“Don’t you think I’m an anomaly of nature?” Czeslaw Milosz asked me when he reached the end of his ninety-second year of life. And it occurred to me that he was like a mighty Lithuanian oak tree, its leaves rustling with poetry. His mind, supported by a memory I have never known anyone else to have, tried more and more often to fathom the essence of illness, and also death. It never seemed to rest at all, except during sleep, which sometimes lasted longer because of illness. Once, after several days of deep unconsciousness, as soon as he came to, he said a brief thank-you and at once added: “A new book absolutely has to be written about dying and death.” “A sort of modern version of the Ars moriendi, transferred from the Middle Ages?” I asked. “Would anyone want to read it?” He had no doubts about that. He knew he would not have time to write the book himself. In any case, he reckoned a doctor should do it, to show how we undergo this final test, describe the process of dying and the ways in which death comes upon us and achieves its end.
“But there are a thousand ways to die (Occurvunt animo
pereundi mille figurae), said Ariadne when Theseus deserted her. This foreigner, whom she had helped to kill her bull-headed stepbrother the Minotaur, for whom she ran away from the royal palace and whose feet she was willing to wash in Athens like a common serving maid, left her on a wild, rocky island, which became once and for all “the landscape of rejected love.” As she spoke these words from a clifftop by the sea, was she thinking of her magnificent, shameless mother, Queen Pasiphae, and her sister Phedra, wracked by pangs of conscience, both of them overwhelmed by the bewitching power of love, which drove them to suicide? Did she already know she was destined for the same fate too? A violent death, which by its sudden and unexpected nature shocks the victim’s loved ones and everyone around them, and brings a pain that can only be compared with the despair of a mother when she loses the child she is expecting before it is born? Sudden death, which Hippocrates called apoplexy, explained as “striking one down like a thunderbolt,” is present today, just like thousands of years ago, whether self-inflicted or caused by someone else, by a disease affecting the heart or the brain, a traffic accident, a tsunami or the collapsing roof of a covered market. We always fear it, and we can hear an echo of that fear in the Catholic prayer: “Deliver us, O Lord, from a sudden and unprovided death.” In my childhood years, before the Second Vatican Council, in the days of the Latin liturgy, sudden death had the face of the Normans. So, quite unwittingly? we were still issuing a collective imprecation from centuries ago, praying for God to avert their furious advance and save us from the furor Normanorum. Invaders from the north attacked suddenly, bringing death and leaving nothing:
An immense coldness from the Longohards
Their shadow sears the grass when they flock into the valley
Shouting their protracted nothingnothingnothing
There are still plenty of descendants of the Longobards around, but in his everyday practice the doctor encounters sudden death in illness: in heart attacks, strokes and poisoning, and after road accidents. Immediate resuscitation can often bring the patient back to life. But if it is performed with a few minutes’ delay, even though the heart starts to beat again and the lungs to respire, consciousness does not return. The family and the doctor wait in hope, counting the days and then the weeks, but the patient does not awake from his coma. And so belated resuscitation transfers the rescued person to another state of existence, unknown to mankind in our entire history. This is vita vegetativa. Do these patients really live the life of plants? Because they remain rooted to a single spot without moving away from us or coming towards us, and without reacting? They lie in hospitals, hospices or at home, suspended between life and death. They do not react to external stimuli. They are fed through tubes inserted into the stomach. They make grunting sounds and sometimes they move a hand or open their eyes, but their gaze remains empty. They have extensive damage on both sides of the cerebral cortex, although the structures of the brain stem remain intact. They really are alive; no one doubts it —they are on the same side as we are. So we try to make contact with them, if only the merest hint of it. We are on the alert, like wireless operators waiting to hear if something will break through all the buzzing and crackling in the headphones. The patient’s loved ones try to get through to him, wherever he is, and give him a sign that he has not been abandoned, to show they are still with him. They squeeze his hand, adapt the rhythm of their own breathing to his and whisper stories of everyday life into his ear in an effort to transfer him into it. It is like sending signals into outer space in search of extraterrestrial civilizations, and just as hard to get an answer. And when we see a mother remaining with her child who is in a coma, not for months but for years, out of what the poet Cyprian Norwid called
“fellow feeling,” in other words, a feeling shared with the patient, it occurs to us that perhaps “life involves maturing to the awareness that it is all about being dedicated to others.”
In situations of this kind we cannot avoid the question of limit. For how long should this other state of existence be artificially sustained? This question went around the world in the case of Terri Schiavo, the forty-year-old American woman who in early youth, for reasons that cannot be fully explained, suffered cardiac arrest and underwent clinical death, but was resuscitated after a tenminute delay. For the next fifteen years she was in a deep coma, completely out of touch, although her heart was beating and she was breathing. Her life was kept going by sustenance fed to her intravenously. Finally her husband made a decision, in defiance of her parents’ wishes, and the federal courts confirmed it. Her drip was disconnected, and Terri died ten days later, on 30 March 2005. Who really has to decide in such situations? The spouse? The court? The parents? In fact it is usually the mute decision of the doctors.
But some doctors believe that in a flooded brain some islands may have survived that show traces of life. And they try to get through to them. When the observations made by some British neurologists in the case of a twenty-three-year-old woman were published in fall 2006, they caused quite a stir. Five months after an accident, the patient was in a coma and fulfilled all the criteria for a vegetative state. When this deeply unconscious person was told to imagine she was playing a game of tennis,” and another time that she was visiting all of the rooms of her house,” signs of activity appeared in her brain in two areas, different from each other, but corresponding to ones that in many healthy people are activated after the same instructions. These islands lit up on the screens of a functional MRI, testifying to increased consumption of oxygen by the
ON DYING AND DEATH
cerebral tissue. However, the skeptics are not convinced that they were the regions of the brain “necessary or sufficient for performing” these tasks. It is also claimed that the patient may already have entered the first stage of improvement, which was evident several months later. Either way, the definition of the vegetative state may be questioned in the not-too-distant future.
This is also implied by the story of a thirty-nine-year-old man who, after a serious motorcycle accident, spent nineteen years in a state of so-called minimal consciousness, which means that he sporadically reacted to a voice by moving his head, but could not communicate either by gesture or word. In 2003, in the course of a few months, he regained the power of speech, and ultra-sensitive examination revealed that “neurons in his brain had been slowly reconnecting over the years to bypass damaged regions.” Need I add that the first word to emerge from the lips of the patient after almost twenty years was “Mom”?!
For thousands of years, medicine used the classic criteria for death: cessation of circulation and breathing. When the blood stopped circulating, the dead person’s body went cold, livid spots (livor mortis) appeared and finally rigor mortis set in. These were the irreversible hallmarks, and the only thing left to consider was the funeral. The spread in the 1960s of resuscitation and the use of respirators revealed the inadequacy of these criteria for death. Indeed, in many cases the circulation and breathing could be restored; clinical death had become reversible. The brain and its ways of dying then found themselves at the center of interest. A new criterion for death was formulated: irreversible, permanent cessation of brain function. Particular attention was paid to the brain stem, and we began to identify the life of the brain stem directly with the life of the entire brain, and indirectly with the life of the organism as a whole.
The stem is the structure that links the brain to the spinal cord. It houses the centers that control breathing, the working of the heart and muscles, blood vessel tension and coordination of eyeball movements. Nerve paths run through the stem to the cerebral cortex from all parts of the body and go back to them through the stem too, though along different routes. Here too is the “reticular substance” (substantia reticularis), which turns on the cerebral cortex and maintains its state of wakefulness and awareness. How does a doctor seek symptoms of the death of the brain stem? He shines a light in the eyes and confirms that the pupils are failing to react, touches the eyeball and sees that the eyelids are not blinking, presses the trigeminal nerve in the face to cause pain but gets no response and moves the breathing tube but fails to prompt a reflex cough. He performs all these simple tests and several others at least in order to check if there is still a flicker of life in some hidden corner of the brain. He repeats them three or six hours later, and if the result is just as negative, he diagnoses death and recognizes the patient as deceased. And so he establishes the diagnosis by doing some relatively simple tests, without any sophisticated equipment; in many countries, including Poland, not even an electroencephalogram is required, because it is not fully reliable. In the modern understanding, death takes some time to occur. It is not a single moment, but a complex process. A person dies in stages: first biologically, when the brain stem dies. The remaining organs and groups of cells die later, each in its own time.
The definition in which brain death means the death of the organism as a whole has been adopted by most countries. Yet it still stirs emotions and objections. Let us think what a family experiences when they come into contact with a loved one who has been declared dead according to the new criterion for death. The loved one’s body bears no signs of death: it is warm, it is breathing, the heart is beating and the blood is circulating. “If the sick or dying
person looks exactly the same today as he did yesterday, why is he being treated as if he were alive yesterday but dead today? Can the pronouncement of death have no connection with the experience of death?” Naturally, among the critics we hear voices saying that brain death has been invented for the needs of transplant surgery. The complexity of the problem is revealed by the debate about Terri Schiavo. To this day some leading authorities believe that the changes in her were not irreversible; she was breathing on her own and her brain stem was functioning. “But in spite of that the decision was taken to starve her to death, because the law allowed it.”
