Life’s Like That

Why is Life so hard to define? When I was in school, it was easy –as mentioned in a BBC article on the topic: -Life was MRS GREN (Metabolism, Reproduction, Sensitivity, Growth, Respiration, Excretion, and Nutrition). That’s all you needed for the exam –although I’m glad they never asked for an explanation of Sensitivity. But times change, and as do definitions, so by the time I was in university, I was confused. Every faculty had its own perspective –chemists defined in terms of chemicals, biologist preferred DNA, and physicists were partial to the dynamics of molecular properties that bypassed structural components in favour of information transfer.

Me? I wandered around a fair amount in my undergraduate years before I ended up in Medicine so, already rainbow-hued, I opted for a just-right-baby-bear definition -not too much of anything. By then, I understood that Life was an amalgam –but the product and not the recipe. The final taste, and not the way the ingredients are cooked. Telos, I suppose, rather than methodos– words sufficiently nebulous as to dissolve in most of the more erudite proposals. To me, Life is a story – scilicet, a spirit-  and one whose progress is tied to the outcome. We humans are requisite classifiers and groupers –itself a story- and we thereby miss the uniqueness of entity, the magic of identity; for us, something is either alive or not. Black or white. It’s an important distinction to be sure, but as I said, it misses the pungency of the flavour. The excitement of the effect. The Proustian Phenomenon of the madeleine biscuit soaked in tea… My route explains nothing, I’ll concede, and yet somehow, it’s what makes it Life, and not something else.

But I was always hopeless at philosophy, and despite my zeal for it, perhaps wisely accepted parental advice and wandered off into Medicine and eventually a career as an obstetrician/gynaecologist. I suspect they were concerned that otherwise I might end up living with them at home.

From time to time, however, I am still tempted to wax lyrical on Life with the occasional patient who seems to require some additional prodding with regard to their own. I can’t say I’ve achieved any truly publishable results, but the process is nonetheless enjoyable for me on those otherwise interminably complaint-ridden days that crop up from time to time.

It usually requires a stimulus –an opportunity when my input would not be construed as an imposition on their time with me.

Janet, for example. She was a forty-one year old woman who had pursued her own career as a lawyer at the apparent expense of a stable relationship. Intelligent, and attractive, she had finally ‘decided to accede to an intimacy request’ from an acquaintance –that’s how she put it- and when she had first made the appointment had wanted some advice as to how to avoid pregnancy. Her would-be partner was an older man who had not felt comfortable using condoms however. So he hadn’t. And she was. Not only that, but she was confused about it.

“Doctor, I’m almost forty-two years old, and despite the occasional ‘dalliance’ I’ve never been able to become pregnant…” She stared at me like I was somehow to blame for the vagaries and vicissitudes that had befallen her.

I could almost see the quote marks around her word ‘dalliance’. “You said ‘able to become pregnant’, Janet. Were you trying?”

She shook her head almost before my question reached her, but I could tell by her expression that she wasn’t sure. “Life is such a precious thing… I’d want to be sure about everything…”


“Like whether I could care for it. Whether I would regret whatever decision I made about a pregnancy I hadn’t planned.” She didn’t even mention what effect the father might have on the process. “So…” she thought about it for a second. “…So I suppose I’m happy I didn’t have to make that decision before…”

“And now…?”

She shrugged and sent her eyes, like beggars, to ask my face for something –wisdom, maybe; suggestions, at least. “I mean, what are my chances, doctor?”


“You know, that I won’t miscarry anyway. Remember, I’m forty-one now… And there’s also a risk of genetic malfeasance, isn’t there?”

Even though I have many lawyers as patients, I’d never heard the risks of pregnancy in an older mother put quite like that… I’m definitely in the pro-choice camp, as she well knew, so I realized she wouldn’t think I was trying to sway her ultimate decision no matter what I said. But still… “We can do the usual prenatal testing to identify any genetic problems beforehand, Janet. And yes, miscarriages are more common with pregnancies in older mothers…”

Her eyes grasped at the hems of mine like supplicants. “And if I were your daughter…?” I knew I had to be careful then -she was asking for an opinion, albeit framed as a personal one.

