In the midst of life we are in death.1 Any of us can drop dead at any moment in time. It used to be common thus more obvious.
Cardiologists Michel Accad, Anish Koka and their guest John Mandrola released a program “Adventures in Fibrillation” about a man named John who died2 suddenly during a mountain bike ride, was successfully revived without any complications that affected his personality or ability to be/think/talk/remember/eat/drink/move.3 A doctor recommended to him to implant a defibrillator into his body, a device that would discharge electricity to “shock” his heart if it beats irregularly4 into a normal5 heart rhythm or make an attempt to “restart” his heart if it suddenly stops again.6 John decided to forgo this treatment.7 The program details some of the thinking behind John’s decision and opinions of three physicians on this rather unusual case in the present day US.8
The discussion started with a very much alive resurrected John retelling the story of his death and mysterious intact revival. Three physicians interpreted the events through the means of technology and deliberation of John’s rejection of medical salvation in the future in terms of anatomy and physiology,9 power,10 law,11 ethics,12 and values13 of modern American society. John spoke as a living breathing man who needs, desires, loves, and infuses meaning14 into what gives him will to live.15
What I will present is incoherent.16
Reality is not more complex than we think, but more complex than we can think.17 What we watch and listen18 to in the episode presents a curious mix of seen and unseen, known and unknown, past and present, felt/sensed and imagined, concrete and abstract, certain and uncertain.
I want you to understand that what we hear is a retelling of the events in the past. Each speaker occupies a point from which he looks at the events of the past - from a point of view. The details we hear are selected, consciously or unconsciously, by each speaker by their understanding of what merits attention. What is unsaid?19
I want you to be aware that what you see, hear, and interpret is yours. What I present here is mine. It is what we call “subjective” - a subject that comes up during the program.20
I want you to understand the difference between “John21 is lying dead on the side of a mountain road in California with a bicycle laying by his side”22 and “John was lying dead…” and “John was lying dead… and was revived by passersby”. What is the difference? What was reality? Pause. Imagine. Think.
I want you to think what an event in the past means to John here and now. What does it mean to John when he imagines the future? What do the same events in the past, John here and now, and an imagination of John’s future mean to a cardiologist?
John is forced to make a decision in crossfire of the old ways of being and new means of existing.23 John forgets what he knows - “I’ve really put it out of my mind” and hopes “I accept that [the possibility of sudden death in the future] but I don’t think it’s gonna happen”.
The reality is what we see sense. Here and now. John is alive. Happy. Smiling.
The ability to hold multiple sensed realities in past and present while simultaneously holding many abstract ideas about how knowledge and reality is constructed, should lead you to a simple question that nobody asked of John:
QUO VADIS? WHERE ARE YOU GOING?
Addendum. 10/04/2021. The unsaid.24
Media vita in morte sumus (in the midst of life we are in death) is, supposedly, an 8h century anitphon, or a 9th century battle song that became a common dirge and a song of supplication on all melancholy occasions by 13th century. The antiphon was credited to Notker Balbulus by the St Gall historian J. Metzler in 1613, with a story about workmen building a bridge and placing themselves in danger; but this attribution is insecure. It was found in Germany in the Middle Ages as ‘En mitten in des lebens zeyt’ and as ‘Mytten wir ym leben synd/ mit den todt umbfangen’ (Wackernagel, Das Deutsche Kirchenlied II. 749-50).
The theme of dying in the midst of life in popular culture:
Templar chant Media vita in morte sumus (with lyrics in Latin and English translation). What does the author ask of God?
The Highway Men Highwayman - is a song written by American singer-songwriter Jimmy Webb, about a soul with incarnations in four different places in time and history: as a highwayman, a sailor, a construction worker on the Hoover Dam, and finally as a captain of a starship. The song was influenced by the real-life hanged highwayman Jonathan Wild. What is the meaning of incarnation for Jimmy Webb who wrote the song? What is incarnation for a Baptist Christian?