For us, the doctors, turning off a respirator is an admission of failure. Deep in our hearts, each of us deludes himself that maybe in just a little more time, just a few days, maybe the organism will get moving. But you cannot go on like that ad infinitum. Hence the need for objective criteria that dispel the doubts and avoid the insoluble situation in which the quantum physicists found themselves with Schrodinger’s cat —half dead and half alive.
One might think resuscitation came into being only in the lifetime of the last generation; certainly, in that time it has become available publicly and on a large scale. But in fact it has its roots in the dawn of medicine. It was for this, for resurrecting the dead, that Asclepius, the god of medicine, was struck down with a thunderbolt. Later on, the idea of “reanimation” was always recurring in dreams and fantasies about loved ones who were lost and gone. It accompanied doctors and charlatans seeking applause and fame. It also attracted the imagination of painters, and not surprisingly, Caravaggio could not resist it. He painted his picture The Raising of Lazarus in the final period of his life, when after escaping from prison on the island of Malta by letting himself down its precipitous walls on a rope straight into the sea, he got across the bay and
reached Sicily. In Messina he received a commission from a rich Genoese merchant called Giovanni Battista de Lazzari. The painting made reference to the merchant’s name and was destined for the altar in the chapel of a hospital brotherhood caring for the sick. Caravaggio, the greatest painter in Italy, accepted a huge fee in advance and was given the hospital’s best rooms as his studio. He worked in secret, and made the workmen posing for him hold up a corpse that was already in a state of decay, and that served him as the model for Lazarus. The picture amazed the citizens of Messina, who expressed certain reservations. Enraged by their provincial complaints, Caravaggio ripped the painting to shreds with a stiletto. Once he had calmed down, he painted a second one, and this version has survived.
The story of Lazarus is told to us in the Gospel of Saint John. He was dying in Bethany, and his sisters sent for Jesus, but when the Savior arrived, He found Lazarus had already been lying in his grave for four days. He ordered the stone covering the tomb to be moved aside and called out in a loud voice. And the dead man came out with his hands and feet bandaged. Caravaggio’s Lazarus is getting up with great difficulty; his transparently painted body is still rigid with rigor mortis, and only his right hand is opening to accept Christ’s light. His outstretched arms herald the crucifixion. His body remains torn between light and shadow. The picture, as envisaged for the hospital chapel, shows the struggle between life and death and the hope for atonement. It has feverish, apocalyptic overtones: in it the “desperate longing for grace, the terror of the dreams that may disturb the sleep of death” are striking. Shimmering with reflections, the paint seems to correspond to the artist’s state of agitation. It is said that one day during a break in work on The Raising of Lazarus, Caravaggio went into the nearby church of the Madonna del Piero. There he was offered holy water to wash away his everyday sins. “It is not necessary,” he replied, “since all my sins are mortal.”
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Caravaggio was no exception. Other master painters too sometimes painted death from nature, by looking at corpses, even obtained for a single night. But, of course, they could never compare in number with all the doctors who from Renaissance times onwards sought dead bodies in order to investigate the obscurities hidden by layers of flesh and open up the world locked inside us —in short, to perform postmortems. William Harvey, who discovered the mystery of blood circulation, personally performed autopsies on his own father and sister, not to mention his wife’s beloved canary. As he said himself, he had no choice. Never for a moment did he consider stopping his scientific research, and he had no intention of stealing corpses from the graveyard. However, this was a practice that was already common in his lifetime, in seventeenth-century England, and that would become extremely widespread over the next one hundred and fifty years, because the law threatened severe punishments for stealing valuables from tombs, but not dead bodies. Teachers of medicine encouraged their apprentices in the medical art to obtain corpses for practical studies. Records have survived saying that at some Scottish medical schools, tuition fees could be paid in bodies instead of money. At the London academies, demand grew so rapidly that a clan of body hunters came into being. In a document issued by the House of Commons in 1828, we read that a gang consisting of six “resurrectionists,” as they were called, had dug up three hundred and twelve bodies in the academic season, in other words, from October to May, earning one thousand pounds a year, which was several times more than an unqualified workman earned. And in addition, the document states, they had the whole summer off.
Professional grave robbers stole thousands of corpses from their tombs for Doctor John Hunter, a Scot, the most famous surgeon in eighteenth-century London, whom the British like to call
“the father of modern surgery.” He dissected all the dead bodies obtained for him and made some original observations in the fields of anatomy and embryology. An ardent supporter of experimentation, he told his pupil Edward Jenner, who discovered the inoculation for smallpox: “I think your solution is just, but why think? Why not try the experiment?” He was not puffed up with pride, but could see the limitations of his profession, and left us the following definition of a surgeon: “An armed savage who attempts to get that by force which a civilized man would get by stratagem.” But this sober man with his feet fixed firmly on the ground was overcome by desire. He longed to possess the body of the famous Irish giant, Charles Byrne, who was dying of consumption. He sent his lackeys after him, who pursued him day and night, waiting for him to die. The terrified giant drew up a will in which he gave instructions for his body to be sunk in the Irish Sea. Hunter spent a fortune to bribe the undertaker, who at a roadside tavern on the way to the sea, extracted the corpse from the coffin and replaced it with cobblestones, while the mourners, who were extremely drunk, were fast asleep. And so the great surgeon’s dream came true.
Let us remember Rembrandt’s painting, The Anatomy Lesson of Professor Tulp, featuring the grandeur of death, and the concentration and awe of the doctors faced with the mysteries of the human body. Taking part in an autopsy was in those days regarded as such a distinction that the names of those present are written on a piece of paper being held in the picture by one of the men gathered around Professor Tulp; they have survived to the present day. However, once dissections had become a common affair, their image changed too. In 1828 the young Hector Berlioz assisted at a postmortem and left a description of it in his diary. He was shocked by the sight of the floor covered in puddles of blood and scattered bones, with rats roaming among them. We shall spare the Reader further details of his description, from which it is easy to
understand why the young man chose music and not medicine. But even Doctor Robert White, the eminent American neurosurgeon, who is the only man to have transplanted the heads of chimpanzees, told me in 2004: “I have never dared show anyone the film of that experiment. It was such a bloodbath!”
As for modern anatomy lessons ... You might think we are light years away from Rembrandt. It is the year 2003; let us transport ourselves to the Atlantis Gallery in London. Outside there is a very long queue of people waiting to go in. Every day, thousands of the living file past the dead, who have been preserved far from here, in Dalian, a northern province of China. There, in mighty bunkers, two hundred Chinese are busy removing the skin from the human bodies sent from all corners of the Earth, taking months to prepare them so that millions of people worldwide can “see what’s under your hood.” The mummification technique was invented by German anatomist Gunther von Hagens. They call him “the Walt Disney of Death,” although he prefers to say of himself that he simply reveals the beauty hidden under the skin. He dehydrates the corpses with ice-cold acetone and then injects them with synthetic polymers, plastic. The organs and tissues keep their build, right down to microscopic structures.
In the gallery the crowd walks among the “plastinates,” which are displayed in various poses. But we are not at a waxworks exhibition. The plastinates are not imitating people. They are people, dead ones. One of them, stripped of his skin, is holding it like a jacket over his arm; he looks like a figure from Michelangelo’s Last Judgment. Others are standing or sitting in relaxed poses. Besides the “full human specimens,” there are some separate exhibits including a pair of tobacco-blackened lungs, a liver eaten away by cancer and a heart destroyed by an infarction. The visitors
inspect them with curiosity. Do they also feel a shudder? More like a tickle, as here in the gallery you can hear occasional bursts of laughter and jovial comments. Before the Londoners, millions of people in New York and Munich came to see the plastinates. The exhibition is touring the world. In Korea the crowds came flocking day and night, and they had to keep the doors open round the clock to accommodate more than two-and-a-half million people. All over the world, the reactions are positive. Almost five thousand of the visitors have expressed a wish to be plastinated too.
The multiplied nature of the exhibition is a reflection of our world. Everything has been multiplied in this modern, mass anatomy lesson. Instead of a small group of students, leaning over a single corpse, hundreds of people are walking about among dozens of exposed bodies. Is it exhibitionism? All just for show? Many people believe these are features of our world. In the modern postutopian discourse, writes Chantal Delsol, “one major idea dominates ...: the certainty, clung to come hell or high water, that man is indeterminate, thus preserving our liberty to do with him what we will. Man must be empty and malleable, capable of becoming anything.” Thoughts about departing this life and the threat of death, seen face-to-face, have been left far behind. Rest in plastic, Reader!
Fifty, one hundred, five hundred years ago, those who departed this life did not have to be sought in museums. The dead came out to meet us themselves. So it was during the summer holidays of my childhood that I spent in Pilzno, my father’s small native town in the Carpathian foothills. The local train, known as the “Bummelzug,” panting away, would stop at the empty little station in Czarna. There the horses in harness would already be waiting to take us, our parents and all our holiday luggage home through the dark woods along a rutted sandy track. Whenever I read Mickiewicz s epic Pan Tadeusz, it is this white, stone quasi-manor house
with a wooden veranda and a large garden that always springs to mind as soon as the hero’s estate, Soplicowo, is mentioned. On hot summer afternoons, when life was at a standstill and the heat came wafting all the way from the Ukrainian steppes, the bells of the parish church and the monastery would ring out. After a brief jangling, the swinging tones would fall into a steady rhythm, and a funeral cortege would emerge from the parish church, cross the town’s market square and go up Wf gierska Street. It would pass under our windows on its way to the cemetery, which lay on a hill among old oak trees and poplars; through them in the distance we could see the river glinting and the outline of the mountains. At the front walked a peasant in too short a surplice, holding upright, in both hands, a long cross, taller than himself. Then came the coffin, on a horse-drawn hearse, though sometimes the relatives carried it on their shoulders. Next came the priest in his stole, holding a missal and a sprinkler, and behind him came the procession of people in black. Many years later we carried my father along this same route. The bells rang steadily and the singing of the mourners carried a long way. Ever since, I have heard these two bells, from the parish church and the monastery, in the funeral march out of Chopin’s sonata in B-minor. They rang in two chords basso ostinato, relentlessly repeated, as the dotted, melodious tune unrolled above them.
