What's behind the sky?

What's behind the sky?

At age 4, Kaia put this question to her mother. She meant it literally          
of course, but to me it is a beautiful, poetic summation of all the         
Big Questions: What is life? Where did we come from? What happens when          
we die? And just what is behind the sky?

   In this post, envisioned as the first in a series, I want to take up the        
topic of life, death and dying, in particular as it relates to cancer.          
I don't see it as a negative topic; I see it as framed perfectly by my wonderful
granddaughter's question. On the other hand, it means that I will be            
talking openly about the possibility of dying from this cancer myself,          
and I worry that this will be viewed as ``letting down the side'', as           
some kind of breach in the wall of optimism I've erected up until               
now. For me, there is no contradiction between the optimism and a frank         
acknowledgement that yes, the cancer could kill me. And in fact I need          
to think about this because I will likely have a difficult decision             
coming up in a couple of months or so. In any case, if you are                  
uncomfortable thinking about such things, it would be best to avoid this        
particular series of posts.    

One other caveat: It is well-known to those who know me well that I have        
a low opinion of dogmatic religion. Very, very low, approaching zero in         
the limit as time goes to infinity. Here the term `dogmatic'' refers to         
the practice, common to most of the world's major religions, of making          
up random, irrational nonsense which is then advertised as Absolute             
Truth. In a discussion of death and dying religion will inevitably come         
up, sooner or later, and I won't be shy about expressing my opinion.            
Anyone who might be offended by my views on the subject is therefore            
cordially invited not to read the posts entitled ``What's behind the            
sky?''.                                                                         
                                                                                
It will take some time to even reach the sky, let alone get behind              
it. I'll begin with some philosophical---and to my mind, very                   
practical---remarks on living with cancer, and with the prospect of             
dying from it.    

Part I. The Hollywood cancer script and the first stage of grief.               
                                                                                
It isn't really fair to blame Hollywood. Novels as well as non-Hollywood        
films often feature an exchange something like the following, just after        
a patient has been informed he or she has terminal cancer:                      
                                                                                
``How long do I have, doc?''                                                    
                                                                                
``Six months. Maybe a year.''                                                   
                                                                                
This I have never understood. The question is absurd because no one on          
earth can know the answer. Certainly not the doctor, who would be               
well-advised to rethink his or her reply. And for the patient to accept         
the verdict at face-value is even more absurd.                                  
                                                                                
My own experience to date is limited to the question I've mentioned             
elsewhere concerning what would happen if I opted for no therapy at             
all. But even then it makes no sense to ask ``if I refuse all therapy,          
how long would I have?''. I put it to the doctor like this (if memory           
serves, this was the exchange verbatim):                                        
                                                                                
``Suppose I had no therapy at all. What's your best estimate of what            
would happen?''                                                                 
                                                                                
``You could die within three to six months.''   

Well, those are certainly numbers that get one's attention. I admit they        
surprised me, especially the lower figure, since I was then and am now          
still experiencing no symptoms, no pain from the cancer. But my                 
scientific side was almost tempted to call his bluff: ``Okay pal, you're        
on. I'll bet you a million dollars I can make it longer than six                
months.'' Now I'm joking, of course, but I am curious about it. Even            
granting that cell division is a textbook example of exponential growth,        
from ``feeling great'' to ``dead as a doornail'' in three months would be an    
impressive demonstration indeed.                                                
                                                                                
It isn't a hypothetical issue, which brings me to the ``difficult               
decision'' alluded to above. I am going to be under considerable pressure       
from the oncology team to undergo a cystectomy. Their strategy is that          
the chemo reduces the cancer to a confined state within the bladder             
itself. Then one removes the bladder, along with any cancerous lymph nodes      
nearby. The risk of foregoing this step is that the cancer can return,          
and return aggressively. But it can return anyway, and there may well be        
suspect lymph nodes that are too scattered through the abdomen to remove        
them. For these and other reasons, it doesn't sit right with me to give         
up the old bladder without a fight. I would rather pursue the chemo as          
far as it will go, then turn to alternative approaches. 
Up to now I have had only brief discussions about this with the                 
oncologist and the nurse practitioner. Judging from body language,              
expressions and one or two comments, I'm certain that they view me as           
being in ``Denial'', that is to say in the first of the Five Stages of          
Grief (originally applied by Kubler-Ross to death of a loved one, but           
now commonly applied to learning one has cancer). This too is part of           
the Hollywood Script. But let me be clear: At no point in the process           
have I been ``in denial''. I have been and remain optimistic, but for           
me, it is equally important to avoid the fundamentally arrogant error of        
pretending that cancer only kills other people. In the journals of Lewis        
and Clark, one of them (I forget which) makes a statement that has stuck        
in my mind ever since: ``It is a sin to anticipate evil.'' A great              
attitude, but it doesn't mean that they set off into the wilderness             
unprepared. Trust in God, but be prepared for the Devil.                        
                                                                                
If I go against the doctor's recommendation, it will be with eyes open,         
knowing that if my choice fails there can be no regrets, no ``damn, I           
wish I'd had my bladder cut out''. Of course the cancer can kill me, no         
matter what path I choose. There is no denial. But in the meantime, I'm not     
going to anticipate evil.                                                       
                                                                                
I'll talk about the ``second stage'', anger, in a subsequent post. First        
I want to talk about another emotion associated with cancer: fear. Fear         
of dying, fear of chemotherapy, fear of the unknown.  