I sighed and sat back in my  chair. “A new life is a new story, Janet –a bit of yours, a bit of the father’s- but at this stage, most of it is still an idea somewhere. It doesn’t have to get written to qualify –we all have ideas inside when we stop and think about them. We write down some of them, I suppose but sometimes even then, we just can’t get the wording right. Or the idea, once on paper, doesn’t seem what we thought. Remember, a story is no less a story for not being completed, and no less a creation for not being read… But sometimes, you just have to take the chance that you’re on to something.”

Her eyes flew away and settled on her lap for a moment. “You’d make a great lawyer, doctor,” she said, with a mischievous smile, her eyes back on mine once more. “Obfuscation is something they just can’t teach…”

I’m not sure she followed my argument so I risked a little smile. “Isn’t it what you do when there really is no case to be made beyond a reasonable doubt?”

She rolled her eyes and chuckled. “I don’t take cases like that anymore.”

I suspected she hadn’t this time, either.




Earthing Unearthed

Sometimes I feel disconnected. It’s almost as if I have been traveling on a highway all my life, largely unaware of the myriad roads that emanate from it. Unaware of the different coloured horizons that have been hiding out there all along. Or is skulking sometimes a better descriptor? Every so often I come across a concept so… bizarre, that I wonder how it even survived long enough to acquire a name. ‘Earthing’ caught my attention immediately.

I feel I have to explain that I don’t go looking for these things, but in the spirit of full disclosure I will confess to being a one-time member of the Skeptics Society –one time, I suppose, because the time constraints of a busy medical practice required that I relinquish at least some of my addenda. Now, retired and awash in compensatory time, I dabble once again.

‘Earthing’, for those of you as naïve as myself, is the act of walking barefoot –not just on the beach or over the soft grass of a lawn, however. It is to soak up earth’s energy fields previously denied to you –blocked, in effect- by your shoes. These energy fields apparently supply free electrons replete with many health benefits. Shoes, as disruptors, ‘[…] allegedly cause inflammation and autoimmune diseases, circadian rhythm disruptions, hormonal disorders, cortisol disorders, heart rate variability problems, arthritis, herpes, hepatitis, insomnia, chronic pain, exhaustion, stress, anxiety, premature aging […].’ Uhmm…

How could I have journeyed so far along the trail of years and not heard this coming up behind me? Call me old fashioned, if you will –or just ‘old’, perhaps- but I would still feel more comfortable if there were credible, corroborative and objective evidence to substantiate assertions before I even decide to consider them -let alone examine them seriously… Anybody can claim things, but as Carl Sagan once declared: ‘extraordinary claims, require extraordinary evidence’.

Now I have to say that just because something seems counterintuitive, I don’t think it should be simply dismissed out of hand. Paradigms do shift, after all. But they still require critical analysis; it is not enough to suggest that, as in the case of homeopathy, for example, any attempt to verify it destroys the field in which it exists. Nor are statements like, ‘It may be that our connection with the earth carries information, helping align us with the greater network of intelligence of our planet.’ either provable, or refutable –the famous philosopher of Science, Karl Popper’s belief that what distinguishes science from pseudoscience is its potential for refutation. For example, to say that all swans are white, only holds until a black one is found. The assertion –if properly attested by observations- is scientific in that the demonstration of even one black swan is able to refute it.

But, academic considerations aside, there is something troubling about ‘Earthing’ and its ilk. That something like this arose at all is, I suppose, a function of the random accretion of isolated and misunderstood bits and pieces of our complex modern world that are only describable in metaphor –as in, say, electrons are the carriers of electricity. True, as far as it goes, I guess, but misleading if taken as literal. Maybe some shoes –all shoes?- may block electrons… But so what?