These days, the town no longer comes out en masse to bid farewell to the deceased. No cortege crosses it, and no bells ring. From a chapel in a new part of the cemetery the coffin emerges on the platform of an electric trolley, on which it travels to the spot prepared for it in a long line of confusingly similar graves.
For centuries death communed with a man for a long time before taking him away. It accompanied him in his thoughts, conversations and prayers. In the fifteenth century didactic poems, such as The Plaint of the Dying, for example, were meant to “encourage a
person to be pious, make him abhor sin, and instill in his heart a fear of death without repentance.” The most successful of them, and “of all medieval Polish poetry in general,” was Master Polikarp’s Conversation with Death. At his request, Death appears in a church to a learned man named Master Polikarp. The Master faints, regains consciousness and starts up a conversation with Death. He asks about its origin, and it replies that it was born in Paradise, when Eve plucked the apple: “Adam tempted me with the apple.” Angry and ironical, Death unfurls its vision of omnipotence and might. Then the Master timidly asks why we have doctors. In reply he hears: “Every doctor’s a cheating fraud; none of his ointments do any good.” And to dispel any doubts, he adds:
There’s no escaping from my scythe
I slash the throat of all who live.
In our poem about Master Polikarp, Death was depicted as a decaying corpse; this element of horror was not at all exceptional in those days. However, the personification of death that prevailed was not known to the ancient world or in the early Middle Ages —in this version it was embodied as a skeleton. Especially popular in painting and in fairground shows was the danse macabre, or Totentanz. It expressed the medieval concept of human life, where everyone is equal, heading towards death. Death leads the dance, in which people of every age and status take part, including a pope, an emperor, a cardinal, some bishops, a girl and a child. In the Bernardine church in Krakow a fiddler and an organist with a small harmonium play along to some skeletons dancing a quadrille. Death has one paw resting on the fiddler’s shoulder and is holding the organist around the waist, while politely holding up his notes. A caption under one of the dance scenes assures us that “what a dreadful leap up high, when the tune screams you must die.”
The presence of the dead weighs heavy on the Middle Ages, both in the real and the imagined world. From the tenth century onwards, stories about ghosts that torment the living are heard everywhere. These ghosts are usually the phantoms of people who died violently — murder victims, women in childbirth, unbaptized babies and suicides. They demand support from the living —alms and prayers—which will allow them to escape hell. Sometimes the phantoms emerge from their graves, attack the living and drink their blood. In the word “macabre” some historians have noticed an onomatopoeia, hearing “the rattle of bones,” while others have interpreted it as “the dance of the spindleshanks” (mactorum chorea). The whole art of the macabre —the iconography, frescoes, sculptures, miniatures and etchings — shocks the mind with the threat of death. In contrast to our era, where fear focuses on the pain of dying, in medieval times the greatest fear was prompted by sudden death. It carried the danger of departing this life in a state of mortal sin, and thus increased the threat of damnation in hell. Only the eighteenth century brings a third place, a waiting room for ordinary sinners — purgatory.
Did its omnipresence in the Middle Ages mean that death had become something tame and familiar? Was it less bitter and cruel than nowadays? This is a marked contrast to the modern attitude, in which we do our best to forget about death —we have driven it out of our world. “Death is a scandal, just like pain and suffering.” But in his extraordinary, pioneering book The Waning of the Middle Ages, Johan Huizinga reckons that when the world was over five hundred years younger, all forms of human life had far sharper contours than they do today. “The contrast between suffering and joy, between adversity and happiness, appeared more striking. All experience had yet to the minds of men the directness and absoluteness of the pleasure and pain of child-life. There can be no doubt that in the Middle Ages people spoke more sincerely and
commonly about dying and death than today, which does not mean it was any calmer a process.
These matters cannot be generalized, just like the trauma of the death of a loved one and our reactions to their death, which the hospital doctor sees every day. Often it is a silent grief, a torpor, a desire to get away from the place of suffering, a speedy farewell—especially when the illness has gone on for a long time, chronically. But a great many people are dumbstruck at the news of sudden, unexpected death. Their expression goes blank and they fall silent, as if “tongue-tied,” while in fact they are in the grip of some powerful emotions that have shattered their peace. This sort of situation is described by the myth of Niobe, who after the death of her children freezes on the spot and turns to stone. Another response to the news of the death of a loved one is fainting — terrifying fear of an extreme situation that cannot be altered. Keeping calm and still can at any moment turn into an outburst of spasmodic pain. “We would recall the irrevocable; we would cry out to one who cannot answer; we beg for the touch of a hand whose loving pressure we shall never feel again.” Joanna, the sixteenthcentury Queen of Castile, known as the Mad, twice had her husband s coffin opened at Miraflores where he was buried. According to some accounts, she tore the clothing from him, kissing his feet and hands; others say that she stood motionless, without shedding a single tear. One of the most famous examples of long-term mourning in history is the case of the British queen Victoria over the loss of her beloved husband, Albert. Even though in time she managed to overcome her initial state of depression, she could not control her extravagant grief. She always dressed in black; imposed a strict cult of the deceased, celebrating the anniversaries of his birth and death and the dates of their engagement and marriage; had Albert’s rooms kept in an unaltered state and for a long time failed to observe mourning for any other member of the family. So
is it true to say that “in all these strivings of ours to keep the dead from really being so, we begin to encompass their real extinction within us”?
In the German language, as in ancient Greece, death (der Tod ) is of the masculine gender. In the first of three drawings by Albrecht Diirer, known as masterpieces, Death and the Devil never abandon the knight in armor, who resembles an equestrian statue in bronze. In Paul Celan’s most famous lyric poem, Todesfuge — “The Fugue of Death” — “‘Death is a master from Germany’ and is embodied in the figure of a man playing with snakes; he has blue eyes and forces the Jews to dance. ‘In German art, from Holbein’s to Rethlowski’s Dance of Death , death remains an aggressive, active, vigorous man, sometimes in armor, sometimes on a horse.’”
In the Polish language, this association is not made because death ( smierc) is of the feminine gender and has a woman’s face. Jacek Malczewski painted her many times over a twenty-year period, and no other theme appears so consistently in his work. Nor does any other more powerfully depict the tension between the biological and the transient. In his painting Death , dated 1917, a strong, healthy looking girl stands by the smooth white wall of a cottage. She has black, slicked-back hair with a flower pinned in it and is wearing a simple, deep purple dress tied at the waist. She is waiting by an open window, in which we can see the face of an old man. Leaning against her shoulder there is a scythe, “painted with tangible precision.” She has turned her head towards the open window. In her there is strength, physicality, beauty and indifference. “She is young —so she has time to wait..., she is healthy —so she conquers even the healthiest.”
In another painting a naked woman of luxuriant physical beauty invites an old man to come through the gate, beyond which there
is no return. Another especially eloquent painting is Death , dated 1902. A young woman reaper is wielding a scythe, and an old man has knelt down and folded his hands in prayer, accepting the light but attentive touch of her fingers on his eyelids as a revelation. This sort of image of death — gentle and feminine — seems to imply being reconciled with fate. There is nothing off-putting or threatening here. The picture radiates extraordinary charm, emanating benevolence, tranquility and solace. Death by touch soothes the pain, betokens another life and promises “unity with whatever man loved most ardently in life.”
The mood for crossing to the other side in silence and solace is set — as well as by profound faith — by old age. The time when “the clocks began to turn / faster and faster above us.” Ever more frequent signals appear telling us that “... the whole thing must oxidise, / disintegrate and cool, turn pabulum.” For ages we do our best to resist them: “Each night, each day the tiresome exercise / so no small change should change the enterprise.” But it is late already. We cannot hold back the changes forever. And so we start to move away from life. We stop expecting anything, either good or bad, and nothing unusual or surprising is likely to happen any more. Man ages gradually; first his curiosity about people and the world wanes. Gradually, it all becomes familiar and obvious, and things lose their mystery. At the same time the body grows older — not the whole thing, not all at once, but in parts. The vision and hearing grow weaker, and the heart or lungs deteriorate. A sort of worm seems to be gnawing away at us. Our physical powers diminish and tiredness sets in. Every outing from home becomes a problem and assumes the proportions of a major event. Meanwhile, hope remains alive within us, the desire for change and even joy. But once they too have gone and there is nothing left except memory and vanity, then old age takes possession of us for good and
all. We just continue to watch over the body, the fabric that keeps disintegrating faster and faster, irreversibly. Along with old age, death starts to creep in. Things that were never going to concern us come closer and make a lair for themselves inside us. Death blends in, “She is a body in your body.... She swells in you, rots like an alder trunk felled into water.” The rotting stump becomes more and more of a burden. Frightened, confused signals run round the body and reach the brain. It tries to stifle them, until gradually it slides into depression. Death does not come from the outside. It is inside us. One day “we find it, like something that is found in the pocket of a winter coat.”
