not before we ourselves must die.”

“The places that we have known belong now only to the little world of space on which we map them for our own convenience. None of them was ever more than a thin slice, held between the contiguous impressions that composed our life at that time; remembrance of a particular form is but regret for a particular moment; and houses, roads, avenues are as fugitive, alas, as the years.”

“Then, quite apart from all those literary preoccupations, and without definite attachment to anything, suddenly a roof, a gleam of sunlight reflected from a stone, the smell of a road would make me stop still, to enjoy the special pleasure that each of them gave me, and also because they appeared to be concealing, beneath what my eyes could see, something which they invited me to approach and seize from them, but which, despite all my efforts, I never managed to discover.”

And so I concerned myself no longer with the mystery that lay hidden in a form or a perfume, quite at ease in my mind, since I was taking it home with me, protected by its visible and tangible covering, beneath which I should find it still alive, like the fish which, on days when I had been allowed to go out fishing, I used to carry back in my basket, buried in a couch of grass which kept them cool and fresh.”

“I never thought again of this page, but at the moment when, on my corner of the box-seat, where the Doctor’s coachman was in the habit of placing, in a hamper, the fowls which he had bought at Martinville market, I had finished writing it, I found such a sense of happiness, felt that it had so entirely relieved my mind of the obsession of the steeples, and of the mystery which they concealed, that, as though I myself were a hen and had just laid an egg, I began to sing at the top of my voice.”

That accuracy of detail which it is easier, often, to obtain when we are studying the lives of people who have been dead for centuries than when we are trying to chronicle those of our own most intimate friends.

Style might be the best reason for reading Proust. I can’t think of any other book that has such, flowing, mellifluous sentences that are filled with acute observations and metaphors and similes that you have never heard before. People describe Karle Ove Knausgaard as the Norwegian Proust, but, although he and Proust have in common that they examine their lives in minute detail, they have very different styles. (I’ve read two of Knausgaard’s six volumes and appreciated them, but I doubt that I’ll read more.) Similarly, people talk of Anthony Powell’s Dance to the Music of Time as the English equivalent of In Search of Lost Time, but it is different except in that it is multiple volumes and covers the activities of a large group of people over decades. The Dance has its own unique style and pleasures, which delight me enough to have read it twice and will read again.

I found it difficult to adjust to the style when I first read Proust 40 years ago, and the book is not one to read on the tube: it needs and deserves full concentration, which for me means quiet, no interruptions, and the early morning. I now find Proust much easier to read (as I do everything), which is probably the result of a lifetime of reading. But I know that many people find Proust’s style too flowery and elaborate and consequently unreadable. Anybody starting Proust should, I advise, read at least 50 pages before giving up. It needs time to adjust to the style, which is true of most great writers.

Here are some examples of Proust’s style. I could have picked them at random, but I didn’t.

“Come and bear your aged friend company,” he had said to me. “Like the nosegay which a traveller sends us from some land to which we shall never go again, come and let me breathe from the far country of your adolescence the scent of those flowers of spring among which I also used to wander, many years ago. Come with the primrose, with the canon’s beard, with the gold-cup; come with the stone-crop, whereof are posies made, pledges of love, in the Balzacian flora, come with that flower of the Resurrection morning, the Easter daisy, come with the snowballs of the guelder-rose, which begin to embalm with their fragrance the alleys of your great-aunt’s garden ere the last snows of Lent are melted from its soil. Come with the glorious silken raiment of the lily, apparel fit for Solomon, and with the many-coloured enamel of the pansies, but come, above all, with the spring breeze, still cooled by the last frosts of wirier, wafting apart, for the two butterflies’ sake, that have waited outside all morning, the closed portals of the first Jerusalem rose.”