Just try and understand the electric fields on the earth and in the atmosphere. As an example, a description from (shudder) Wikiversity: ‘The Earth is negatively charged, carrying 500,000 Coulombs (C) of electric charge (500 kC), and is at 300,000 volts (V), 300 kV, relative to the positively charged ionosphere. There is a constant flow of electricity, at around 1350 amperes (A) [approximately 1100 A], and resistance of the Earth’s atmosphere is around 220 Ohms. This gives a power output of around 400 megawatts (MW), which is ultimately regenerated by the power of the Sun that affects the ionosphere, as well as the troposphere, causing thunderstorms. The electrical energy stored in the Earth’s atmosphere is around 150 gigajoules (GJ). The Earth-ionosphere system acts as a giant capacitor, of capacity 1.8 Farads. The Earth’s surface carries around -1 nC of electric charge per square meter’. Do you see why most of us non-experts are dependant on metaphor? And why explanations such as this about ‘constant flow of electricity’ unaccompanied by suitable annotations may lead to some unfortunate and perhaps misguided applications?

On the other hand, I think that trying to dissuade gullible adherents requires some tact. Attempts to ridicule them by referring to the authors of a book on the subject: Earthing. The most important health discovery ever? and saying ‘None of the book’s authors is a physicist— it shows.’ is just ad hominem. Or suggesting that scientific credentials are not available: ‘The studies were not published in mainstream journals. They involved small numbers of subjects and usually failed to use any controls.’ While true -and to those of us with any acquaintance with how science works, compellingly obvious- it likely fails to convince those who mistrust the scientific paradigm and its lack of certainty to start with. And it may antagonize them to the point of utter rejection of any meaningful dialogue. It becomes another us-and-them standoff.

So, what to do? Tolerate or proselytize? Divide and conquer? Provoke and legislate…?

Perhaps it’s my age, but I’ve seen many fads arise and then dissipate like waves on a beach, with any one of them having about as much individual significance. Think of alien abduction, recovered memory therapy, pet rocks… Each seems to have a brief super nova-like appearance, and is intriguing for a while, and then, when a new star is born, interest flags. Social media may extend the lifespan, perhaps, but novelty is usually trump for those attracted to the fringe belief realms. I’ve learned not to obsess on what I consider the irrational; I will attempt to educate, but not to the point of taking arms against a sea of trouble and by opposing, ending them –as Hamlet would have us decide. If they are not harmful, then they will, as certain as the tide, recede.

In the turmoil of this uncertain world I think we all try to find secure and novel refuge, and when the storm has passed, set out again. It’s what we do –Shakespeare again: ‘Wise men ne’er sit and wail their loss, but cheerily seek how to redress their harms.

Earthing, with benign neglect, may itself be unearthed…


What is it like to be a…?

I should have known not to answer her question like that. I should have seen the book she was reading; I should have seen how heavy her briefcase was… But I’m getting ahead of myself.

I’m a doctor now -an obstetrician/gynaecologist- but in the beginning I wanted to head in an an entirely different direction: philosophy. And it has remained in the background, nagging at me from time to time -always superficially, of course. My adventures were often confined to a simplistic skimming of the surface of the words, with their all too frequent academic double entendres escaping me completely. But nothing ventured, nothing gained, eh? And I did learn a lot of new phrases that I found I could sometimes slip into my consultations…

Usually I would get away with the occasional philosophical nuance, but I could also be careless at times. One has to be cautious with new patients; there are signs that should be read. For example, it is common sense never to wax philosophical with anyone carrying a heavy book and wearing unstylish, heavy glasses until you know them better. To ignore this maxim is to court embarrassment –or worse, acknowledgment that a boundary has been crossed.

Sandra exhibited all of the danger signs as she sat engrossed in a tome sufficiently heavy to require both knees to support it. A young looking woman with short brown hair and a blue skirt and blouse, she looked as if she were deeply concerned about the meaning of something on the page and as I watched from behind the front desk, she both underlined it and then wrote something in the margin. Even at that distance, I could see she was deadly serious about it. I debated for a moment whether or not to give her additional time to finish her deliberations and see another patient first, but just at that moment she spotted me and smiled.

“Sandra,” I said, walking over to her and wondering how she was going to manage to shake my hand and keep the weighty book safe from the floor.