If the circle of life heads towards its close by bringing us via old age —that “second childishness” —back to the beginning, then death goes even further, reaches back even earlier and, in marking the limit of life, evokes the first moments of our existence. For it is then, paradoxically, that it makes its very first appearance within us. In embryonic life, inside the mother’s womb, some of the fetus’s cells grow, but others perish. Their death does not happen by accident, but is carefully prepared, planned in advance. Most of the cells in adult human beings preserve from that remote time a precise mechanism for suicidal destruction. It is built into their structure and is called apoptosis. When the right signal comes through, the cell goes into a lethal trajectory. And like an intercontinental missile, it is steered by a program that has been prerecorded in minute detail, and that has just one aim: annihilation and self-destruction. A network of specialized enzymes is set in motion, called caspases, which disjoint the cell into pure, defined pieces without stimulating the inflammatory reaction that always accompanies its unforeseen damage and disintegration. So, for example, in early fetal life, to begin with our fingers are fused together, but they separate when the cells joining them enter into apoptosis and die.
However, in waterbirds they remain alive, creating web footing. It is also thanks to apoptosis in the early stages of life that the thymus eliminates autoreactive lymphocytes, instructing the immune system how to distinguish the “self” from the “non-self.” A cell in which the apoptosis mechanism has once been set in motion goes on a journey from which there is no return, heading for the same goal as an old person, for whom we cannot restrain the process of dying.
When Seamus Heaney, the great poet and Nobel Prize winner, visited Czeslaw Milosz a few months before his death, he found him in the sitting room, face-to-face with a bronze bust of Carol, his second wife who had died a year earlier. Heaney got the impression that the old poet sitting on the far side of the room was staring at the bronze bust and everything else from another shore. Around him were his daughter-in-law, our two best nurses and, in the background, his invaluable housekeeper and his secretary. All this vigilant care and his host’s altered expression made Heaney think of Oedipus, nursed by his daughters in a grove at Colonus. The old king had come to the place where, as he knew, his life would end. For Milosz, Krakow was not his native city, but it was there, like Oedipus at Colonus, that “he had come home to himself, to the world, and to the otherworld.” Here for the whole eighth decade of his life and the years that followed, he was living testimony to Goethe s words about the potential that remains in old age, about the fact that “it does not have to be nothing but decay, but can also be Steigerung, a heightening.” When, less than a year after this final visit, Heaney flew to Milosz’s funeral, he brought his own adaptation of an extract from Sophocles’s Oedipus at Colonus. In it, as
he bids his daughters farewell, Oedipus takes them into his arms and says:
... “My children, ” he said—
And the rest of us felt that we were his then too —
“Today is the day that ends your father's life.
The burden I have been to myself and you Is lifted. And yet it was eased by love.
Now you must do without me and relearn The meaning of that word by remembering. ”
Sometimes a person does not know life has already started to escape him “like grains of sand pouring through a sieve.” He comes to see the doctor with some fairly trivial complaint, but the examination reveals the unexpected truth: the signum mali omnis — a sentence against which there is no appeal. A portent of life’s end can also reach us by a different route, as it did Homer. One day, he was walking along the beach when he stopped by a boat, from which some young fishermen were unloading their catch. “How did you do, boys?” he asked. The youngest one replied with a riddle: “All that we caught, we left in the sea; all that we did not catch, we are taking home with us.” Then Homer remembered the words of the Delphic oracle, warning him against boys talking in riddles. He did not understand what the youth’s reply meant, but he did realize that the end of his life had come. He died three days later. However, what the fishermen were thinking of was fleas. Any that they caught on themselves, they threw into the sea, but of course any that they did not catch, they brought home with them. No account has survived of the last three days of Homer, who was himself one great enigma. However, we have no reason to suppose he did not show the same arete — courage determining perfection as his compatriot Socrates did hundreds of years later, the man who the Delphic oracle would say was the wisest of the Greeks.
He could easily have avoided death, but he refused to do so, and insisted on obeying the law. To the very end he talked with
his pupils and accepted death with exemplary calm and bravery. “Everyone unanimously admits that no man before, as far back as our memory reaches, ever looked in the eyes of death with greater dignity,” wrote his pupil Xenophon. Socrates was the son of a midwife, who understood that the truth arises among questions, and who called the method of reaching the truth that he created maieutics , or the art of obstetrics. He believed that the truth is inside us, though we are usually unaware of it. He aimed to bring out of hiding, into the light of day, some invariable truths and fundamental ideas, mainly concerning morality. Before his death he turned his thoughts to medicine. His last words were: “Crito, we ought to offer a cock to Asclepius. See to it, and don’t forget.” His enigmatic words, still discussed at length, are interpreted in various ways. Was this his way of saying that to live means to be ill for a long time, and so we should thank Asclepius for postponing the end? No one has offered a more radical interpretation than Friedrich Nietzsche, who wrote: “Socrates wanted to die ... He forced Athens to sentence him ...; he said softly to himself ... ‘Socrates himself has merely been sick a long time.’” But it is hard to regard Nietzsche’s judgment as impartial. Indeed, after discerning with astonishing perspicacity the wave of European nihilism heralding “the death of God,” he was looking for its genesis and perceived it... even in Socrates’s rationalist dialectics. Yet he admired him for his death: “To die proudly when it is no longer possible to live proudly.” And he was probably thinking of Socrates when he wrote appreciatively about freely chosen death as “death at the right time, brightly and cheerfully accomplished amid children and witnesses: then a real farewell is still possible, as the one who is taking leave is still there.”
Socrates’s last words, uttered while fully conscious, have come down to us unchanged. However, the doctor’s mind has a right to
be doubtful when he reads about words spoken in the final throes of death. We find the first version of Slowacki’s last words, spoken on his deathbed shortly after listening to a letter from his mother, in a letter written by his friend Zygmunt Szcz^sny Felinski the day after his death. The poet spent his final hours dictating to Felinski corrections to the second rhapsody in King-Spirit , and then finally asked to be laid on the pillows in his bed and was supposed to have said: “Maybe it will be in this position that death will find me.” But a dozen years later Felinski, then a senior church hierarch, made these words sound more impressive; others then “worked some more on the phrase,” which in the ultimate version was to be: “The time has come to cast off this tattered mantle.” Yet Slowacki died suffocating. Terrible attacks of breathlessness and coughing interrupted by fainting fits came one after another, without any respite towards the end. His words must have been mixed with whistling and wheezing, and it was probably very hard for them, especially the final ones, to break through his airways once they were blocked.
Do dying people see visions in their death throes, and of whom? Does anyone come for them? We can only make guesses, as did Giuseppe Tomasi di Lampedusa. As Prince Fabrizio, the keen amateur astronomer, was dying, his mind was plunged in darkness and he kept losing consciousness. It seemed to him as if, with a small group of relatives surrounding his deathbed, “suddenly amid the group appeared a young woman; slim, in brown traveling dress and wide bustle, with a straw hat trimmed with a speckled veil which could not hide the sly charm of her face.... [She] drew closer. It was she, the creature forever yearned for ...; the time for the train’s departure must be very close. When she was face-to-face with him she raised her veil, and there, chaste but ready for possession, she looked lovelier than she ever had when glimpsed in stellar space.”
♦ ♦♦
Perhaps we should talk less about death and more about dying. And not be afraid of the subject, not push it away. “It is a matter of prime importance for the ordinary man who, by contrast with the doctor, may only encounter death once, or maybe a few times in his entire life.” And then he has to cope alone —for better or worse —when it happens to him. Because: “But a common night awaiteth every man, and Death’s path must be trodden once for all.”
Various paths lead us to death. Incurable progressive illnesses are often the starting point for one of them, illnesses that keep marching forward relentlessly, destroying and laying waste until they have exhausted all possible forms of treatment. Then palliative medicine comes to the patient’s aid, caring for him at the close of life. Its name comes from the Latin words palliare, meaning “to wrap or cover,” and pallium, meaning “an overcoat,” and so it involves “wrapping an overcoat” around abandoned patients whom medicine designed to find a cure can no longer help. We associate palliative and hospice medicine with soothing pain and with sedation, in other words, applying drugs that dull awareness for patients who are suffering greatly. Indeed, that is a feature of its effect, but by no means the only one, because it is performed by a qualified team of caregivers (doctor, nurse, social worker, psychologist, chaplain, physiotherapist, volunteer) and should be available, first and foremost, as a round-the-clock home counseling service or at a day-care center, or ultimately a full-time nursing home. It is estimated that of the nearly four hundred thousand people dying of chronic illnesses in Poland each year (including about a hundred thousand who die of malignant tumors), more than half require palliative care.
We would all hope to be sure of a dignified death, without suffering, and to benefit from the loving presence of someone dear to us, and some solid support and reliable information about terminal illness, “essential for closing the most important stage —the end
of life.” Meanwhile, the carers avoid tricky questions by fobbing the dying person off with perfunctory answers. Many families do so in league, feeding them false hopes for a chance of getting better, and denying the inevitable approach of death. And how many of us doctors are incapable of talking to dying patients, avoid contact with them and limit ourselves simply to prescribing drugs, often without discussions with the family. Eventually, the moment comes when it is too late for that deferred, neglected contact. This is the agony of death —just over two-thirds of patients partially or entirely lose consciousness in the final twenty-four hours of life.