Far-fetched though it may sound, my days as a rockclimber have been a           
great help to me in this department. To explain this, I need to first           
describe the two major forms of rockclimbing---free climbing and aid            
climbing---as well as a third, less popular form known as free-soloing.         
Both free and aid climbing use ropes and other equipment. The difference        
is that in free climbing the equipment is there only as a backup to             
catch you if you fall, whereas in aid climbing it is also used to aid           
your upward progress. Free-soloing means climbing with no rope at all,          
in which case the consequences of a mistake are unequivocal: you fall,          
you die.                                                                        
                                                                                
In all forms of climbing, fear management is important. In free-soloing         
it is essential. If you're going to be scared on a free-solo, don't do          
it at all. I've done a fair bit of free-soloing in my day, including for        
instance a route called ``The flame'' near Leavenworth. I was familiar          
with the route already, and only one move on it concerned me, a little.         
It wasn't a hard move but involved stepping across a gap with a small           
assist from gravity, almost falling forward in one big step. I might            
have been over-dramatizing the situation, but it seemed to me at the            
time that the move was irreversible, and therefore once across I would be       
committed to finishing the route (it ended at the top of the cliff; then        
one can just walk down around the side). At that decision point there is        
some anxiety, if not actual fear. But once across, there is nothing to          
fear at all. You are committed. You can only go up. Take it one move at         
a time, and enjoy. (It was awesome, by the way, one of the most                 
exhilarating experiences of my life.)

I did very little aid climbing, as it is too slow and I don't like being        
so dependent on the equipment. And indeed sometimes, you are totally            
dependent on it. I still vividly recall a climb in Zion National Park,          
on a fortress-like rock peak called the Watchtower. I was climbing              
second on an aid pitch. In aid climbing it is common for the second to          
not climb the rock at all, and to instead speed things up by climbing a         
second rope, anchored above by the leader, using mechanical                     
ascending-devices called jumars. What was unique about this particular          
pitch, for me, was that it was severely overhanging. This means that            
once you release your own anchors and step onto the jumars, you will            
swing out into space, away from the cliff. At that point you are totally        
dependent on the rope, obviously. You fervently hope that it has been           
well-anchored by the leader (hmm...I haven't said anything to offend Al         
lately, have I?). Now, because of the overhang the leader and                   
I can't see each other, and neither of us can see the full length of the        
rope. As I began my jumaring I couldn't help thinking of the                    
possibility---remote, but possible---that unbeknownst to us, somewhere          
above me the rope had passed over a sharp edge, and my ascending motion         
was gradually sawing it in two. There was no fear, however. I was               
committed, the rope was hanging well away from the rock and there was no        
way to turn back. In the unlikely event of the worst-case scenario, you         
are dead for sure, but why worry about it? You can only go up. Just             
relax, take one step at a time, and enjoy the beautiful view of Zion in         
spring.

 My point is clear enough, and it is the same with cancer. There can be          
considerable anxiety at the branch points of the decision tree, but once        
the decision is made there is no point in worrying, no point in being           
scared. At the moment I am committed to chemotherapy, probably for many         
more weeks. Why worry about the outcome? At this moment, I'm fine. Life         
is good. There is nowhere to go but forward.                                    
                                                                                
In one variant of the Hollywood Cancer Script, the person with ``terminal''     
cancer rushes about trying to do all the things they always wanted to do        
in life but never did, to fulfill their ``bucket list''. Nothing wrong          
with that, but I would take a rather different view, namely, to just keep       
doing the things I normally do: spending time with friends and family,          
doing mathematics and teaching it, doing Italian, going on hikes,               
etc. etc. This would be true even if I were told my cancer was                  
``terminal'', because even if that were so, what has really changed? It         
is written from the day we are born that we are going to die, but do we         
let this stop us from going about our daily life? The point is made by          
Robert Louis Stevenson in his fable ``The sinking ship''. I first came          
across this short tale in ``Zen in English literature and oriental classics'' by
R.H. Blyth, to which I was introduced at age 20 by friend and one-time          
climbing part Roger Schlatter. You can easily find the complete story           
online; here I will just give a couple of excerpts.

``Sir,'' said the first lieutenant, bursting into the Captain's cabin,          
``the ship is going down.''                                                     
                                                                                
``Very well, Mr. Spoker,'' said the Captain, ``but that is no reason for        
going about half-shaved. Exercise your mind a moment, Mr. Spoker, and           
you will see that to the philosophic eye there is nothing new in our            
position: the ship (if she is to go down at all) may be said to have            
been going down since she was launched.''                                       
                                                                                
In the powder magazine they found an old salt smoking his pipe.                 
                                                                                
``Good God,'' cried the Captain, ``what are you about?''                        
                                                                                
``Well, sir'', said the old salt, apologetically, ``they told me as she         
were going down.''                                                              
                                                                                
``And suppose she were?'' said the Captain. ``To the philosophic eye            
there would be nothing new in our position. Life, my old shipmate, life,        
at any moment and in any view, is as dangerous as a sinking ship; and           
yet it is man's handsome fashion to carry umbrellas, to wear                    
india-rubber over-shoes, to begin vast works and to conduct himself in          
every way as if he might hope to be eternal. And for my own part I              
should despise the man who, even on board a sinking ship, should omit to        
take a pill or to wind up his watch.''   

I don't plan to go down any time soon, with or without a ship. But              
suppose I did? To the philosophic eye, there would be nothing new in my         
position. I have no watch to wind, but I'll keep recharging my                  
cellphone. There is nowhere to go but up, free-solo if I have to.               
                                                                                
To be continued: ``Anger, self-pity and other delusions''.