How can a doctor resist an essay entitled The Sickness unto Death? Kierkegaard, the darkest of the bleak existentialists, begins by asking, “Is despair an excellence or a defect?” Can despair be an excellence? It is November in Oregon, the rain comes down in sheets, with only a few hours daily of half-light. Kierkegaard’s winters in 1840 Denmark must have felt a lot like this, so I press on.
“In despairing over something, he really despaired over himself, and now he wants to be rid of himself.”
In my hospital medicine practice I see a lot of death and dying. Most weeks I attend to 2-3 patients with imminently terminal diagnoses, either arranging hospice at home upon discharge, or assisting with actual symptom management of their final few breaths. Are my dying patients in despair? And if they are, is this an “excellence or a defect?” Or perhaps the essay refers to my own existential predicament as I face my inability to perform my duty to heal? Most of my dying patients seem inexplicably at peace, whereas their families and I are clearly despairing.
“Thus to be sick unto death is to be unable to die, yet not as if there were hope of life; no, the hopelessness is that there is not even the ultimate hope, death.”
Kierkegaard refers of course to the Christian faith of physical death not signifying ultimate death, that in fact physical death is the ultimate hope. But the essay also refers to an earthly despair as well, “there is not one single living human being who does not despair a little, who does not harbor an unrest, an inner strife…” I have seen patients sick unto death even as they were young and quite alive.
My hospital is on the front lines of America’s heroin epidemic, and if there is any substance that manifests Kierkegaardian despair, it is heroin. This week I am caring for a 30 year old woman who arrived in the emergency department with a fever of 103, rigors and pinpoint pupils. Her body hurt “all over,” but mostly when she took a breath, when the pain radiated to the middle of her upper back. Her left forearm had needle tracks with a palpable corded vein where the poison had clotted and scarred injection sites. There is a wild look in heroin eyes that radiates despair.
The reader knows how this story proceeds, for it is a Greek tragedy with its ending foretold before the story even begins. The “heroine” has a fatal flaw. A heart valve infection from dirty needles and dirty drugs — right sided endocarditis with septic pulmonary emboli. Blood cultures with Staphylococcus aureus. Homeless. A “boyfriend” who brings a backpack to her hospital room and spends a lot of time in the bathroom. The standard of treatment for this woman would be intravenous antibiotics for weeks; we used to recommend six. But the logistics of that are impossible. How to maintain an IV line in someone who would rather use it as access for the next high? How to deliver medications at home when there is no home? Various infectious disease studies have experimented with a shorter treatment course, down to even two weeks of IV antibiotics. Even this will be nearly impossible for her to accomplish.
The addict lives entirely for the moment and cannot conceive of tomorrow, much less two weeks from now. Just two months ago she delivered a baby, could not stay clean, and lost her infant to state protective services. If she could not stay clean for her own baby, how will she do so for a mere life-threatening blood infection? My patient has no hope for life, nor even for death, because she cannot conceive even of death. When I talk about “life threatening,” her eyes wander to the window. She has no conception of any future. And without the ultimate hope of death, she is truly in despair, without even the benefits of despairing, and thereby perhaps changing her life.
“Not to be in despair must signify the destroyed possibility of being able to be in despair; if a person is truly not to be in despair, he must at every moment destroy the possibility.”
Kierkegaard’s dark essay may actually be about light. The possibility of despair may be essential to the human endeavor of hope. The sickness unto death has a double meaning. Cancer and heart failure are sicknesses unto death, but so is the loss of despair. As one Kierkegaard commentator puts it, “to ‘despair’ is precisely to act in accordance with the facts, to give up the attempt because the goal is impossible.”
The double meaning of despair takes on a cutting edge in the setting of hospice. The formula for all despair is to “want to be rid of oneself.” The addict despairs in this sense. But the hospice patient has accepted despair and thereby rid himself of it because he no longer wants to be rid of himself, and has finally, and perhaps for the first time in his life, accepted himself.
The Portland rain continues. Don’t despair.