A person who is incurably sick, especially as he approaches death, does not just suffer physically but also spiritually, existentially. His sense of isolation increases — “the metaphysical isolation of a man who is passing over into death, the great chasm of the unknown,” a feeling so strong that even true believers think God has abandoned them at such a moment. Questions about the meaning of human existence keep insistently recurring, prompted by suffering and the fear that comes with it, rather than by a theoretical interest in philosophy. A troubled conscience increases the dying person’s sense of responsibility for life, for the wrong he has done. How important it is to be at his side just then! However, we do not need to fill these moments with advice and consolation. We do need to listen. “One should not fear silence.” Or drown out the dying person’s thoughts. Sometimes it is hard to find the answers to his questions, and he is aware that we do not know them. But we do not need to be in a hurry to explain, or feel ashamed of our helplessness. Usually the best answer to those questions is our loving, devoted presence.
Can we possibly fail to think of the Polish Pope in this context? John Paul II always did his best to visit the sick and to be with people who were suffering, and he thought about suffering very
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thoroughly. But then a time came, the final stage, when he could no longer write or speak about suffering, and instead he became suffering. And then through his own example he showed us how, by strength of spirit and faith, it is possible to overcome suffering and, by one’s own suffering, enrich the lives of millions — something that had seemed impossible, because a time comes when the suffering goes beyond measure, when the bond breaks and the sick person is shut away from us in some other world.
But he knew that this bond with us —made of the same fabric as the bond with heaven that we are always breaking —should never be broken. And when we saw him for the last time, on Easter Sunday at a window of the Apostolic Palace, he was still trying to share his words with us, even though he could not. Perhaps he was hoping to cheer us up, as he had done so many times in the past? Or maybe, as on the final page he wrote on his deathbed with the help of his entourage, he wanted to thank the young people whom he had sought out all his life and who had now come from all over the world to be with him? We will never know what else he wanted to say, but he left us the image of himself at the window, when the words could no longer come out, but he raised his drooping arms, as if trying to embrace us, as if he were saying goodbye with them, like the wings of a mortally wounded bird as it flies away ...
He also showed us how it is possible to die, and how a person should die. He invited us to keep him company in death. Some people thought it rather a pitiless novelty, admitted one eminent writer who is an avowed atheist, to show that “one does not die in isolation or seclusion, but in the public gaze; but then that is exactly how Jesus died. He showed that a person who is completely immobilized, nailed to a cross, unable to utter any words, can do a great deal. He showed this to a world that wants to be young forever and has pushed dying and death out of its conscious mind, denying them the right to exist. Are we not often like the people
in Brueghel’s painting The Fall of Icarus who cannot even be distracted from their mindless, everyday occupations by something as astonishing as a boy falling from the sky right next to them? Everyone calmly walks away from misfortune.
Death kept pace with John Paul II throughout his life, from the loss of his mother in childhood, and soon after his father too, through to the assassination attempt of May 1981. During his pontificate he was in the hospital twelve times in the Gemelli clinic and had numerous operations. In his final years his illness advanced, and we watched with aching hearts as he looked ill and visibly suffered. Yet at the same time, to the very end his suffering went hand in hand with courage, great persistence and determination. He even accepted his increasing lack of mobility with good humor, jokingly calling his mobile platform a “wheelbarrow.” “Anyone who witnessed the passing of John Paul II will remain cautious in presenting some of the arguments about euthanasia.”
The Pope taught us that we should accept pain and suffering fully and totally, and no one could possibly have sounded more convincing when he said that a vocation for suffering is a way of sharing in the suffering of Christ. He showed us the mysteries of suffering and death. Without him we were ready to forget they exist. We did not know how to take them on board, but we did know that he understood them and could introduce them to us — with his entire self, his teaching, his life and death.
Francisco Goya
Game of the Little Giants, 1792-1793 Prado, Madrid
In 1955 President Dwight D. Eisenhower had a heart attack. He was given morphine, put to bed and told to stay there for four weeks. In a heart attack, or myocardial infarction, the sudden closure of the coronary artery leads to the demise of the part of the cardiac muscle that was nourished by this artery. Thus it was believed that lying flat for a month facilitates healing within the damaged heart and helps produce a strong, tight scar. Forty-five years later, U.S. vice president Dick Cheney suffered an infarction: at the hospital a coronary catheterization was immediately performed, and the closed branch of the artery was identified and opened by introducing a small balloon. The patient was given strong anticoagulant drugs, and after four days he left the hospital in good form, on his own two legs. What a fundamental difference in treatment methods!
Coronary artery angioplasty, as the opening of a closed artery is called, usually supported by implanting a stent, in other words, a delicate metal scaffold that keeps the blood vessel open, helps the patient to survive the toughest stage of the illness and often saves
his life. If it is performed early, in the first few hours of sickness, it reduces the area of the infarction. But even so, part of the muscle dies for good, especially as many patients don’t reach the hospital quickly. If only it were possible to revive that dying area! If only we could introduce new cells in that spot, that would take over the function of the ones destroyed by the infarction. Such an idea could have wide application in treatment, leading to the medical breakthrough of the twenty-first century. Indeed, infarctions develop not just in the heart but also in the brain, lungs and many other organs. In each case tens, hundreds of thousands of cells die. Just as much, or sometimes even more, damage occurs without an infarction, for example when the spine is broken and the spinal cord is injured, or in diseases such as Parkinson’s, Alzheimer’s and other degenerative brain conditions. In all of them, regeneration of the damaged areas could reverse the course of the illness. The dream solution would be young, developing cells full of energy, which when injected into the disease-affected organ would transform into its own cells and restore its healthy functioning. You have probably guessed, Reader, that our sights are set on stem cells. It is on them, above all, that medicine is placing its great hopes.
So what are these creatures on which we are pinning so much hope? They are the primary cells from which specialized cells develop. It is from them that the cells of the muscles, liver, bones and brain originate. They are the stem from which the branches of the tree grow; this central feature has given them their name. But the root of their Polish name, komorki macierzyste, which means literally maternal cells,” is apt too, because it refers to the mother who gives birth to offspring.
Where can we find them? How can we obtain them? They lie dormant in most of our tissues and organs, but they are scattered and not numerous. There are a few more of them, though still not many, in the blood. However, their main storehouse is the bone
marrow. It is there that the remaining blood cells develop from them —red, white, and all the others. From the bone marrow, the stem cells make their way into the blood system and probably settle in at least some of the organs.
Cells gathered from the bone marrow were first injected into patients in an area of the heart altered by an infarction at the start of the current century. The first reports were electrifying. They spoke of a rise in the contractibility of the heart muscle of as much as thirty percent. But in the latest, comprehensive publications a note of skepticism has already emerged. We should remember, however, that the groups treated so far are still very few in number. A transplant of cells is usually combined with revascularization, or an improvement in the blood supply by means of a simultaneous angioplasty and stent implant. Thus it can be quite impossible to determine what has produced the favorable result of these operations. We discovered for ourselves how hard it is to assess this promising course of action when, after reading the first article published by Japanese scientists on treating atherosclerosis of the arteries of the lower limbs, we conducted similar experiments at our hospital. So far they have included only about a dozen people with advanced lower limb ischemia in the course of Buerger’s disease or atherosclerosis. These were patients with constant pain at rest and non-healing ulcers or superficial necrosis of the feet, which were already under threat of amputation. We collected bone marrow from each patient’s ilium, and after brief preparation we injected it subcutaneously into the muscles of the foot or calf in at least forty places. The first striking effect was a cessation of pain one or two days later, enabling a radical reduction of analgesics. In over half the patients the necrosis gradually lessened and the healing process for the ulcers began, which was confirmed by angiographic tests that indicated an expansion of the network of vessels of the shin and foot and an increase in the blood flow. But in some
patients the illness progressed, resulting in amputation. So are there patients who react to this treatment, and others whom it leaves unaffected? How can we tell them apart? And how much autosuggestion is there in all this for a patient who is already expecting amputation and who is suddenly offered hope? The cold observer will say the group we treated was too small to draw any binding conclusions, and he will be right. He will also add that it is essential to conduct the experiments using a placebo, so that half the patients are injected with physiological saline instead of bone marrow, and neither doctor nor patient will know who has been given what until the end of the experiment, when the code disguising the patients’ names is revealed. Without doing this, the cold observer will say, you will never know the truth. And he will be right. But if we keep hearing the happy chirping of cardiologists all around us, announcing fabulous results in infarction cases, what is to stop us from applying the same treatment to patients with chronic lower limb ischemia? Or to those who have already been through every degree of suffering? Are we to inject physiological saline into painful areas and keep an eye on them for over a month? But without doing that, won’t we keep wandering in the dark forever? It is extremely likely, and our results will certainly never be regarded as credible. After the initial, open attempt at treatment, randomized research involving a double blind test will be essential. This example illustrates the modern requirements for new forms of therapy.