But she managed it with the skill I would have thought only an older and more experienced scholar could aspire to. And then with a quick, practiced sweep of her other hand, she realigned her glasses further up on her nose, without dropping either the book or her smile in the process.

After that, she, the book and her briefcase followed me to my office and all three of them found a space across from my desk. Once settled, she scanned the room with curious eyes which flitted about like a pair of barn swallows but finally came to rest on a little carved wooden effigy of an African woman holding a baby in her arms.

“What’s it like to be an obstetrician,” she said after examining the woman for a moment.

Although the question seemed simple, it caught me off guard, for some reason and I was suddenly struck with the difficulty of answering something that really had to be experienced to be conveyed, let alone understood. It was almost like trying to describe what its like balancing on a bicycle, or what it would be like to be a police officer walking in a dangerous neighbourhood. It’s a subjective thing that can not accurately be described from the outside.

I’d recently been reading the famous 1974 paper by Thomas Nagel entitled ‘What is it like to be a bat?’ in which he confronts those who would attempt to answer the question by resorting to either physicalism (the idea that everything can be explained by some sort of physical process) or reductionism (by and large that the whole is equal to the sum of its parts):

I have to admit that I succumbed to the temptation of pretending I understood more of what he wrote than I did. “What is it like to be a bat?” I said -it just slipped out before I could stop it. I suppose that somewhere inside I was thinking I was being clever and that I could then throw out a loose reference to Nagel’s paper –something like his ‘To the extent that I could look and behave like a wasp or a bat without changing my fundamental structure, my experiences would not be anything like the experiences of those animals.’ And so, their experiences being totally alien to me, I would not be able to describe them in words.

But as soon as I said it, I could see by her expression that I had inadvertently crossed a border into the country where she lived. A country where I, perforce, had become a bat. Her bat.

Her eyes immediately hummed with interest. “Fascinating you should ask that,” she said, choosing her words almost as if she were trying to keep them simple –much as we might when speaking to someone from another country. Another culture. “It’s difficult enough to describe what we do to someone in a different field, but an order of magnitude more difficult to describe what it is like to do it…” She smiled disarmingly and then continued. “As Nagel said,” and here she reached down and picked a somewhat lighter book from her briefcase and thumbed through it- ‘Our own experience provides the basic material for our imagination, whose range is therefore limited.’ He picked bats instead of wasps or flounders, he says, ‘because if one travels too far down the phylogenetic tree, people gradually shed their faith that there is experience there at all.’ I suppose he could have chosen dolphins or orcas but… whatever.”

I felt encouraged at her use of ‘whatever’. I thought maybe I could change the subject, but she immediately launched into a description of her position on his argument.

“Me,” she said as if we were sitting in a university lounge discussing the issue over a coffee, “I subscribe to a more intermediate position between reductionism and pure physicalism. I would put myself somewhere in the epiphenomenalist camp.” She looked up from the book and sent her eyes on a brief mission to study my face. The report was evidently not encouraging, so she decided to explain. “Epiphenomenalists posit that mental states are byproducts of physical processes –much as energy and its ability to do work are a product of, say, a steam engine boiling water.”

She carefully replaced the book in its briefcase-vault and stared at me again. Then she shrugged and a mischievous expression gradually conquered the previously academic one. “I think I will rephrase my original question and let you get on with your job. Do you enjoy being an obstetrician?”

“It’s sometimes Hydra-headed,” I said without thinking, and then quickly hid behind the computer screen when I saw her eyes light up once again.

A Gift of Age

Is philosophy a reward of age, or is age itself a gift that metaphysics merely opens: Weltanschauung? Is it just that there is a time when thoughts flow along different and unaccustomed neurons? Or are they maybe shunted to the diminishing residua of nerve cells that are still firing? I ask myself these questions sometimes when night closes in and stimuli flee. At times like this, I wonder if the weight of years are more hindrance than benefit. Less a present, more a penalty.