Did John die? The definition of death is ambiguous. It was not so for most of history. What happens when your heart and breathing stop? What is cardiac arrest? What is the difference between a stopped heart and a cardiac arrest? Is there a difference? Who decides that someone is dead? How did death change in the course of history? How many times do you want to die? Did this question ever exist before today?
Cardio-pulmonary resuscitation (CPR) is a technique that we use in an attempt to make a heart that stopped beat again to revive (what used to be for all history) a dead man. We compress the chest to make the heart “pump” as if it were beating as well as breathe into a mouth to force oxygen into your lungs to make sure that oxygen gets to the brain. (Cf. And the LORD God formed man of the dust of the ground, and breathed into his nostrils the breath of life; and man became a living soul.) When oxygen does not get to the brain for some undefined time, you will change. We use arbitrary 2-3 minutes that start the clock of “poor prognosis” that we call “neurological damage” or “brain injury”. Prognosis is a prediction that may or may not happen in reality that we sense.
Neurological damage or brain injury mean nothing to you but mean a lot to those who have witnessed what it looks like in reality. You may have a random combination or complete set of the following: you may not know who you are, where you are, and have any idea about time. You may not be able to remember some or all of your life. You will not recognize or remember any of your family. You may not be able to move parts of your body, that means you may be paralyzed. You may be incontinent of urine and stool involuntarily rely on others to clean you if or when they notice. You may not be able to swallow well or at all. That means you won’t be able to eat or drink what you like for a period of time or ever again. You may not be able to eat at all and will sustain your nourishment through a tube inserted into your nostril or a tube inserted into a hole cut into your stomach. You may become a man nobody recognizes - who and what you are, your personality will be gone. Your arms and legs may get contracted and hurt. You may have seizures. You may not be able to see well or go blind. You may not be able to speak, understand, or both. Your head may hurt. You may feel dizzy or feel like an astronaut with no sense of balance or coordination. You may be constantly anxious or have panic attacks.
Did the ER nurse and surgeon with other bystanders understand the implication of reviving a dead man? What are the chances that these two people have seen the final results of reviving dead people? Did they study this issue? Did they look at research? Is it logical, customary, or ideological?
Based on the John’s outlook about living and dying after the cardiac arrest and post-workup, would John want to be revived? Would he want to be revived in view of the upcoming wedding? Just that one time?
Can you imagine a movie with a point in time and place that signifies a bifurcation in history that proceeds in different scenarios based on what we do not do or do? Did people in history decide if they wanted to die or not? Did people think they have power over who lives and who dies in circumstances like John’s? What is the significance of an American writing Advanced directives and deciding if he wants to be revived or allowed to remain dead (do not resuscitate or full code designation in hospitals).
When most people hear or feel irregular heartbeat, it means absolutely nothing, unless it makes them feel bad in the moment. To a physician an irregular heartbeat on an EKG strip means a bunch of conditions they imagine may happen based on what already happened to some people with the same irregular heartbeat.
What is normal? Can a man with a physical or physiologic abnormality live well without medicine? Do they?
What does it feel like to have a surgery? What does it feel like to be shocked at random? Note the unsaid. The absence in the conversation.
Why did John forgo the suggested treatment? What was the treatment for? Note what Dr.Accad speaks about at the end of the program - prevention of a future event. What is unsaid - that may or may not happen. Does John have a problem now? If yes, according to whom? What is the criteria for establishing a problem? Does John think he has a problem? If so, what is the problem? Does a cardiologist think there is a problem? Is it a problem now or imaginary future?
How many people live with he same type of heart and never experience any issues? Do we know? How does imaging technology create disease? Would we have faced this issue 40 years ago? Did this diagnosis exist 40 years ago? Notice the words along the lines of “pushing well beyond my limits”. Why are extreme sports so popular today in the US? Did extreme sports exist in the past? When and under what circumstances? Does the habit of killing pain contribute to seeking pain? What is the meaning of pain? Notice the word pain come up several times during discussion.
Ivan Illich. Killing of Pain. The writings of Illich touch upon the subject of limits - Medical Nemesis. Limits to Medicine. How does American psyche related to the notions of proportion and within limits. What is “more” for an American?