I shall cite an unusual example of the application of stem cells. A young Catalan woman, the mother of two children, fell ill in 2004 with tuberculosis. The illness took a severe course and refused to respond to drugs. The tubercular swellings were blocking her airway. In 2007 the diameter of the trachea contracted to four millimeters. The trachea was removed, a fusion with the bronchus was
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made and a stent was put in, but none of this helped, and the patient continued to suffocate day and night. Then something unusual was done. Stem cells were taken from the patient’s bone marrow, as well as cells from her airway, and these were sent to a laboratory in Bristol, England, to be multiplied in vitro. At the same time, the trachea was removed from the body of a fifty-one-year-old woman who had died of a brain hemorrhage. It was totally cleansed of its own cells, and also sent to Bristol, where, in a bioreactor flown in from Milan, it was seeded with our patient’s previously multiplied stem cells. These cells took root in the trachea and grew over it. And so a new trachea was produced, the solid structure of which, the skeleton, came from a dead patient, but the walls of which were made from cells taken from the living patient waiting for a transplant. Meanwhile, time was rushing by, and the patient’s condition worsened abruptly. A regular flight from Bristol to Barcelona refused to take the “manufactured” trachea on board, but fortunately a German student on his practical training tracked down a friend with a private plane, who flew to Barcelona in time. The colonized windpipe was implanted into our patient, and as the cells were the patient’s own, the transplant took perfectly, with no rejection —the bane of this sort of procedure. Apparently, three months later the patient, a fiery thirty-year-old woman, danced half the night away at a ball on the Costa Brava.
The substance we implant from the bone marrow is composite material. Here too some people perceive divergent results for treating heart attacks, and they say: “Mixed cells give mixed results.” If only we had pure stem cells! But of course we do have them —they appear in fetal life, at the very start, before the diversification stage. It is from them, these primal embryonic stem cells, that the cells of the heart, liver, brain and other organs will later develop. Human embryonic stem cells could be obtained by means of cloning. What does cloning involve? The nucleus is removed from an egg cell and
another nucleus is put in its place, taken from the cell of a mature organism. Then an incredible, mysterious reaction occurs: the nucleus radically rejuvenates; the hands on the clock go back to the beginning, to the embryonic state. In this mature nucleus, under the influence of “female” cytoplasm, genes are aroused that were active a long time ago, in fetal life, but were then extinguished. The cloned egg cells, with their mysteriously reprogrammed nuclei, are implanted into the uterus of an adoptive mother, and months later she bears a child. So in 1997 Dolly the lamb was cloned, and after her other sheep, cows, a horse, a piglet, a wolf, a mouflon, a buffalo, a donkey, a mule, a cat, a dog ... Ten years after Dolly’s birth her creator, Ian Wilmut, says: “we should still be surprised that cloning works at all.” Another renowned biotechnologist agrees with him, asserting: “cloning is still essentially a black box” —its workings are incomprehensible. Its efficiency is also far below expectations. Nowadays, only from two to four percent of cloned animal embryos are born as healthy individuals. That is not much better than ten years ago. Of two hundred and seventy-seven cloned embryos, Dolly was the only one to be born and to have survived.
Reproductive cloning, in other words, experiments aimed at reproducing a complete human being, is against the law in all countries. But for using stem cells for scientific research and ultimate medical purposes, the situation is different. And so there are three sources of stem cells. The first is the bone marrow, though there they are found in a highly dispersed state. The second is cloning. Here the problem is with the eggs. It is difficult for scientists to acquire enough female ova for their needs, and so they pay volunteers enormous sums of money for them. The third source is human embryos from the period before they take root in the uterus (blastocytes), which are available at clinics treating infertility (with in vitro fertilization), where they are sometimes obtained in excess, as so-called surplus embryos. They are doomed to perish, or to be
preserved in a frozen state, if the parents envisage further pregnancies. Both cloning and the manipulation of early-stage human embryos prompt serious ethical objections and are the subject of a wide range of regulations in different countries.
All these difficulties and obstacles may be mitigated by a new approach, involving a revolutionary concept. What if, the thinking goes, one were to reprogram a mature, developed somatic cell without the help of the cytoplasm of an egg cell? What if one were to work directly on its DNA, and wake up the genes that are dormant within it and have been inactive since the embryo stage? This fantastic vision became a reality at the turn of 2007 and 2008, thanks to Japanese scientist Shinya Yamanaka. He took mature cells (from the facial skin of a grown woman) and introduced into them four genes (in specialized terms known as “transcription factors”). A month later, they had transformed the cells into human stem cells (in specialized terms “induced, Pluripotent Stem Cells,” or iPSCs). Thus a mature cell had reverted many years backwards, to the earliest stage of its existence, to begin life over again so to speak. These results have already been confirmed in many laboratories. Yamanaka, a forty-nine-year-old scientist from Kyoto who had wanted to be an orthopedist but took up research when he realized he did not have the manual skills, recently won the Lasker Award, which is the last step before the Nobel Prize.
But there is no doubt that a breakthrough has been made, a shake-up in the scientific world. Ian Wilmut, creator of Dolly the sheep, said that from now on he would stop experimenting on human embryonic stem cells, because the new discoveries opened up far more interesting prospects. And something just as important: they have eliminated a weighty ethical problem. To recreate stem cells in the future, it will not be necessary to turn to human reproductive cells or embryos. Those whose lives are consumed by cloning but made unpleasant by ethics are also aware of this. On
first hearing about the breakthrough discovery described here, one of them announced with satisfaction: “People working on ethics will have to find something new to worry about!”
With the help of this particular method — the reprogramming of mature cells stem cells have already been obtained from patients with Down syndrome, muscular dystrophy, insulin-dependent diabetes and dozens of other hereditary illnesses. These cells are multiplied in a culture, and are long-lived. The plan is to remove from them the defective genes responsible for the illness, implant normal genes, and inject the patients with these “repaired” stem cells —and thus to correct a defective mutation permanently. Stem cells obtained from patients can also be transformed into the more mature cells of individual organs (e.g., the cells of the heart muscle) in order to test their response to drugs.
However, the road to clinical application is immeasurably long and abounding in difficulties. The vehicle that introduced the four reprogrammed genes into the mature cells (the “transcription factors”) are viruses that also carry countless dangers, including the potential to cause cancer. Similarly, in the stem cells themselves the potential to cause cancer is strong. The first doubts are also appearing as to whether during the reprogramming process “genetic and epigenetic abnormalities in the iPSCs” might result, which would call into question their future application in medical treatment.
There is also the issue of time. The flow of time, the relentless passage from past into future, is one of mankind’s most basic experiences, a fundamental feature of reality. We talk about the arrow of time and it is an apt metaphor since, just like a flying arrow, time does not keep still, but races irreversibly in the direction the arrowhead is pointing. However, it is not always perceived like that. In music, the linear passage of time didn’t take hold until in the works of Mozart, Haydn and Beethoven, marking the advent of musical modernity. We define the arrow of time as cosmological when we
wish to stress the existence of one common time for the entire Universe (which is not at odds with the theory of relativity, according to which the passage of time is different within different frames of reference). For indeed the Universe is expanding, galaxies are moving apart, and as this process continues the density of matter diminishes, and of two states of the Universe, the one where the density of matter is now greater is the earlier.
By reprogramming a cell we reset its time to the earliest stages of its life. It does not seem right to say that we have turned back the arrow of time. After all, time has not run in the opposite direction; it wasn’t that a movie has been run backwards from a certain point, or a tape gradually rewound. Instead, intuition tells us that time, like the hands on a clock face, has turned a circle and gone back to its beginning. The words of Pythagoras come to mind: “the world turns a circle,” and so does the Greek Stoics’ idea of eternal return and the cyclical nature of the world’s history. After each cycle the world was meant to return to its primordial state (apokatastasis) and exactly the same structure was rebuilt. Nietzsche was particularly fond of this concept, which re-echoes nowadays in Henri Poincare’s famous recurrence theorem, and also in Kurt Godel’s closed timelike curves, which set off a landslide of works about time loops.
The large number of legal regulations, their diversity and spread between extremes, reflect the temperature of ongoing debate around the world concerning the ethical grounds for cloning and interfering with the origins of life. The truly phenomenal development of the sciences, especially biology, seems to be prompting questions that were quite unknown to previous generations. Yet they are echoes of the questions and tests that have been with us since almost the dawn of history. How did man come to be?
Could man alone, by his own art, produce living creatures, or even another human being? And is it at all possible to produce life from inanimate matter? Yes, was the reply to that question given in the sixth century bc by Anaximander of Miletus, who stated that sea creatures arise straight from earth and water under the hot rays of the sun. Therefore man could have come into the world from fish, having been born in the form of a shark. This theory was deduced from observations of natural phenomena: a certain species of shark (Mustelus laevis) gives birth to its young and does not lay eggs. So the idea of life spontaneously appearing had already surfaced several hundred years before Aristotle supported and developed it in his treatises. For hundreds of years people believed that from one species of declining fauna another could arise. In his Metamorphoses Ovid describes how bees emerged out of the decaying bodies of cows, wasps out of horses and scorpions out of crab shells, and in the fourth book of Virgil’s Georgies there is a recipe for making bees hatch out of a dying bull calf. And indeed, more than fifteen hundred years later John Locke —the founder of empiricist philosophy, the major scholarly trend of the Enlightenment —a man of moderate and sober mind, in his manuscript “To Make a Toad or Serpent,” gave a detailed description, rich in technical minutiae, of the enterprise defined in the title that begins with boiling a goose or duck over a slow fire. It ends with the assurance that a certain doctor from Poland, using the given recipe, produced works of creation as many as six times, to which the Duke of Hannover can testify, having watched him in wonder and amazement.
