Reviews

Learning to die: wisdom in the age of climate crisis

Robert Bringhurst and Jan Zwicky University of Regina Press, 2018 ISBN 978-0889775633 I am not sure how I came across this book; I think I followed a link onTwitter. It appealed to me immediately and I ordered it from Mr Bs, our Bath independent bookshop, then promptly forgot all about it. When I learned it had arrived, I asked my wife to pick it up for me while she was in town. ‘What’ s it called?’ she asked, and I couldn ’t remember. She brought back this tiny book with a shocking cover and title. I opened it and was immediately engaged. It may be tiny, but it explores a huge theme: How should we die at the end of times? Or as Margaret Atwood puts it,

‘Truth-filled meditations about grace in the face of mortality ’ .

Robert Bringhurst and Jan Zwicky are Canadian scholars of international repute: he a typographer, poet, and translator; she, a philosopher and poet. Learning to Die is beautifully designed, typeset and bound. It feels quite apt to study almost unthinkable topics through a beautiful physical object.The book contains two short essays and an afterword that critiques Stephen Pinker ’ s

Enlightenment Now.

The first essay, by Bringhurst, The Mind of the Wild, sets out our predicament, that we are at the end of times. He considers the nature of the wild Earth, ‘living life to its full… self-directed, self-sustaining, self-repairing, with no need for anything from us ’ . Humans are, of course, part of this, but, in a telling phrase, he describes us as ‘liminal creatures ’ , on the margins of the wild, sometimes tempted to believe the ‘ witch tale ’ that we can live entirely outside it.

The wild world is extraordinary resilient, and yet it has been pushed by humans beyond its limits: ‘Does anybody honestly suppose that nature can be tricked into giving more and yet more every year, without end?’The dominant human culture is increasingly toxic to the wild, bringing about mass extinction of life on Earth, the sixth such great extinction. If anything survives, ‘it will again be the wild… that is responsible for the healing ’ .

This extinction includes humans. ‘Cultures change.And ours will soon be changing big-time… If there are any human survivors of the next mass extinction, the cultural slate will be wiped pretty clean. No one may have heard of Shakespeare or Bach, Picasso or Plato ’ . Life will not go on forever, but somehow, we are making it shorter by far than we need to.

Bringhurst is demanding we look reality in the face, challenging us with the realities of death: ‘You, your species, your entire evolutionary family, and your planet will die tomorrow. How do you want to spend today?’We are up against a wall; more and more of those who care are standing against the unsustainable mainstream.We may not be able to save the world, ‘but you might just manage to save your self-respect. ’

Jan Zwicky picks up this essentially moral question.The title of her essay, A Ship from Delos, refers to the death of Socrates. Because executions are proscribed during the annual embassy to Apollo at Delos, his is delayed; but when the ship returns, his death is inevitable. ‘Humans collectively are now in Socrates ’ position: the ship with the black sails has been sighted. Catastrophic global collapse is now on the horizon… nothing remotely like adequate measures are being undertaken… when we go, we are going to take a lot of innocent beings with us. ’

Zwicky ’ s essay explores the question, ‘What constitutes virtue in such circumstances?’The answer, she tells us, is surprisingly straightforward: ‘ what has constituted virtue all along. We should approach the coming cataclysm as we ought to have approached life ’ . She translates ‘ virtue ’ as ‘ excellence ’ : it’ s about being an excellent human being.The excellence she pursues is based on the ‘ suite of virtues that Socrates cultivated… and… embodied clearly on the day he learned he was going to die ’ , arguing that ‘these virtues are a good starting place since they are the foundation of moral thought of the industrial culture that is the root of the crisis ’ .

From Plato ’ s account, Zwicky derives a list of core Socratic virtues: • Awareness coupled with humility regarding what one knows • Courage • Self-control • Justice • Contemplative practice • Compassion So much of the discussion about the ecological catastrophe is couched in practical terms, about carbon reduction, alternative economic models, politics and human rights, species conservation. Rarely do we go to the moral and ethical heart of the matter, usually staying at a level of guilt-inducing should/should not injunctions. Zwicky ’ s essay fills an important gap. So how might we practise these virtues ‘in the face of sighting our own ecological ship from Delos?’