Anatomy and physiology that is created by making static snapshots with tests of reality in a moment in time (it changes in physical reality ), as interpreted by a fallible man (note Michel pointing out the difference between MRI and biopsy to establish the composition of heart wall tissue).
Who, when, and why has the right to make decisions about treatments, living, and dying?
Note the hospital holding John hostage until he agreed to a life vest. Was it legal? Against medical advice is a phenomenon. What did doctor’s do to manipulate John into agreeing? How did they use his family as a trump card?
Note the repetition of coached by US legal system “informed” decision that John is allowed to make. It is a prayer like repetition “completely and utterly informed” with strong emphasis over a short period of time during discussion. Informing comes down to presenting statistical data about risk reduction, all abstract notions that majority of experts cannot accurately interpret themselves due to their very abstract nature. We are not good at abstraction. We are not good reading and understanding what we read. This is how bad we are in abstract thinking. A layman outside of the profession has no means of understanding the imaginary “reality” created by abstract calculations. What are the consequences of knowing? What happens when you know too much? Much knowledge brings much sorrow. What do we make of that? What do you do when knowing too much prevents you from living? John answers this question in the program.
Save life, death as defeat, treatment at all cost that often amounts to torture. Ideology that presents as ugly reality. Good taken to a limit-less extreme reveals the mystery of evil.
Do note Anish’s infectious laughter when he hears John make a break from the hospital when ER/ICU physicians attempt to save him with a defibrillator or at least a life vest. Also notice that John, who is knowledgeable well beyond the level of an average American fails to make sense or remember many of the names of the manipulations performed on him (a wire something, which was an angiogram).
John’s wife appears to share the same values as evidenced by her behavior as retold by John. These values are in clear opposition with ER/ICU physicians’ who are doing something that makes sense to them but not to John. The unsaid. This issue does not exist in cultures with unspoken values that are shared by all. The necessity to talk profane and sacred, which death certainly is, may not be necessary under those circumstances. The nature of death discussions can range from acknowledging death and means to make peace with this reality (see the chant) or acknowledging death in legal context of the US when talk of death can sap the will to live. It would be cruel to tell a man he is going to die in many cultures but a legal context of the US hospital makes it a necessity that is good and ethical. Dr. Mandrola brings up the goodness of contemplating our own morality as “life-giving” when he speaks as a man as opposed to a physician with a duty to a patient who may come from a different background. Dr.Koka touches upon this variation in patient attitudes as well.
Can you write a computer program to hold complexity of known and unknown reality here and now as residing in a breathing man? It is an incomplete analysis of a one hour conversation. To encompass the span of everything that takes place would take more time that I can afford.
A paraphrase of “Nature is not more complex than we think, but more complex than we can think” written by Egler, F. (1977) The Nature of Vegetation as quoted in Weaner, L., Thomas, C. (2016). Garden Revolution. How our landscapes can be a source of environmental change.
If you want to listen the program first as a podcast then watch it as a Youtube video, you will probably notice a large difference in your perception of what takes place. A feeble breaking voice of John (he must be quite frail) will be adjusted by the fact of video delay and distorted representation of John via technology. He is in fact quite vibrant and very alive. You will be illuminated by the glorious smiles of each participant. Notice how differently each smiles. If you happen to think of doctors as evil goblins, Anish, Michel, and John are extremely likable. Imagine how much we miss by not knowing them as men in flesh. The “unseen”.
When we speak, those who hear us do not know or understand where we come from. What shapes our literal point of view. All three physicians share something in common yet each of them has a different history as you can tell from their names, accents, looks, what they say. How does a perspective of a man in flesh who lives differ from a physician who is an outside observer of the unseen “something” as created by imaging technology. Listen to two Johns, both cyclists, who share an idea of “a good death”. Notice the deviation within one man from a very strong imperative of John the Physician (a person, the word that comes from Latin that means an actor behind a mask) to inform of the “consequences” of “choices” to John the Man (a being behind the mask, the person) who finds the reality of living appealing.