We too, following the Duke of Hannover’s example, are filled with admiration for the skills of our colleague and compatriot. But what is the use, we may ask, of yet another toad or yet another serpent? To create a man would be the summit of arcane knowledge! The
first news of it comes from third-century Egypt. It is the story of Salaman and Absala. It takes us back to ancient times, when King Harmanus ruled the kingdom of Rum, which covered Egypt, the shores of the Mediterranean Sea and Greece. The king is childless, but at the thought of intimacy with a woman he is overcome by a strange disgust. So for help and advice he turns to his divine counselor Qualiqulas, an ascetic who has already lived for thirty generations, dividing his time between educating the king in the sciences and solitary contemplation in the cave of Serapeion, aiming his thoughts towards perfection and a life of purity. After some hesitation the king agrees to the master’s suggestion to conceive an heir by artificial means. Qualiqulas puts the king’s semen in a bottle the shape of a mandragora and by his mysterious art causes a human being to appear, equipped with a soul. Salaman, for that is the name given to the boy, is suckled by a beautiful young girl named Absala. When he grows up, he falls madly in love with her and she with him, but the king soon becomes an obstruction, expecting his one and only son and heir to turn his mind and soul towards the world of ideals. The lovers run away from the king. Ever-greater obstacles pile up in front of them, until finally, to remain together forever, they decide on a suicide pact. She drowns, but he is saved at the last moment by a sea spirit. Insane with longing, he dreams of just one thing —to see her once again. So Qualiqulas summons up the spirit of Absala, having first obtained the young man’s pledge that he will spend forty days alone with him, meditating in the cave of Serapeion. What death has failed to do, Aphrodite almost achieves, by appearing more and more often to Salaman instead of Absala. But finally he rejects carnal temptations and, in accordance with his father’s wishes, takes over the kingdom.
This tale was listened to for centuries, and even the Persian sage and great doctor Avicenna wrote about it. In modern times the cave has even been located where Qualiqulas is meant to have devoted
himself to his meditations. It has also been noted that the names of the heroes may have their origins in the remote past in Sanskrit: Salaman may have been derived from Sraman, meaning “ascetic,” and Absala from Absara, a succubus sent to tempt ascetics. Regardless of its Platonic elements, this story tells us for the first time of the artificial creation of a human being from the semen of a man and is the starting point for the history of the homunculus, which will carry on for centuries, reaching its zenith with Paracelsus.
Bathed in glory, the miracle-working doctor Paracelsus was a restless, adventurous soul. Ever on the move, he traveled about on horseback, practiced in different countries with consistent staggering success, wrote by night and slept with a sword at his side. From a portrait of him by Rubens in the Musee Royal des Beaux Arts in Brussels, his piercing gaze stares out at us from under flame-red hair. He has a solid build and his face is rather puffy, because he did not deny himself alcohol. His remains, preserved in the church of Saint Sebastian in Salzburg, where he died in 1541, have undergone detailed analysis. From the measurement of his pelvis and long bones, there has even been an attempt to draw the conclusion that his gender could just as well have been female as male! He proclaimed that medicine should preoccupy the whole doctor, as his subject was the whole human body. Though in the pommel of the sword from which he was never parted he had a hollow sphere full of pills for his patients, in his writings he repeated that “the best medicine is love.” He went his own way, and encouraged others to do so to the maximum: “Let no man belong to another that can belong to himself” {Alterius non sit, qui suns esse potest).
Paracelsus and his predecessors and imitators created the image of the alchemist as a magus coelestis, a sorcerer close to divine creative powers. In working together to refine matter, they aimed at their own perfection. While, a few hundred years earlier, alchemy had already been a powerful magnet for restless, inquiring minds,
it was only Paracelsus and his contemporaries who pushed it to the limits of its potential. Its crowning achievement was the homunculus, the artificial man, affording his creator the position of a quasi-demiurge, a virtual god. It was the ultimate act in man’s domination of nature, the mystery of all mysteries. It was produced from a man’s semen, kept warm for forty days. Towards the end of this period the ethereal outline of a transparent, incorporeal man emerged. After another forty days, fed sporadically on blood, it took on a human shape as if born from a woman, but smaller. In its mature form it possessed might and rare abilities, because it was a work of art. It did not need to learn from others; it came knowing mysteries and arcane matters.
Goethe knew the recipe for creating a homunculus from a book ascribed to Paracelsus called De natura rerum and made certain changes to it. In the second book of Faust , Wagner, the Master’s pedantic assistant, toils away in the fairytale alchemist’s laboratory, unsuccessfully trying to create a man in a retort. He explains to Mephistopheles, who is watching him, that he has mixed hundreds of substances and subjected them to repeated distillation, in the hope that the expected, live result will finally crystallize. It is only Mephistopheles’s magical power that brings the enterprise to a successful end. Out of the chaos of unformed matter a tiny, wellshaped little man emerges who instantly engages in a philosophical dispute, inspired by being shut in the glass confines around him. The homunculus, Faust and Mephistopheles leave Wagner with his fat alchemy books and set off for Thessaly on Walpurgis night. There the homunculus launches a lively debate with Thales and Anaxagoras. Proteus joins them, and advises him that to achieve mature existence he should travel with him to the high seas. Only in the boundless expanse of the waters will he be free “to move in
all dimensions and directions.” Stunned by the beauty of the ocean and the strength of the emotion arising within him, the homunculus smashes the glass bottle keeping him captive. And then, in a flash of light, the little figure evaporates forever. In a conversation with Eckermann, Goethe stressed the superiority of the homunculus over Mephistopheles because of his “tendency to the beautiful, and to a useful activity.” He has been compared to Plato’s daimon, though, of course, he was derived from Paracelsus’s tradition as an incorporeal creature that knows the secrets of arcane matters. For Goethe he was “a symbol for the human intellect and its liberating capabilities.”
But in Judaism things were different. Jewish thought produced one of the most intriguing ideas —the golem. It prefigured Adam, and an early stage in the effort to create it appears in the Talmud. However, only from the thirteenth century, among the Ashkenazi Hasidim, does the golem start to signify an artificial man. When the rabbi set about creating a golem, first of all he fasted for five days, then he molded the little figure of a man from mud and clay and said to it: Shem ha-meforash, meaning “the distinguished Name of God,” and on its forehead he wrote: emet, meaning “truth.” This word contains the Hebrew alphabet, from aleph to tav. Written in a mystic trance, among linguistic permutations, it achieved its aim: the little figure came to life. Although it could not speak, it understood what was said to it, and did all the housework, although it was not allowed to leave the Jewish home. It grew slowly, but steadily, turning into the golem, who surpassed the household in strength and height. Once it became a threat to them, the first letter was wiped from its brow, and emet was transformed into met, which means “dead.” Then the golem disintegrated into the bits of clay from which it had arisen. According to legend, the golem
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created by the tzaddik Elias Baal Shem of Chelm grew to such a height that the tzaddik could no longer reach his brow. So he told the giant to bow down and take off his boots, so he could change the inscription on its forehead. And so it happened. But as the golem collapsed into lumps of clay and mud, it buried him and crushed him, like the sorcerer’s apprentice.
The most famous golem was created in the sixteenth century in Prague by the alchemist, kabbalist and astronomer to the Emperor Rudolph II, Rabbi Judah Loew ben Bezalel, to defend the persecuted Jewish community. Thanks to its superhuman strength, the golem performed its duties excellently. But one day it went berserk and started blindly sowing destruction, and the decision was made to destroy it. Echoes of this story resound in the novel Frankenstein, or the Modern Prometheus by Mary Shelley, second wife of the poet Percy Bysshe Shelley. The novel was written in Switzerland, where the Shelleys and Byron spent a rainy summer amusing themselves by writing ghost stories. In her story Frankenstein, the Genevan philosophy student, discovers the secret of animating matter. Using body parts stolen from graveyards and mortuaries, he creates the repulsive, powerful monster, who feels lonely and unhappy. In vengeance against his creator, he commits some dreadful crimes and finally takes his own life. In popular culture through the years, especially under the influence of the movie versions, the name “Frankenstein” came to stand for the monster himself, and not his creator, the modern Prometheus.
The successive incarnations of the golem and Frankenstein inspired terror with their superhuman size and insuperable strength. Terror overcame the gods on Olympus for the first time when the giants, offspring of Gaia, the Earth, born from the blood that ran from the wounds of her husband, Ouranos, came into the world.
As soon as they were born they threatened the heavens, hurling up burning trees and mighty rocks. The gigantomachia was the toughest war the gods ever fought, and the horror of these battles is shown to us on the pediments of Greek temples. Dante encountered the defeated giants in hell. Their torsos and huge hands petrified him and filled him with fear, and so he said with relief:
Nature did well to leave off making these Creatures and other creatures like them, taking Such monstrous ministers away from Mars.
And, though she still continues with the whale And elephant, if one considers subtly,
That turns out to be well advised as well.