When viewed from outside the prevailing ethos, age –especially its accumulation- is a gift. A bonus on the journey from which only the very young think they are exempt. And despite the mounting detritus of discarded cells and greying hair, it is a book whose pages, although well-thumbed and sometimes soiled with regret and torn by mistakes, are nevertheless extant, and readable. They are stories told without a plot and written, often, for the author with little hope or even desire for publication.

And yet, congratulations are sometimes lip-serviced  -the words mere decoys to disguise a different meaning: better you than me. In underestimating the years attained, the truth is seldom spoken except casually, as a joke –retractable, and yet echoing uneasily in the room long after it is uttered. Age is a gift, and yet shoddily packaged, the ribbon askew and poorly tied, the paper faded and rumpled with constant handling. Still, it is something at least… A recognition if nothing else.

But I’m making aging sound like night thoughts: a punishment rather than the achievement that it is.

We were talking about this, a patient and I, when she came in for a renewal of a hormonal therapy that helped her cope with one of the gendered ravages of her wealth of years.

“The young just don’t seem very thankful for what we’ve done for them, do they?” she said with a maudlin sigh when the subject came up.

I sat back as well as I could in my creaking chair, and smiled that gently exasperated smile that old folks are allowed. “But we look back; they look forward, don’t you think? Retrospective analysis is the domain of the experienced. Why do you think we have memories?”

“I suppose,” she said shrugging her shoulders in polite acknowledgement of a point with which she was evidently not in complete agreement. “We always seem to criticize generations other than our own when they do things differently, don’t we?”

I nodded. “But if each generation didn’t change a little, we’d probably still be chipping away with stone axes…”

A tiny smile crept onto her lips in spite of her attempt to remain pessimistic. “Speaking of the youth looking forward, I remember thinking of that when I had my first child. You probably don’t remember, but I had a rough pregnancy –high blood pressure, gestational diabetes, and then Melissa not growing as fast as she should in the womb…”

I actually did remember. “She was born prematurely – I induced labour about 34 weeks gestation or so, didn’t I? I recall being rather worried…”

Her face lit up with the shared experience, but her eyes stared far off into the past. “I remember thinking that she should be so thankful she was born. So thankful she was healthy.” I nodded again. “Anyway, a friend who came to see me while I was still in the hospital said that as well as getting presents on her own birthday, Melissa should give me a gift each time. A celebration of how lucky she was.”

I sat up straighter on my chair. “What a great idea, Melanie. And..?”

Her eyes twinkled at me. “Yup –all three of my kids. It’s a sort of family tradition now. Some of their friends are trying it as well, they tell me.”

The idea struck me as terribly innovative. Maybe others had done it, but I hadn’t heard about it. “Think it’ll catch on?”

She shrugged. “It’d be sort of like an accessory nipple in a way don’t you think?  I mean, I suppose that’s what Mother’s Day is for…”

I thought about it for a minute. “Mother’s Day is a bit generic, though. A child’s birthday is unique -an acknowledgement of its own presence in the world… and all because of its mother. It’s not a national day, it’s a personal day. And that’s what makes it so special.”

She stared at her hands she’d folded in her lap and was silent for a moment. We were both quiet. “Why do we think about these things more as we get older?” she said finally, breaking the silence almost reluctantly. “Or is it just me?”

I shook my head slowly. Absently. I was also lost in my own questions. She was right; it did seem to matter more nowadays that we poked around in the past, stirring the embers. But why? Did we really need the fire? The heat? The light? Were we awakening memories, or searching for something else? Looking, perhaps, for ourselves..? As if in the ashes of the dying fire there were patterns. Clues which, if properly mixed, could tell us where we, the lighters of the fire, had gone.

I could feel Melanie staring at me. “I can see you rummaging around in there, doctor,” her voice said, rustling through the room and bursting past the opaque curtain my eyes had drawn across it. “Come out again. I still need you…”

I had forgotten to write her the prescription for more hormones, yet somehow I only heard the words ‘I still need you’. But they were enough. I suddenly realized that the most satisfying gift of all, the most welcome treasure of age, was presence, not presents. And despite anything else that might go amiss, I was needed. Isn’t this what we all work for? When all is said and done, does anything else really matter?