What is truth? What is knowledge? What is objective? What is subjective? All of these are unsaid questions that permeate the program from all participants. Dr. Accad brings up the philosophical question of the nature of diagnosis. See “What’s a diagnosis about? COVID-19 and beyond”
John observed that specialists see what they expect to see. How does our history and worldview formed by education force us to see what somebody else wants us to see? What do we not see? How will reality of John’s situation here and now change if he and the doctors went only by the sensed reality of what John experienced in his body and what doctors can observe with a naked eye and feel with with their hands? What happens if we “unsee” the MRI and the EKG and dwell in what we can sense?
How do we know what we know? John goes extensively into description of his sensations, how they correlate with technology, how technology captures something he does not sense, and how he reconciles these two realities - one physically sensed, one created by technology.
Who John is when we listen to him now (when the program was recorded) is different who John was on the fateful day of his death when he was revived. During the episode that we listen to we see a slim man with a beaming smile reading notes (he can write and read). He is 61, healthy and fit, has been into sports all of his life, takes care of himself, he is married, his daughter (Is she the one who is a physician? Is she the only daughter?) got married two days after he had the fateful event that is the subject of the program, he used to be an avid runner but he gave it up because it was hurting his knees, he enjoys the pain of exertion from mountain bike riding.
His grandfather was and his brother is a physician. He says he respects physicians based on his familiar relationships. (What is respect? How does what we say correspond to what we do? How is respect manifested in behavior?). John declined knee replacement and thyroid surgery in the past. He explains why and describes the results of not only questioning but refusing medical treatments. The question that nobody asked - why did he question doctors at that time? What knowledge or experience brought him to the point of questioning an authority that he claims to respect? Is questioning authority disrespectful? How much of what we say is to appease those who listen?
He uses gadgets to monitor his internal functions and tracks the numerical and graphical output of his biometric functions. He interprets it in some way that makes some sense to him. (How? What sense does he make? Does it make sense? To whom? Is there any use of it? How does it change John’s perception of self? Does it inhibit or enhance his sensing of self as a physical body? Does it inhibit or enhance his sensing by altering what bodily sensations he is focusing on? Was he ignoring any sensations in the absence of electronic tools? Why? Why not? Note that Dr. Mandrola gave up the use of the same tools for his own reasons (what were they?).
Would we say that John “believes” in science and medicine? What does his behavior indicate? Does his education make him well integrated into modern society and able to use medicine as intended? Why is there such good understanding between the physicians and John?
The meaning of this fact of reality is different for John at that moment in time in the past (he had no awareness of it, listen to him describe the events from his point of view) as opposed to a passerby who found him dead.
John must reconcile his feeling now, with his story of the past, what technology reveals that would be otherwise unseen to him, what physicians forecast based on sparse statistical data that cannot be applied to John because he is not the average of the people in the samples that provide the data. “I’ve really put it out of my mind.”
Some of the issues were mentioned in passing or not mentioned but implied:
insurance and payments. How financing affects medical research and treatments.
do something approach to avoid quick and sudden death in favor of slow and expected death that medical treatments produce
body as a machine and mechanical approach to solving problems contrasted well by John’s going “blind” by feel
the way of talking about the problem - focused on sensing and values for John and dry technical language of physicians - that shapes thinking and what solutions are acceptable
treatments and fixes that are unacceptable to patients for any reason and lack of knowledge, skill, or desire to come up with solutions within the framework of John’s understanding of living, dying, and acceptable solutions. In this case John is masterminding his own fortune which is very much in style of Ivan Illich - bearing your own reality. John has the capability to solve his problem at hand. How many don’t? How many face “my way or highway” in healthcare? How many physicians are willing to learn from John and suggest his way of coping with his reality to other patients as an option? How many are willing to learn another way of looking at a problem and work from the outside guided by man’s sensations without relying on technology?
John’s traditional mindset and will to live as is (today we call it courageous or having high tolerance for risk and uncertainty) that presents a gift to any physician to see a traditional way of coping with the reality of living with some malady and adjusting to carry on without relying on medicine or advanced professional technology.