As I write this, I remember my own particular experience in this respect. Once, when I was a young doctor in Wroclaw, I was just starting one of my first shifts. On a sunny afternoon I was walking down a long, bright hospital corridor under the high vaults of neoGothic arches. Ahead of me there was a bend curving at a rightangle, and then just a straight stretch to the ward. Suddenly from around the bend in the corridor a shadow loomed towards me. It grew, and quick as blinking it had filled the whole space with darkness. I felt a chill and a rush of inexplicable fear. The idea of a solar eclipse had just crossed my mind when from around the bend a giant emerged. He was bearing down on me, filling the entire corridor. As we passed each other, I shrank against the wall and heard a voice booming somewhere high above my head: “Good evening, Doctor.” I sighed with relief. That was my first encounter with Michasio, our giant, an acromegalic.
In the rare illness of gigantism, in childhood or very early youth the pituitary gland produces an excess of growth hormone, and the person grows and grows until he reaches superhuman proportions.
PROMETHEAN AMBITIONS
The tallest giant recorded in medical chronicles was eight feet, seven inches high. Our Michasio was eight feet, three inches. We invited him to the hospital two or three times a year, not just for treatment, but also to show him to the students. Special preparations were made in advance of his admission, because we had nothing for him to lie on. I well remember how a nurse and I dismantled a hospital bed, attached a table to its legs, and then another smaller table, and then covered it all in mattresses. Michasio’s fellow patients on the ward, their masculinity fired, often wanted to arm-wrestle with him. Without any enthusiasm he would accept these challenges, and in a couple of seconds settle them to his advantage.
By nature he was gentle and cheerful, and did not flaunt his strength. He liked to arrange flowers, embroider and play chess. He found the perfect job, at Jelcz, a car factory in a Wroclaw suburb, where he painted the buses. As he used to take pleasure in saying: “With me there, they don’t need a ladder.”
The giant, whom a doctor will meet at best once or twice in his professional career, provides a reminder of the mythical origins of the world. He also reminds us of the times when people tried to create an artificial man. There was one question that bothered all these creators — alchemists, magicians, shamans or doctors. It was not a technical one, or anything to do with the recipe. It was this: Do they have a soul? Making the magic come true, realizing it to perfection depended on the answer, because if the little men out of a retort, the homunculi and golems, were not meant to have souls, what exactly were they? Sub-humans? Surrogates? Soulless robots? In the story of Salaman and Absala, we read that the homunculus who arose from the king’s semen, transformed inside a bottle shaped like a mandragora, was given a “rational soul.” We are not surprised, as we are dealing with a moral tale that aims to describe
the passage of the soul from the world of matter into the reality of ideal, universal forms. Questions about the soul worried people in the Middle Ages too. For centuries a tale was told about a famous Catalan doctor, Arnaldo of Villanova, who at the last moment was overcome by fear of mortal sin and smashed the retort containing maturing semen when the shapes of a homunculus’s body started to emerge from it. The Catholic theologians had to speak out against the popular spread of attempts at artificially creating people. Reviling the charlatans and citing reasons why the enterprise was impossible, they sometimes resorted to some astonishing logic. Thus one of these seventeenth-century arguments stated that the soul of a homunculus, created de novo , would be devoid of the original sin passed down to us from Adam, and so the homunculus would not need salvation through Christ. Proof indeed via a reductio ad absurdum.
Meanwhile, Judaism found an ingenious way to solve the problem of the soul by introducing gradations for it. The transformation of inanimate chaos into a well-shaped being, into a golem, ends with giving him the lowest soul (the nefesh) by branding his face with the word emet. In the hierarchy, the golem’s soul (the nefesh ) is inferior to the higher soul of Adam (the neshama ). A being produced by the hand of man is not equal in perfection to the work of the Creator.
Increasingly often, we read that cloning human beings is an inevitable business, and we could start to believe the process is near to happening. Science fiction features discussions on the souls of clones. The story of the rise and fall of Hwang Woo-suk, mentioned earlier, should stand as a warning to us. In 2004-2005 this
renowned Korean scientist, who had cloned an Afghan hound before then, published several papers in prestigious journals on procuring the first human embryonic stem cells, showing pictures of them. The way forwards for regenerative medicine lay open. We were to regain our lost capacity for perfect regeneration, as preserved by the salamander, the newt or the hydra. And cloning an entire human being was inevitably approaching. The Korean team was the talk of the whole world, which for several years now had placed its greatest hopes in this field. In California, to bypass the ethical provisos of the federal government, three billion dollars were allocated from the state budget and work was begun to create a cloning center. Other states followed this example. At the height of these expectations it was discovered that Hwang’s results were a fraud, one of the biggest in the modern history of science. In just a few weeks Hwang, the national hero, admired by the world, lost everything, including his honor and university post. The flagship Korean airlines took away the free lifelong first-class air ticket they had awarded him earlier. The postage stamps depicting a wheelchair-bound patient leaping to his feet after an injection of stem cells were withdrawn from circulation. For a while the whole field, regarded as the most important in biology and as the future of medicine, was under a dark cloud.
The icon of regenerative medicine should really be Prometheus, whose liver was eaten by a vulture on a daily basis for thirty thousand years but grew back each night. The liver’s ability to regenerate is confirmed by modern medicine, which contrasts that organ with the heart muscle. The popular myth of Prometheus has various original versions, because myths were nomadic tales, and the Greeks were accustomed to the idea that the same stories could be heard in different versions. And so, by being flexible, the myth
avoided becoming ritual. It was a story that was composed over and over again, each time becoming slightly different. Something might be left out, and something else added. These variants “keep the mythical blood in circulation.” Thanks to this, the myth could “breathe deeper” within literature.
According to one version, man was created by Prometheus, who molded him out of clay mixed with tears. In Boeotia until recently there was a hut on display where Prometheus did his work. Around it lay lumps of clay-like red earth emitting an odor that smelled like a human body. The first people wandered about “like faint apparitions out of dreams,” helpless against the might of nature. Then Prometheus crept into heaven, stole a spark and carried it down for the mortals. Fire gave people power over all creatures on Earth, because it was part of the power of the gods. For this deed Zeus stunned Prometheus with a thunderbolt and chained him to a cliff in the Caucasus, where the vulture daily ate his liver until Heracles released him from this torment.
The myth of Prometheus, one of the noblest characters in mythology, had a very strong power to influence and has been expressed in art like few others. Aeschylus’s tragedy Prometheus Bound had already shaped him for rebellion against tyranny and a relentless fight for the happiness of mankind and freedom of spirit, ending, after immeasurable sufferings, in victory. And so it went for centuries: in the poetry of Goethe, Mickiewicz and Shelley, in Beethoven’s overtures, symphonic poems by Liszt and Skriabin, and paintings by Titian and Rubens. Promethean fire would forever be associated with the spark of the gods, inspiration, heroic courage and creative force. All those who have tried or try to create man de novo , outside the forces of nature —as a homunculus, golem or clone they all have their origin in Prometheus. They have turned to magic, the Ars Magna and its reflections in
Judaism —the alchemy of the word —and finally, in modern times, to molecular biology, in order to know just a fraction of the mystery that belongs in its entirety to God alone.
Shackled to the rock, in a conversation with Zeus, Prometheus says that he brought man freedom by giving him fire. He broke the chains that made him a prisoner of the gods’ laws, and set him free to achieve humanity, to create himself. To which Zeus just as splendidly replies:
You think you freed him? You separated him From the illumination of heaven,
From the wisdom and certainty of heaven.
You freed him
To grope his way into the mine shaft, into the hank vault Of his own ego, his selfishness And his pride....
You cut the nerves
That connected him to his own soul ....
When man has learned to live without his soul I shall he redundant...
His ears will fill up with different voices...
These words imply a profound lack in the human condition, a hidden contradiction. That is why man appears torn “between good and evil, strength and weakness, wisdom and the desires that control him, between what is small and what is great, lust and virtual sainthood, truth and appearance.” His tragic fate makes it impossible for him to be an unambiguous figure. And man stands facing a border that pride tells him to cross. He is ready to use force or violence to get beyond this border.
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KORE
The great Greek tragedians knew all about hybris and hamartia, unrestrained pride, the ambition to cast off the fetters of prohibitive rules and norms, to gain absolute freedom at any price. Nowadays only the scenery has changed, while our nature has remained the same. However, for a doctor it is harder to find a foothold in the modern world, where postmodernism promotes “a model of life that is not conditioned by norms,” a limitless pluralism of beliefs, relativism, a mild global outlook and uncritical consent for all manner of strange and alternative behavior; a world that is animated by the will to demystify authority and to deconstruct, and that also brushes aside the question about the meaning of existence, a meaning that is established without our involvement and perceived in an act of amazement. Where should we seek the limits of freedom? These questions are especially close to medicine, whose patron, Asclepius, went beyond the limits of the human sphere of existence by resurrecting the dead, for which he was struck down by a thunderbolt. So how are we to delineate the border beyond which biotechnology should not interfere in our organism? What, after all, are we trying to protect it from? The essence of our humanity, the kernel in which man’s dignity lies and the laws resulting from it? The concept of man’s dignity, as the leading theme of John Paul II’s pontificate, now stands before us with astonishing relevance. The border Asclepius crossed does exist, even though it is so hard for our eyes to see it.
Giovanni Lorenzo Bernini Ecstasy of Saint Teresa, 1645-1652 Cornaro Chapel, Santa Maria della Vittoria, Rome