The Solopsist

I have always been influenced by something Lewis Thomas, the American polymath writer-physician once said at a lecture I attended. He felt he would be better served by a doctor who had read Shakespeare than someone who had merely focussed all of his formative years on learning medicine. His point, I think, was that to really help people you had to understand who they were, what they thought, how they lived. We are all more than our bodies.

Me? I have always loved philosophy, cherished its Greek etymological roots: love of wisdom, and at least pretended I understood how it might help me to interact with my patients: to accept all points of view with equanimity –or to spell it as Sir William Osler did in his famous essay, Aequanimitas –imperturbability.

Philosophy helps you to do that, but only if you don’t get too enmeshed in the details. Only if you don’t privilege one tenet over another. Only if you never accept that you are at the end of the journey. Or meet someone who is

My conversations with patients have changed over the years from that of an expert trying to impress, to a teacher trying to listen -the difference between an encyclopedia and a manual, I suppose. Part of it is age, I’m sure, but a better part is the belief that, as Osler put it: “Listen to your patient, he is telling you the diagnosis.” And although directive listening works best, sometimes the topic turns an unexpected corner and a tangent is entered. I like tangents but not in the office -they can terminally entangle the discussion. They are like blackberry bushes in a field: I try to stay away from them.

There was a patient who wouldn’t let me, though. A PhD candidate in Philosophy, she had come to see me because of pelvic pain. And while she readily conceded that she was under considerable stress writing her dissertation, she felt that her problem was reality-based. I should have just written it down; I shouldn’t have asked what she meant…

“Reality is the sum total of all that is,”  she said, settling back all too comfortably in her chair. “The question, of course, is does it include potentiality –all that might be, or could be imagined to be?”

Of course.

She closed her eyes, for a moment as if digesting the profundity of what she had just said, and then opened them suddenly and stared at the ceiling. “But our realities differ, don’t they? I mean, you inhabit a different mental world than me; you can no more apprehend my sensations than I can yours. We are on different sides of a wall.”

She had to be kidding; I didn’t ask anything like that. But nonetheless, I felt it incumbent upon me to defend my profession –my humanity, for that matter. I decided to sit back in my chair as well- fight opaque answer with precise question. “But surely if you really believed that I couldn’t appreciate your pain, you wouldn’t have come here.” I then pasted on my most innocent smile. “And anyway, I don’t have to feel your pain, just accept that you are experiencing it and take it from there.” I put on a more contemplative, but satisfied smile.

My answer didn’t faze her in the slightest. I think she had her rebuttal ready before my smile had even fully blossomed. It started with a deep theatrical sigh. “Do you ever wonder if we define the world, doctor –our own world, that is?” She was sitting on the opposite side of the desk from me, but suddenly she leaned forward and put her elbows on it to fix me with a stare that would have done Medusa proud. I even stiffened reflexively.

“Don’t we all define our worlds?” I said, rather proud of my response.

“Yes, but differently.” She looked as intense as her words. “Pain has a different meaning to each of us: a different feeling, a different impact… it is only an If  to anybody but myself: If, as you say, you have pain; if as you assert, the pain is seven out of ten… If all of these things are as you tell me, I have only your word to go on. There is no objective way of demonstrating your thesis. So aren’t you left with the same undefinable as you started..?”

Wow. And to think I was only going to ask her how long she’d had the pain. She ended her explanation rather tentatively, thank god, because I had lost her shortly after her first attempt at clarification. I began to wonder if this dissemblage was a PhD syndrome: full of sound and fury, yet signifying nothing –practice for the defence of her thesis. Equivocation. Obfuscation. Playing with words like others play with cards.

Sometimes, however, it is necessary to find out more about the pain than its meaning. I wanted to pin her down on the more mundane aspects of her symptoms: more like where than why. Or when, not if. It occurred to me that her road to if  was not the road to solution and I was trying to figure out how to phrase it more philosophically when she straightened in her chair as if she’d suddenly received an electric jolt and stabbed me with her eyes.