Awareness is about ‘knowing what’ s what’ , about looking the truth in the eye, acknowledging what is the case.This is a significant challenge; for it is often argued that to be aware that death is imminent is to extinguish hope. Zwicky explores these issues carefully, not allowing easy answers. Hope is not destroyed. Beauty remains.The human inventive spirit remains. The Earth is prodigious, life will proliferate again.And awareness must be coupled with humility: we do not know what the future will hold. On the other hand, denying responsibility, denial of our complicity is part of refusing to know what’ s what. Zwicky challenges us: those of us who have enough to eat and freedom to think must see clearly what our situation is: ‘Its desperate character, its blinding pain, must become an integral part of what we know. ’

This will take courage. It will take physical courage to stand up to the inevitable pain and duress; it will take civic courage to live with wars and violence; it will take moral courage to exercise the virtue of awareness with humility. It demands. Selfcontrol seems to be something the dominant culture lacks: not just ‘ grim, Procrustean self-denial’ , but knowing when enough is enough, embracing simplicity.And it will require compassion, particularly so we do not indulge in contempt for those struggling to come to awareness, who deny ‘ what’ s what’ .

The virtue of justice is more complex. Zwicky compares the Platonic notion of justice as the ‘ order of the soul’ with the modern view articulated by philosopher John Rawls that it is about fairness.There is a complex argument here, which includes the question: since we cannot remedy the situation we

are in, why bother with justice at all? Here it seems that Plato ’ s view of justice has real bite: the order of the soul is about inner harmony, the self-sustaining interdependence of awareness, humility, courage, and self-control, maybe better called ‘ nobility ’ . What is good is beautiful. Zwicky contends: ‘the older I get, the more it looks like Plato was onto something: there are people in all walks of life who… are seized by the need to do the right thing… [W]hen you are in the presence of someone who is acting from direct perception of the good, you can tell. ’

Contemplative practice of any sort involves attention. ‘We attend to the real, physical world, its immense and intricate workings, subtlety; its power, its harshness and its enormous beauty.We attend to the miracle of it, that there is something –this, here, now – rather than nothing.We attend to the rhythms of this world as they play out in our lives… ’ Contemplation allows us to see the beauty of brokenness. ‘The more we attend to the world, the less we find ourselves wishing to control it. ’ In place of control, we may desire to become, as Aldo Leopold puts it, a ‘ plain member and citizen ’ of the land community.

These virtues form an organic whole; they concern ‘ excellent human being – here, now, in this world.There is little point asking how to live or how to die if we won ’t, or can ’t, act on the answer. ’This means that knowledge, if it is to be morally excellent, must be taken into the heart as well as into the mind. Or, to put this another way, that for virtues to be virtues they must be practised in concert.

‘So how are we to die?’ asks Zwicky. In the end, this must also include a sense of humour: ‘ a Socratic sense of humour will be manifest not as slapstick and belly laughs, but as the lightness of touch that comes from not taking one ’ s self too seriously. We will sense it as a smile: the absence of fear and the refusal to despair. Even in the face of death. ’

I started this review with an account of how I stumbled on this book by chance. It has utterly engaged me, and several of the people with whom I have discussed it, for several days. I find that it cuts through the unending, superficial debates of our time. It asks us to take our life seriously, to consider, how will you live? And leads us through ways of considering the question. I find this invaluable.

Peter Reason, writer

This review was first published by Shiny New Books https://shinynewbooks.co.uk

Admissions. A Life in Brain Surgery

Henry Marsh Weidenfeld & Nicolson (2018) ISBN 978 1 474 60589 2 How much can autobiographical reflections help us face our larger shared problems of humanity?This essayed review explores Admissions, a very personal and long-term view of healthcare.

