Day -1

It’s Wednesday. Last Thursday, feeling reasonably healthy I checked into this stem cell transplant unit. I did that completely voluntarily in the hopes of curing a disease that would otherwise kill me in the coming few years. A week ago I could easily run several miles, lift weights for a good half an hour, do work related tasks, and make meals for my family. I’ve had good care here. I’m in excellent hands. Yet, when I got up out of bed to shower this morning, I was so weakened that thought I might black out in the shower stall. The doctor was not surprised to hear this. He recommended using the shower stool they provide. That’s why it’s there. He explained that as a result of the chemotherapy my hemoglobin has dropped so low that I am very weak, when I stand up and go into warm shower I have a low blood pressure moment, and black out is a possibility. I guess it’s all routine. I had no idea what routine was when I checked in last week. I still really don’t. And I guess it varies a fair bit from person to person. But I’ve become astonishingly weak, very quickly. I’ve never read any first person an accounts of stem cell transplants. I could find nothing on the internet to prepare myself. Now I wonder if there is a secret confederacy of patients, dedicated to not telling others how crappy it gets, in order not to scare people away from having the life-saving procedures.

Tomorrow is transplant day, soon after which I hope the pendulum swings from destruction to re-building. If I were to walk out of this hospital today, I would not get far. Before long I’d succumb to fatigue, and without much of a working immune system, I would probably catch a severe infection. The bodily processes that make up this living organism that I am would go into deep crisis. I have no choice but to move forward with the transplant. It’s the only option now, but it was also the best option, I’m confident, when I chose it. I do have a choice, however, regarding how I face the travails and risks that are ahead.

Aristotle thought that courage was the virtue that is particularly called upon when facing fear, and the fear of death in particular. Courage is not only a martial virtue, but is has particular application in battle. Like all virtues of character Aristotle thought it was concerned with feeling and acting neither too much nor too little but the right amount, in the right way, and at right time—a mean between extremes. The courageous person is neither fearless, nor a coward, but feels the fear that is appropriate and acts accordingly in the face of it. As with all virtues of character, Aristotle claimed that we come to be virtuous by imitation. If at first we have to quell an excessive level of fear in order to act in a way a courageous person would, over time so acting may produce results. We may become the courageous person we were imitating.

Curiously, Aristotle thought that courage had no role to play when facing the dangers that manifest as the result of ill health. This might have been true given the health practices of his time, but it’s not true anymore. Aristotle thought that the virtues were only applicable where one has the capacity for choice. No one chooses to be sick. And once sick, in his time, there were few choices regarding care, or how best to live with illness. In the surgeon Atul Gwande’s important book, Being Mortal: Death and What Matters in the End, he writes that “For all but our most recent history, death was a companion, an ever present possibility. It didn’t matter whether you were five or fifty. Every day was a role of the dice…Life and health would putter along nicely, not a problem in the world, then illness would hit and the bottom would drop out like a trapdoor…” People did not linger in death, and they did not live for long periods of time with serious chronic illness. How to live in the face of a chronic disease, how face the risks of medical treatments, how to prepare for one’s steady decline are not questions that people have long asked. But confronting such questions oneself certainly raises the matter of how to proceed in the face of the fear of death.

Patience seems particularly appropriate in regards to waiting, for a diagnosis, for the test results, for a therapy to show some effect, or for some counts to improve. Patience counsels the continued enjoyment of the value that life offers, the value that anxiety about the future eats away. Courage is appropriate once the risks are known, the diagnosis and prognosis are in, or the risky course of care lies before us. Patience is needed in the face imagined risks, courage in the face of real ones. But they have a similar importance, both direct us to the continued pursuit of the value that remains in life in the face of fears that could overwhelm us and could prevent us from the full appreciation of that value.



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Day -2