“I realize that my approach to pain is different from yours, doctor, but the reason just occurred to me: I have defined it that way. Not you; not your reality. Mine… I am the one at fault.”

I tended to agree with her, although I probably wouldn’t have put it that way. “So…” -I sensed an opportunity when her face wrinkled as she thought through the ramifications of her enlightenment… A word-gap- “Where, exactly does…”

But she saw through my plan, and the door closed again. “You see I create the reality in which I suffer…” She paused, but not long enough for me to remember what I was going to ask, let alone to say it. “And so by coming here, I define you in a way… Both you and your response… Do you see what I mean?” She said it with such hope in her face that I almost said yes.

And then, just as suddenly, her face fell on hard times and the intensity disappeared. “But despite my solopsism, I still have pain.” Gradually, her expression refocussed like a magnifying glass and I could see her deep brown eyes dissolve in tears. “Can you help me even from your side of the wall?”

Solopsism? I smiled a real smile and nodded. I looked up the word as soon as I got home.

The Awe of BRCA

Awe: the word has been pasteurized, connotized almost beyond recognition. But I suppose that’s what happens to all really powerful words. There’s a life-span to language; a generation if you’re lucky; a year if social media gets hold of it –likes it… But I think the ship of awe and all of its elegance went down quickly -even before Facebook or Twitter could sink it. It’s a shame because I am sometimes filled with it.

Different things inspire it in me; there’s no formula, no recipe for the appeal. I am sometimes simply stopped in my tracks, occasionally accorded an audience with grandeur. Majesty. Awe: the ineffable sublimated and instilled wordlessly into my head.

Most recently it was occasioned by genetics -unsurpisingly, because I understand so little of it nowadays. Since the genetic code was cracked and genes in all their undress were unfurled from where they ruled unseen in their closet, I have been a stranger in an even stranger land. I sometimes feel as a child must, confronted with an explanation that has not lost any of its initial magic. Any of its mystery…

And it’s not merely the unravelling of the genetic puzzle that intrigues me. I am scarcely moved by the knowledge -no, not the knowledge, the words- that on the short arm of chromosome 3, position 21 (have I got that right?), there exists a gene that makes a chemokine (a what?) that has an important role in the resistance to infection. I suppose I should care more, but I don’t.

The gene that has captured my interest is the BRCA gene. ‘BRCA proteins are required for maintenance of chromosomal stability in mammalian cells and function in the biological response to DNA damage’ -that from the Journal of Cell Science. In other words, they make sure that the DNA is okay, and deal with it if it is not… They repair damage and keep the cell growing normally. They suppress tumours; mutate the genes -cripple them- and the oversight is lost.

That much I knew, but what intrigued me was that the BRCA genes also occur in plants. They evolved about 1.5 billion years ago in whatever single-celled creature that was the common evolutionary ancestor to both animals and plants. The fact that these genes also exist in plants (most studied in a small flowering plant called arabidopsis, because in 1990 it was chosen by the National Science Foundation as the first plant that would have its genome sequenced) suggests they have an important and enduring function throughout the phyla and kingdoms. Plants, too, need to manage what happens to their DNA: they are rooted to a spot and can’t avoid recurring environmental stress factors that might damage it. As an example, some mutations in the arabidopsis BRCA allow certain cells to divide uncontrollably making the plant very sensitive to various forms of radiation. Sound familiar..?

Not all of the BRCA gene is the same in different organisms, of course: different domains, or portions, with different functions are preserved that seem to have an evolutionary importance relevent to each entity. Why re-invent the wheel? Nature fiddles with what it already has -what it knows. That mutations in this same gene should have such important effects on breasts and ovaries in humans is interesting, to say the least. All organs have DNA that is responsible for their growth and development; all DNA needs surveillance and repair; all organs have a cancer potential…  So was there a common ancestor somewhere whose BRCAs first assumed uber guardianship of breasts? Whose unintended mutations engendered these hereditary risks -a family, an individual..? Presumably stuff has to start somewhere.

