Safe Passage

As many have said more lyrically than I have, literature at its best makes one smile with recognition at a character's politically incorrect but perfectly consonant responses to his situation or colleagues. Like a well-tuned chorus or orchestra where the sine waves of sound "line up", the ring of truth is unmistakable when the writer gets it right. Even if the protagonist is not particularly likeable, you wish you could sit with him over a cup of cocoa (or something stronger) and probe for insights. Of course good stories also may leave us distinctly uneasy because of truths about ourselves that they push us to confront. We are pricked by dead-on descriptions of foibles and faults we know have crept into our own characters. Marge Piercy's Three Women succeeds in spades by the above criteria, and even has plenty of fodder for those enamored with medical puzzles (Patricia Cornwell, go home) to boot.

As this story opens, Suzanne, who is just shy of her fiftieth birthday and a brilliant litigator, is beginning to enjoy (a) the freedom from exigencies incumbent in raising 2 daughters with none-too-helpful or even present mates, and (b) her first sexual relationship in a decade (yes!). Her horizon is first clouded when her dazzlingly beautiful but equally dysfunctional daughter moves back in with her having been let go of yet another job. This is the daughter you wake up nights in a cold sweat, afraid you could be raising. Perceptive enough to hurl streams of accusations that hold sufficient truth to really bite, her world view is bleak enough that she doesn't hesitate for a millisecond to initiate an affair with the husband of her mother's best friend. Prospects further dim when Suzanne's mother Beverly, a professional social activist who has long disdained her daughter's accomplishments as money grubbing, capitalistic, and clear evidence of capitulation to "the establishment", suffers a stroke. She is forced to rely upon her daughter and granddaughter for assistance with tasks as simple and private as getting to and from the bathroom.

The descriptions of Beverly's symptoms are sufficiently detailed that you might deduce the distribution of her CVA. "She lurched to her right and almost fell to the floor, realizing she could not put weight on her right leg. Her right hand would not close." Immediately following the sentinel event, she becomes stuporous for a period of days. Later, "the left side remained loyal, but her right side had betrayed her." When she weeps with frustration and anger tears, "roll down her cheek from her left eye" (extra credit here if you know why). Beverly is "trapped behind that ghastly grimace, that twisted face and limp body". "Eating was problematic. Food got stuck on the other (right) side of her mouth... The Jerk owned the right half of her body". She suffers oppressive aphasia. "Beverly's words beat around in her head like birds trapped in a house, banging themselves on the windows, able to perceive where they wanted to go but trapped by an invisible barrier. She could not think of a damned thing to look forward to."

Can you say left middle cerebral artery occlusion? Perhaps most interesting of all to me were the descriptions of Beverly's symptoms as the stroke was evolving. "The worst pain was in her head... it was lightening in the brain." This description sounds eerily accurate. But none of my patients has ever been able to relate his symptoms during this early phase of a CVA. Nor do I find these data in the medical literature.

These women have a long history of strained relationships, and as you might guess, conflict is a given. To the author's considerable credit, each character is well enough depicted that frustrations with one another are palpable. The grandmother's independence is so fierce that you can feel her bristle at the relentlessly cheerful physical therapists who shout orders at her. She thinks "Right, it's funny for you, you b_tch, to see me crashing to the floor, but it's damned well not amusing to me." Granddaughter Elena accuses Suzanne of always being in a hurry with Beverly; "You can't ever wait for her to finish a sentence!" Suzanne retorts, "I just try to anticipate what she's trying so hard to say!" This one cut me to the quick. How many times have I done this with a patient?

Elena finds her mother intolerably repressed: "… if you followed her plan, all you got every day was older." And yet, in the end, Beverly's clear predicament and repeated insistence that her daughter and granddaughter help her to die forces these three to function as a family after years of very deliberately carving out their own lives. Of course, it also raises tough questions about choices one faces when someone close demands (and absolutely needs if he is to be successful) participation in ending his life, knowing that abetting this cause could encumber significant legal and financial risks to all those involved.

I have long been suspicious of physician assisted suicide for all the standard reasons that you can tick off as well as I. Most persons seeking to end their lives suffer from physical pain that is severe and unremitting to the point that higher functions (such as meaningful communication with loved ones) are all but impossible. Should we seriously consider a request for assistance in dying before mounting a comprehensive assault on all forms of pain and depression that drive this sort of request? The "right to die" can segue too easily into the "duty to die" when the costs (emotional, financial, etc.) escalate. I have seen unparalleled and often unanticipated growth on the part of the patient and family members in the last days of life when people resolve, or at least tackle, old differences and find the strength to stand watch as their loved one takes his leave.

Perhaps the most personally compelling of reasons I have never embraced assisted suicide is that as a physician, I cling tenaciously to the tenant of sustaining rather than hastening the end of life. Admittedly an emotional rather than rational response, the most wrenching professional dilemmas I have encountered are requests by decisional patients to remove life sustaining equipment, a right which is unambiguously protected by law and joyfully embraced by some.

The gift of Marge Piercy's story is that she makes excruciatingly real the perspective of a woman who isn't in physical pain or overly concerned about financial consequences of her illness. Despite her defiant and (her detractors would say) uncompromising approach to life, she grows to accept an existence which includes greatly diminished functional capacity. Hemiparetic and significantly hobbled in speech, she battles back. She learns to use a computer to surf "The Net" and fire off letters to politicos cajoling them into positions she supports, enjoys having her hair dyed, and even concedes to clothes fastened with Velcro (this from a women who long prided herself on her appearance) in order that she might dress herself. Only after a second stroke leaves her effectively blind, her vision a "blurred grayness" (O.K. you crack diagnosticians: what's the differential here?) and nearly mute does she conclude that this life holds nothing more for her. And proceeds to harangue her daughter and granddaughter incessantly to send her to her final home.

Of all the issues that troubled me in this tale, one emerged that I cannot shake. Where were the physicians in this all this? From the women's perspective, they shuffle about, offer terse and grim prognostications, and are generally overshadowed in importance by the ancillary support, such as the nurses' aids. Most damning of all, they barely register as a blip on the horizon of this family's crisis, and when they do, they are obstacles to be overcome rather than part of any solution. If they could not or would not offer Beverly safe passage into the next life (and one could argue that the occasion might have afforded the opportunity for those who loved her to gather and celebrate her life), then didn't they at least owe these women comfort? Counseling? Mind altering drugs? O.K. maybe I reach on this last one.

A final caveat. Marge Piercy writes from a distinctly female vantage point. Every male in this story could be replaced in toto by sperm banks and a selection of imaginative sex toys. For a corresponding overtly male viewpoint, try J. M. Coetzee's Disgrace, though (brace yourself) it is even more bleak in outlook.