“The ‘Méséglise way’ with its lilacs, its hawthorns, its cornflowers, its poppies, its apple-trees, the ‘Guermantes way’ with its river full of tadpoles, its water-lilies, and its buttercups have constituted for me for all time the picture of the land in which I fain would pass my life, in which my only requirements are that I may go out fishing, drift idly in a boat, see the ruins of a gothic fortress in the grass, and find hidden among the cornfields — as Saint-André-des-Champs lay hidden — an old church, monumental, rustic, and yellow like a mill-stone; and the cornflowers, the hawthorns, the apple-trees which I may happen, when I go walking, to encounter in the fields, because they are situated at the same depth, on the level of my past life, at once establish contact with my heart.”

Many people, including me, read Proust because he describes so well much that seems indescribable. One of his favourite themes is love. At least three kinds of love are described in this book: Proust’s love for his mother when he was a child, suffering agonies when she didn’t come to kiss him goodnight; Swan’s obsessive love for Odette, the courtesan, which is mixed with a huge dollop of jealousy and causes more suffering than pleasure; and the boy Proust’s infatuation with Gilberte, a girl as young as him. I remember the adolescent infatuation that Proust describes so well: it seemed silly at the time and plain crazy now, but it was real and hurt badly.

Quotes on love:

No woman ever thought of anything but love, and that there was not one of them whose resistance a man could not overcome,

And at once I fell in love with her, for if it is sometimes enough to make us love a woman that she looks on us with contempt,

of love; it no longer evolves by itself, obeying its own incomprehensible and fatal laws, before his passive and astonished heart.

Among all the methods by which love is brought into being, among all the agents which disseminate that blessed bane, there are few so efficacious as the great gust of agitation which, now and then, sweeps over the human spirit.

But in this strange phase of love the personality of another person becomes so enlarged, so deepened, that the curiosity which he could now feel aroused in himself, to know the least details of a woman’s daily occupation, was the same thirst for knowledge with which he had once studied history.

And this malady, which was Swann’s love, had so far multiplied, was so closely interwoven with all his habits, with all his actions, with his thoughts, his health, his sleep, his life, even with what he hoped for after his death, was so entirely one with him that it would have been impossible to wrest it away without almost entirely destroying him; as surgeons say, his case was past operation.

She concluded with the wisdom invariably shewn by people who, not being in love themselves, feel that a clever man ought to be unhappy only about such persons as are worth his while; which is rather like being astonished that anyone should condescend to die of cholera at the bidding of so insignificant a creature as the common bacillus.

And Swann felt a very cordial sympathy with that Mahomet II whose portrait by Bellini he admired, who, on finding that he had fallen madly in love with one of his wives, stabbed her, in order, as his Venetian biographer artlessly relates, to recover his spiritual freedom.

For what we suppose to be our love, our jealousy are, neither of them, single, continuous and individual passions. They are composed of an infinity of successive loves, of different jealousies, each of which is ephemeral, although by their uninterrupted multitude they give us the impression of continuity, the illusion of unity.

When one is in love one has no love left for anyone.

Proust writes much about the arts, particularly painting, but it was his words on music that caught me in this first volume. Writing about music like writing about wine, perfume, food, paintings, or sex is hard, and best avoided, but Proust does it well:

She had been taught in her girlhood to fondle and cherish those long-necked, sinuous creatures, the phrases of Chopin, so free, so flexible, so tactile, which begin by seeking their ultimate resting-place somewhere beyond and far wide of the direction in which they started, the point which one might have expected them to reach, phrases which divert themselves in those fantastic bypaths only to return more deliberately — with a more premeditated reaction, with more precision, as on a crystal bowl which, if you strike it, will ring and throb until you cry aloud in anguish — to clutch at one’s heart.

There are in the music of the violin — if one does not see the instrument itself, and so cannot relate what one hears to its form, which modifies the fullness of the sound — accents which are so closely akin to those of certain contralto voices, that one has the illusion that a singer has taken her place amid the orchestra. One raises one’s eyes; one sees only the wooden case, magical as a Chinese box; but, at moments, one is still tricked by the deceiving appeal of the Siren; at times, too, one believes that one is listening to a captive spirit, struggling in the darkness of its masterful box, a box quivering with enchantment, like a devil immersed in a stoup of holy water; sometimes, again, it is in the air, at large, like a pure and supernatural creature that reveals to the ear, as it passes, its invisible message.