And although arabidopsis doesn’t have analogous organs to humans, similar BRCA mutations do not seem to be as lethal, so I suspect that studying them may lead to some important insights. Maybe they already have: I can barely understand the way the studies are worded and find myself perusing only the Introduction and then skipping past the Results section to Conclusions where the authors discuss whatever ramifications they feel obtain from the experiment. I still read through a glass, darkly.

But somehow, the knowledge that we are in a sense all part of the same organism is epiphanous. Humbling… As Shakespeare (in Troilus and Cressida) has Ulysses say: “One touch of nature makes the whole world kin.”

Is there ever a correct answer?

“Doctor, can I still get pregnant?” -a seemingly straightforward question, I suppose: quote her some statistics derived from her age, past history and current medical status. But in reality, it’s probably not a single question she’s asking. In many respects, it’s a philosophical question with many facets to consider; it requires a thoughtful reply.

Philosophy, as Michael Blake, a philosopher from the University of Washington once put it, is thinking in slow motion. I like that; it suggests that to answer something, to comprehend the various competing facets of a question, we need to take some time to consider both what is really being asked and whether our answer to it is relevant, sensitive, and in this context at any rate, representative of current thinking.

To make it through even a single day, we all have to make many unexamined assumptions about reality, not to mention about people and their beliefs, hopes and aspirations. Sometimes we assume they share our own opinions, see the world as we do, have the same or similar doubts, exhibit our own biases. But I suspect that this assumption will never properly address the question my patient posed. It may not even come close to answering it.

The question is a tree: it has roots and branches; and rather than existing in isolation, it is probably surrounded by other questions. To understand the tree, you have to understand the forest -or at least look at it in context.

“Can I still get pregnant?” -the very construction of the sentence suggests some of the worries and concerns that she has. It is, on first consideration, merely a question about her ability to conceive and if answered in that framework, is a number. A percentage. It is the product of an algorithm into which you feed her age, past history of pregnancies or diseases, and her current medical status and a type of answer appears. It is a type of answer, because it is really only a statistic -useful for a population of 40 year olds, say, but not necessarily this 40 year old. And what does 20% or even 50% really mean? The question, after all, was “Can I get pregnant?” -not, can a forty-year-old woman get pregnant. Not really; she is asking in effect: “Given what you know of me  and my circumstances, my health, my body, do you think I can still get pregnant?”  And she is asking for your opinion, not a legally binding statement. She is asking what you think…

And “still get pregnant” is important. In itself it hints at other questions: “At my age, is pregnancy even advisable?”; “What might be the problems I will encounter if I do become pregnant?” And “What would a pregnancy under those circumstances look like for me? And for the baby?”; “Are there disadvantages -long and short-term- that you can foresee, doctor?” Once again, you are being asked for an opinion -perhaps even a personal perspective (with all it’s biases and cultural nuances).

There is an uncertainty built into the very question that demands consideration. Perhaps she is unsure about whether even to consider pregnancy; perhaps it was something someone else had asked her -or even demanded she ask. Maybe she is asking for permission not to become pregnant…

What is inserted into an equation, determines it’s answer; the background of a question, the milieu -the forest in which it lives- should suggest the thrust of the response. There is often no correct solution; in fact that may not even be what is sought. Sometimes a question is more of a search for someone to listen, a hope for acknowledgement, a quest for agreement, than a need for an accurate reply. The skill is in recognizing what is being requested; listening not so much to what is being asked, as to what is meant by the question in the first place.

So the importance is in properly and sensitively analysing the question; recognizing that it is a series of probes for which a thoughtful response is required. It is usually not just a number that is wanted -although that may help to give some perspective to the subsequent analysis- it is a respectful appreciation of the concern and a realistic appraisal of the context. “Can I still become pregnant?” requires not only a judgment -even though that is certainly a part of it- but also an opinion: a thorough appraisal and a considered response; it is not necessarily even final: things evolve -questions as well.

It is thinking -and answering– in slow motion.