Why should the fictional narrative permeate the death experience in medicine: A glance at Lev Tolstoy′s " Death of Ivan Illych" through Merleau Ponty′s phenomenological overtures

"Nam Sibyllam quidem Cumis ego ipse oculis meis vidi in ampulla pendere, et cum illi pueri decerent". "I saw with my own eyes the Sybil at Cumae hanging in a cage and when the boys said to her: "Sybil what do you want?" She answered: "I want to die." Satyricon by Gaius Petronius. T.S. Eliot (1922) in his poem "The Wasteland" gives this translation. This story started eons ago, even before Sybil was granted a boon by Apollo. Sybil the prophetess and the great beauty who Apollo so desired and in turn was willing to grant anything she wanted. Sybil asked for eternality that would last for as long as there were grains in a handful of dust. What she forgot to ask Apollo was to retain her youth and beauty and as the grains started falling away Sybil too started crumbling away to immortality. Strains from this song travelled far enough to leave scars in our innermost recesses repeating the sorrow our mortal lives are entwined with each time. This is about how the illness narrative permeates the personal one. How existence precedes essence, rather permeates essence. How our lives are meaningful only as long as our bodies allow it to be! The attempt, therefore, is always at restitution, in keeping up with this enterprise by fortifying all the defense mechanisms to safeguard something that will otherwise collapse at the thought of death's vacuity trying to claim the projected theme of our being. How the self feels tricked and tested during the time of illness; there is no given time or consideration to perceive this broken, fragmented self-assaulted by a disease and the way it attacks the fixated definition of self. How a pervading sense of dissociation creeps in when one is cornered and left to pick up bits of his/her former self after having been battered with the assaults of a terminal illness. We could perhaps take into account here Merleau-Ponty's conjecture when he calls the body the enterprise, a subject in its own right against the Cartesian dichotomy of the mind and the body.[1] Ponty recognized that the body was a "permanent condition of experience", therefore, the study of perception will be incomplete if it does not take into account the inherent function of the body and consciousness together. Consciousness is like the intentionality of the body, the experiential thing sinuously entwined with the world and the human body as a perceiving thing, one that is in constant flux and unceasingly involved. The world and the self then are a continuous sense of becoming.[1]"Insofar as I have hands, feet; the body, I sustain around me intentions, which are not dependent on my decisions and which affect my surroundings in a way that I do not choose" (1, p. 440, 1962). Ponty deduces the experiential state of the body to the most basic sensory level, and this can be equated to how the body is perceived when ill. Illness often involves a feeling of dissociation from the body;[2] a physiological event that intervenes with the body's natural link with the environment. The assault is at a physiological level, so the loss is perceived as a disruption of the body's familiar communion with its environment. The attack is at the experiential level, where the feeling of feeling accustomed to one's environment naturally gets broken. Ponty deduces two experiential realms here, one where the body is perceived through the knowledge and experience of habit and another that is "lived through the moment". Even though, these two realities exist together it is not necessary that they merge together.[2] The illness dissociates the harmony between these two realms; "Even though I am functioning from the body that is sick I am not actually living through this realm. Instead, I still live through the realm that my body was accustomed to prior to my illness, the body that allowed me eloquence both sensational and emotional. The illness now has permeated through my being and caused a marked dissociation between my body as I knew it and the one that I have to live through at present even though out of habit I am still familiar with and am living through the former realm that I was so a used to, one that I so deeply feel, know and used to perceive every sensation with". The analysis here is at the phenomenological level; one directed at the primary, perceptual level. The sensations and feelings described do not belong to anyone person, but is a generalized overview of what the body undergoes when clinically assaulted. But what happens when we take a personal narrative into account. When the body we are talking about acquires a name, a face, its own narrative. Now let us consider the stance of the fictional narrative; can a fictional narrative scramble its way into what has chronicled itself as the Self and decide on how diminutive the course of our personal narratives are, particularly when we are as detached from our lives as we are from our own deaths. Though ideally educating the young medical student and the to be physician about death and the dying would be the quintessence of their learning; many would actually squirm if they are asked to recall or recount the number of times they had actually valued an experience with death without having to battle their own fears and apprehensions about their own mortality. There has been a concerted effort to revive this attempt in many medical schools where literature and philosophy is suffused to instill at a deeper level the empathetic understanding of this primeval human condition. Among the few fictional narratives that have attempted to portray the crisis of a person laboring through the torment of death I think that only a few can match the terseness with which Lev Tolstoy portrays his spiritually and emotionally vacuous protagonist Ivan Illych, in his novel "The Death of Ivan Illych0".