Another good reason for reading Proust is that much of his writing is funny. He’s particularly good with dialogue, capturing well the absurdities and snobbishness of his upper-class compatriots. This volume includes such funny dialogue, but I have selected a description of a man:

With his huge carp’s head and goggling eyes moved slowly up and down the stream of festive gatherings, unlocking his great mandibles at every moment as though in search of his orientation, had the air of carrying about upon his person only an accidental and perhaps purely symbolical fragment of the glass wall of his aquarium, a part intended to suggest the whole which recalled to Swann, a fervent admirer of Giotto’s Vices and Virtues at Padua, that Injustice by whose side a leafy bough evokes the idea of the forests that enshroud his secret lair.

A final reason I’ll share now—and I’ll encounter others as I read on now—is the observations he makes on all sorts of subjects. I’ve selected just three from this volume, the last of which may apply to me in that I’m a doctor who does not believe in medicine.

At Combray a person whom one ‘didn’t know at all’ was as incredible a being as any mythological deity.

There are mountainous, uncomfortable days, up which one takes an infinite time to pass, and days downward sloping, through which one can go at full tilt, singing as one goes.

That curiosity, that superstitious outlook on life, which, combined with a certain amount of scepticism with regard to the object of their studies, earn for men of intelligence, whatever their profession, for doctors who do not believe in medicine, for schoolmasters who do not believe in Latin exercises, the reputation of having broad, brilliant, and indeed superior minds.

Hope is hazardous

None of us knows how we will respond when we are given the diagnosis of a life-limiting illness, just as young men in the First World War did not know how they would respond when commanded to go “over the top.” Will we insist on every last iota of treatment, or will acceptance be a better option? Hope will enter the picture. We will be urged to “hope for the best.” Kind doctors will want to give us hope, keep hope alive. But will our search for hope delude us and increase the suffering of ourselves and those who love us? A study in that must-read journal Psycho-Oncology suggests so. https://onlinelibrary.wiley.com/doi/abs/10.1002/pon.5675

The authors, one of whom is my friend Eric Finkelstein who sent me a copy of the paper, studied 200 patients with advanced cancer or haematological malignancies whom their doctors thought might well not survive a year. The patients were asked how long they might live, and of the 111 who gave a prediction and died most (93%) died sooner than they expected and not one died later than they expected. On average these patients expected to survive over eight years but actually survived less than nine months. The delusions went further in that 40% thought that their treatment would cure them.

This is the well-recognised phenonomen of “optimism bias.” Presumably at least some of the patients were by nature pessimists (I am, like Gramsci, a pessimist of the head but an optimist of the heart), and it shows the power of optimism bias that it could overwhelm any inbuilt pessimism.

Another bias that operates in patients facing death is “the illusion of superiority”: half of the patients though they would live longer than the average and a quarter much longer; less than 5% thought they would survive less than the average. Also at work were the biases of “motivated reasoning” and “self‐deception”: more than half of the patients believed that they were “very informed” about how their medical condition would change over time, while another third believed that they were “somewhat informed.” An important limitation of the study is that the researchers do not know exactly what the doctors had said to the patients, although all the doctors reported that they had informed all the patients of their prognoses. (Doctors, of course, are also prey to all the same biases as patients.)

How does hope influence these biases? It was known before this study that more hope means more unrealistic expectations of survival and cure, but does hope amplify our inbuilt biases?

The researchers measured hope in patients using the Herth Hope Index, which rates people’s level of agreement with 12 items—for example, “I have a positive outlook on life” and “I see possibilities in the midst of difficulties.” The summary score ranges from 12 (least hopeful) to 48 (most hopeful), and the patients reported high levels of hope: the mean score was 39.7 with 32 patients scoring the maximum and the lowest score reported by one patient was 15. The researchers found that the higher the levels of hope the greater all of the biases—in other words, hope is deceiving people.