Henry Marsh, a veteran and pioneering neurosurgeon, has recently published two books since his retirement from the NHS. Both have received excellent reviews from major media critics and have rapidly become best sellers. It is easy to see why: Marsh writes vividly of his exacting and edge-of-life work with humanity, philosophy and compassionate humour. His strong opinions are buttressed by sharp observation and deep thought. He writes self-knowingly as an emotional man striving for the detachment that is necessary both to make sense and to save himself. Often he alternates dilemmas from his work with those from his life – switching from the operating theatre or intensive care unit to his struggle restoring a derelict ancient cottage, for example.

Marsh never uses the word ‘holistic ’ but his descriptions and thinking are enriched by their many levels and aspects of engagement. He seems a sensitive man doing extremely demanding and dangerous work, and I suspect that his sometimes bluff manner might impatiently avoid such a term; ‘holism ’ is so often lost to vagueness.

This second volume, Admissions, is rather less technical and more human than the preceding Do No Harm, focusing less on the neurosurgery and more on his experiences and thoughts of caring for others, and then on his spectered fear of personal decline when he is no longer able to do this.

These are Admissions ’ main themes and Marsh introduces his own writing with three quotes from long-deceased thinkers. The quotes are repeated here as a useful way to introduce Marsh’ s two main themes. His own exceptional clarity merits extensive quotation.

Medicine is a science of uncertainty, and an art of probability…

SirWilliam Osler

Marsh’ s thinking about how we construct and instruct knowledge, and then how we may best live creatively with uncertainty, is wise, pragmatic and humble. His long experience has led him to a very different view from the current trend of risk-phobic professional micromanagement.

Doctors are now subject to a regulatory bureaucracy that simply did not exist forty years ago and which shows little understanding of medical practice.The National Health Service in England … is chronically starved of funds, since the government does not admit to the electorate that they will need to pay more if they want first-class health care. He sees our increasingly stringent methods of governance as departing far from important realities:

Many of our medical decisions – whether to treat, how much to investigate – are not clear-cut.We deal in probabilities, not certainties. Patients are not consumers who, by definition, always know what is best for themselves, and instead must usually accept their doctors ’ advice. Clinical decision making is easily distorted by financial gain for the doctor or hospital … Increasing litigation drives over-investigation and over-treatment – so-called defensive medicine … … but doctors deal with probabilities, not certainties. Sometimes, if you are able to make the right decision, you have to admit that you might be wrong … All good sense, surely? But what Marsh found, increasingly, was management whose systems eliminated such sense:

The feeling that there was something special about being a doctor had disappeared – it was just another job, I was just a member of a team, many of whose members I did not even know. I had less and less authority. I felt less and less trusted. I had to spend more and more time at meetings stipulated by the latest government edicts that I felt were of little benefit to patients …We would often look at brain scans and decide whether the patient should be treated or not without any of us having ever seen the patient.

These depersonalising reforms meant that: … we lost a lot – above all the friendly working relationships that can come when you work in a small organisation where everybody knows each other on a personal level and work together on the basis of personal obligation and friendship …

Marsh has clearly given much thought to how empathic humanity might creatively co-exist with high-risk high-technology:

The moral challenge is to treat patients as we would wish to be treated ourselves, to counterbalance with professional care and kindness the emotional detachment we require to get the work done.The problem is to find the correct balance between compassion and detachment. It is not easy.When faced with an unending queue of patients, so often with problems that we cannot help, it is remarkably difficult.

But Marsh found diminishing scope in the evolving NHS to seriously consider such seminal issues:

So instead … a small fortune is spent on management consultants who subscribe to the ideology that marketisation, computers and the profit motive will somehow solve the problem.

The talk is all of greater efficiency, reconfiguring, outsourcing and better management…

These are not mere abstractions. Marsh offers us many vignettes illustrating the frustrating absurdity and craven pathos of a system groaning under its top-heavy and rigid regulation.