[3] If we bring in Ponty's overtures here we can see that Ivan is clearly battling between two realms, one hinged to his former self in the steep of preserved health and the other in which he lives now and in combat with every moment, the sick body. But of course, Ponty's deductions here are again at a phenomenological level as opposed to the metaphysical doubts that we are going to encounter now. One can accumulate this theme when Tolstoy intuitively hints at Ivan's imminent death in his youth's prime, where there is an innocuous mention of young Ivan donning a medallion inscribed in it the words "respice finem", that connotes "look to the end0" in Latin. Young Ivan then naturally interprets this as the end that meant his goal, "success that follows hard work", but this could also mean reaching one's imminent end, the fact that is both conniving and pithy. Something that never occurred to our young Ivan; the kind of compelling metaphor one is ordained to live by.[3] When Ivan is finally convinced that he is dying, it is the triviality of events that was leading to his end was what annoyed him even more because what had triggered the final event was when Ivan was busy putting up some drapes in the living room when he had tripped and fallen which did not seem consequential then but now to even think that he could be dying because of something so trivial is what he could not live with. It was as if the situation that he was floating in just now was mocking him for the equally trivial life that he was leading. Prior to this, he was able to hide everything under a cheerful inanity, he could put up the screens when life so demanded. But now, his life and his work as a judge, a husband and a father seemed all too mechanical and repetitious, stung by the vice of propriety.[3] It is the latter realm that gave him the courage towards the end to emerge from the vacuous life that he had led, one spoiled by the riches of propriety and bad faith. While in the throes of death's shadow Ivan began to contemplate his life only to realize how shallow and empty the whole charade was. As the events in his life began to unfurl he soon started getting plagued by a dream where he was constantly being shoved into a dark bottomless sack and pulled into a vacuity that was never ending. He would constantly get absorbed by this thought only to be pushed further and further into the abyss with no way out; thereby succumbing to the guilt of a life callously spent.[3] It was only towards the end that the metaphorical sack revealed itself to him; this was when Ivan stopped fighting it and let himself be plunged further into the darkness and be suddenly welcomed with a shock of light. This happened when all of life's essence finally started to uncloak before him.[3] When we stretch this narrative further, we can see how contemporary culture demands a proclivity toward a modern realism where everything is persuasively preserved. A view that does not allow any reality beyond our material, worldly realm; and this can perhaps be equated with Kant's presumption that it is the contingent features of human cognition that ultimately prevail as necessary truths. Foucault turned around this Kantian dialogue by questioning, "What in the apparently necessary should actually be contingent?"[4] This simple query puts at stake the vast human landscape that has evolved around such necessary truths and is inarguably preserved as the most superior form of reality.[4] One that requires a coherent body system with purposefully preserved organs of perception. So not far from this is our modern hero who is entangled in the convoluted loops and crannies of a culture that is constantly evolving in its recycled excess of repetition. A desired trait of this culture is that each lives his individual role to the fullest and be rewarded for the collective portrayal of compulsive goal driven behavior. Death is portrayed as one's defeat, an end external to one's being, an overture best left alone for religion and a philosophy to take on. Our practice of medicine too is based on these "contingent, time-honored historic forces",[4] that shies away from this primeval human crisis. We in the helping profession have very little to offer to the dying in terms of the psychological and physical turmoil and the spiritual crisis encountered.[5] Grof attributed this professional reluctance to our own "unconscious fear of physical suffering, biological impermanence and death". "Something that could easily arouse our own metaphysical anxiety about our physical impermanence".[5] Through his and Halifax's exploratory work with psychedelic psychotherapy using lysergic acid diethylamide, they had showed something that shared its origin with the comparative religions of ancient cultures. "That we all harbor functional matrices in our unconscious minds that contain an authentic encounter with death".[5] Arousing these unconscious structures through certain psychoactive drugs or meditative techniques could actually incite the actual death experience; suggesting that we actually possess in our cellular structures the coercive knowledge of our own deaths; which in a way makes us arrogantly repress anything that remotely resembles death.[5] With the "body as the permanent condition of experience"[1] this was briefing of how the illness narrative permeates the personal one, how the death narrative impermanences the chronicled sense of self and attacks the very meaning of our existence. With this knowledge one simply can′t tether to the loose belief of a morbid realism that sustains itself by repressing the primordial song. In fact, it is this very knowledge that can make one's experiences worthwhile whilst dealing with the dying.

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