Does this matter? Hope is said to have physical and psychological benefits, https://www.ejcancer.com/article/S0959-8049(08)00142-1/abstract but having severely distorted judgements must cause harm. The most obvious harm is that patients continue with treatments that will bring them little or no benefit but cause them side effects that will increase their distress and suffering. There will also be the “opportunity cost” that they will be sick and possibly in hospital when they could be enjoying their families, friends, and nature—or whatever brings joy to them. There may also be regret by patients and their families that the expected survival of seven years turns out to nine months and that most of that nine months has been spent in treatment or in an ambulance traveling for treatment. Hope may also delay patients accepting palliative care, which we know can produce better outcomes.

Hope can also increase people’s vulnerability to quacks, of whom there are plenty. They will also go along with the suggested treatments of doctors whose instinct is for aggressive treatments. I think of Paul Kalanathi, the neurosurgeon who died young and whose oncologist was urging aggressive treatment the day he died. https://en.wikipedia.org/wiki/When_Breath_Becomes_Air  It is sadly much easier for doctors to respond to the delusions caused by hope by continuing treatments than launching into the “difficult conversation” and suggesting to patients that discontinuing “curative” treatment may be the best option. (We always tend to think of these decisions in relation to cancer, but they occur across all of medicine.)

My friend Eric is an economist by training, and the delusions caused by hope contribute to people having very expensive treatments with little or no benefit. For example, Bristol-Myers Squibb charged $80 352 for a course of Cetuximab, an epidermal growth factor receptor inhibitor, to treat non-small lung cancer. https://blogs.bmj.com/bmj/2016/11/11/richard-smith-death-and-the-inescapable-logic-of-greed/  In a large European trial overall survival was increased by 1.2 months, meaning that the cost of an extra patient-year of life was $800 000. Martin Shkreli became infamous through buying the rights to Darapim (pyrethamine) and raising the price by 5000% from $13.50 to $750 per pill because of the possibility that it might prolong life in some patients with cancer.

Eric, a true economist, points out that it could be rational for individuals to spend every last penny on treatments that offer some “hope” as their money will be useless to them once they are dead. But in most high-income countries—and increasingly across the globe with the rise of universal health coverage—people are not paying for themselves. The deception of hope can contribute to excessive expenditure at the end of life, denying treatments to others, bankrupting health systems, and eroding financial support for education, housing, social care, and the environment, all of them important for health.

Were we to go back 70 years when there were few treatments that could prolong life and most deaths were rapid compared with now, then the delusions of hope would cause few problems. But as new treatments, many of them with high costs and limited benefits, are developed the range of options increases and more decisions must be made by patients, families, and their doctors. The deceptive capabilities of hope becoming steadily more important and relevant.

Perhaps writers and poets have a better understanding of hope than doctors and their patients. Elif Shafak writes in 10 Minutes 38 Seconds In This Strange World that “Hope is a hazardous chemical capable of triggering a chain reaction in the human soul.” T S Eliot wrote: “I said to my soul, be still, and wait without hope/For hope would be hope for the wrong thing.” And I found this poem, although I can’t find who wrote it but it’s possible that I wrote it myself:

Big and small hope

I hope you are well

Is small meaningless hope

A gesture, a verb to make a sentence.

I hope this cancer doesn’t kill me

Is a big hope, too big

Big enough to kill you.

PS. After finishing this blog I read in Patrick Radden Keefe’s book Empire of Pain that Oxycontin, the painkiller that has killed hundreds of thousands Americans and will kill many more, was marketed as “hope in a bottle.”

The essential art of not reading

The art of not reading is a very important one. It consists in not taking an interest in whatever may be engaging the attention of the general public at any particular time. When some political or ecclesiastical pamphlet, or novel, or poem is making a great commotion, you should remember that he who writes for fools always finds a large public. – A precondition for reading good books is not reading bad ones: for life is short.

Schopenhauer, Arthur. Essays and Aphorisms