Partly for respite – to re-own and reaffirm his professional skills and identity – he travelled: to the USA for academic exchange, and to the much poorer and medically primitive Ukraine and Nepal to offer his expertise as a charitable project. In each of these places he saw, and worked in, very different ‘ systems ’ (if you can call impoverished chaos a system) to the NHS. Both richest and poorest nations had severe problems, mercifully (if relatively) lacking in our NHS. His vivid descriptions of care amid corruption and severe poverty have a starkness that is shocking and heart-breaking.

He has quite as much, though different, dismissive mistrust of a consumerist-capitalist system.After a reluctant visit to a skyscrapered, plush medico-legal claims office he wrote:

I had to wait for a while, and looked with sour awe at the City under a clear blue sky. Babylon! I thought – the heart of an extravagant culture, consuming itself and the planet, sheathed in glittering glass…

For all his personal frustrations with the NHS, Marsh’ s overall view is sober and conditionally optimistic:

It is true that socialised health care, as the Americans call it, has many faults. It tends to be slow and bureaucratic, patients can become mere items on an impersonal assembly line, clinical staff have little incentive to behave well and can grow complacent.

It is often starved of resources. But these faults can be overcome if high morale and professional standards are maintained, if the correct balance between clinical freedom and regulation is found …The faults of socialised health care are ultimately less than the extravagance, inequality, excessive treatment and dishonesty that so often come with competitive private health care. But then we have this:

The government, driven as always by the latest tabloid headlines, has set up an increasingly complex system of bureaucratic regulation based on distrust of the medical profession and its professional organisations. Of course doctors need regulating but they need to be trusted as well. It is a delicate balance and it is clear to me that in England the government has got it terribly wrong. We should always, as near as we can, be booted and spurred and ready to go. Michel de Montaigne Neither the sun nor death can be looked at steadily. La Rochefoucauld

At the centre of Admissions is a chapter titled ‘MakingThings ’ , in

which Marsh describes the deep satisfactions he gets from making furniture and the formidable challenge of personally reconstructing a long-vacated, now collapsing, ancient cottage. He relishes the attention he must pay, the understanding and skills he must develop, and the sacrifices he must make.Through these he gains a sense of personal transcendence, together with a slow, deep pride that comes from patient mastery. Marsh clearly sees the personal sacrifices, skills and identifications he brings to these domestic projects as akin to what he wishes to bring to his publicly accountable work. His strong, assiduous –even obstinate – tenacity fuels his vocational spirit and his personal raison d’être.

I like to joke that my most precious possession, which I prize above all my tools and books, and antiques that I inherited from my family, is my suicide kit, which I keep hidden at home.

At the end of the book he returns not only to this premonition, but also to what precedes it – what makes life worthwhile. Clearly kinship, fraternalism, making things and personal purpose are all things that have spirited Marsh’ s life.And his perception that he felt these things were perishing in his later years in the culture of the NHS is what so dispirited him.

More specifically, in our inevitable declines:

A doctor ’ s duty is to relieve suffering as well as to prolong life, although I suspect this truth is often forgotten in modern medicine. Doctors are frequently accused of playing God but, in my experience, the opposite is more often the case. Many doctors shy away from decisions that might reduce suffering but which will hasten a patient’ s death.

Almost at the end of Admissions is this defiantly libidinal sentence:

The only meaning of death is how I live my life now and what I will have to look back upon as I lie dying.

And at the very end, his last sentence:

It is enough that I am well for a little longer, that I have been lucky to be part of a family – past, present and future – that

I can still be useful, that there is still work to be done.

Surely this wisely opinionated and personally emotional book has much to tell us beyond Marsh’ s particularly interesting life and work. David Zigmond, physician in psychological medicine; retired GP

J O U R N A L O F holistic healthcare

Re-imagining healthcare

About the BHMA

In the heady days of 1983 while the Greenham Common Women ’ s Camp was being born, a group of doctors formed the British Holistic Medical Association (BHMA).They too were full of idealism.They wanted to halt the relentless slide of mainstream healthcare towards industrialised monoculture. They wanted medicine to understand the world in all its fuzzy complexity, and to embrace health and healing; healing that involves body, mind and spirit.They wanted to free medicine from the grip of old institutions, from over-reliance on drugs and to explore the potential of other therapies.They wanted practitioners to care for themselves, understanding that practitioners who cannot care for their own bodies and feelings will be so much less able to care for others.

The motto, ‘Physician heal thyself’ is a rallying call for the healing of individuals and communities; a reminder to all humankind that we cannot rely on those in power to solve all our problems.And this motto is even more relevant now than it was in 1983. Since then, the BHMA has worked to promote holism in medicine, evolving to embrace new challenges, particularly the over-arching issue of sustainability of vital NHS human and social capital, as well as ecological and economic systems, and to understand how they are intertwined.

The BHMA now stands for five linked and overlapping dimensions of holistic healthcare:

Whole person medicine

Whole person healthcare seeks to understand the complex influences – from the genome to the ozone layer – that build up or break down the body–mind: what promotes vitality adaptation and repair, what undermines them? Practitioners are interested not just in the biochemistry and pathology of disease but in the lived body, emotions and beliefs, experiences and relationships, the impact of the family, community and the physical environment. As well as treating illness and disease, whole person medicine aims to create resilience and wellbeing. Its practitioners strive to work compassionately while recognising that they too have limitations and vulnerabilities of their own.

Self-care

All practitioners need to be aware that the medical and nursing professions are at higher risk of poor mental health and burnout. Difficult and demanding work, sometimes in toxic organisations, can foster defensive cynicism, ‘ presenteeism ’ or burnout. Healthcare workers have to understand the origins of health, and must learn to attend to their wellbeing. Certain core skills can help us, yet our resilience will often depend greatly on support from family and colleagues, and on the culture of the organisations in which we work. Humane care

Compassion must become a core value for healthcare and be affirmed and fully supported as an essential marker of good practice through policy, training and good management.We have a historical duty to pay special attention to deprived and excluded groups, especially those who are poor, mentally ill, disabled and elderly. Planning compassionate healthcare organisations calls for social and economic creativity. More literally, the wider use of the arts and artistic therapies can help create more humane healing spaces and may elevate the clinical encounter so that the art of healthcare can take its place alongside appropriately applied medical science.

Integrating complementary therapies

Because holistic healthcare is patient-centred and concerned about patient choice, it must be open to the possibility that forms of treatment other than conventional medicine might benefit a patient. It is not unscientific to consider that certain complementary therapies might be integrated into mainstream practice.There is already some evidence to support its use in the care and management of relapsing long-term illness and chronic disease where pharmaceutics have relatively little to offer.A collaborative approach based on mutual respect informed by critical openness and honest evaluation of outcomes should encourage more widespread co-operation between ‘ orthodox ’ and complementary clinicians.

Sustainability

Climate change is the biggest threat to the health of human and the other-than-human species on planet Earth.The science is clear enough: what builds health and wellbeing is better diet, more exercise, less loneliness, more access to green spaces, breathing clean air and drinking uncontaminated water. If the seeds of mental ill-health are often planted in an over-stressed childhood, this is less likely in supportive communities where life feels meaningful.Wars are bad for people, and disastrous for the biosphere. In so many ways what is good for the planet is good for people too.

Medical science now has very effective ways of rescuing people from end-stage disease. But if healthcare is to become sustainable it must begin to do more than just repair bodies and minds damaged by an unsustainable culture. Holistic healthcare practitioners can help people lead healthier lives, and take the lead in developing more sustainable communities, creating more appropriate models of healthcare, and living more sustainable ways of life. If the earth is to sustain us, inaction is not a choice.

Journal of Holistic Healthcare

“The Journal of Holistic Healthcare… a great resource for the integration-minded, and what a bargain!”

Dr Michael Dixon

Want to contribute to the journal? Find our guidelines at: http://bhma.org/wp-content/uploads/2016/07/JHH-Essential-author-information.pdf