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The contents of this website are for contemplative purposes only. No medical advice will be given, and emails asking for medical advice will be ignored.

Although patient vignettes are based on my experiences with real individuals, I liberally change details to maintain patient confidentiality.

I also reserve the right to change old postings to correct errors, and to delete comments that include obscene language or that I deem abusive to me or other commentators.  If you are looking for a open mind, I suggest you consult a neurosurgeon.


Book Catechism: Colorless Tsukuru Tazaki and His Years of Pilgrimage, by Haruki Murakami

Describe this book in one word.

Can't do it. I hate reductionism, anyway.

But on the topic of reductionism: There is a great passage in this book about the massive Shinjuku train station in Tokyo. It describes a photograph that was taken at the station in the 1990s that was widely published in the United States, with an accompanying article that said, "Japan may be affluent, but most Japanese look like this, heads downcast and unhappy-looking." The main character of the novel, Tsukuru, disputes this observation: "The real reason that most passengers descending the stairs at Shinjuku Station during their packed morning commute were looking down was less that they were unhappy than that they were concerned about losing their footing."

That is to say, the station was so busy that in rush hour the crush forced people to look down to avoid being run over. It had nothing to be with being unhappy.

This is the non-reductionism at the heart of this fine novel. Murakami never allows us to settle into easy judgments. Tsukuru isn't really colorless. But in a way, he is. He goes on a long pilgrimage, but in the end he finds himself back where he was at the beginning. In many ways, at the end of the story he is the same person he was. But in another way, he undergoes profound change.

Well, that's awfully vague of you.

Ok. How about suspense as a one word description? It doesn't entirely fit but it's as good as a reductionist is going to get.

Now we are getting somewhere. Why suspense?

The book starts out with an inciting event and then slings the reader forward from big scene to big scene. It is very well plotted. It begins with Tsukuru being kicked out of a very close group of five friends he had in high school. His friends shun him from then on, with no explanation whatsoever. This completely unexpected event leaves him in shock.

After a few months of suicidal depression, Tsukuru rebounds with an unexpected friendship with a college student. This relationship ends as unexplicably as the loss of his high school friends. Years later, at the urging of Sara, his rather enigmatic girlfriend, he begins to look into his past, to find out what happened. One by one, he encounters his old friends, and has he does, the revelations mount. Each encounter with an old friend pushes Tsukuru on into the next one. And each encounter drives the reader forward as well.

I kept asking myself, What will happen when he meets the next one? To heighten the suspense, Murkamani sets the final encounter in rural Finland, making the last interview a spiritual and physical encounter. It is nicely done, a simple setup for an intensifying series of interactions, the stakes rising each time. I was surprised to find that the book was a real page-turner, not something I expected at all.

So the book is a mystery novel?

In a way. But some mysteries were never solved. In fact, several of the biggest questions raised by the plot were never answered.

In the hands of an inferior writer, this would be a real problem. But Murakami makes it clear that answering all the questions is not Tsukuru's quest. His quest is to learn to live with unanswered questions.

That is something we all must do. Learn to live with unanswered questions.

If that is true, why bother to read the book at all? In fact, why bother to write a book if you don't intend to answer questions?

It would be grossly unfair to the book to say it didn't answer any questions. It answered many. Just not all of them.

For example, Tsukuru inherits a Heuer watch from his father. It is an old watch, expensive. It doesn't keep perfect time, although it is pretty accurate. It has to be wound all the time or it will stop. Slightly temperamental, impractical, not at all like the rest of Tsukuru's life. Somehow this odd watch says something about Tsukuru, and about his father who wore it before him, but we never really understand what. But this is all right. We are not supposed to understand all of the vagaries about our lives. Tsukuru likes the watch; it is not like him, but not entirely different either. We can assume the same was probably true about his father, whom we never get to know.

And that is fine. Every loop does not have to be closed. Every watch does not have to run exactly on time.


Other Quote of the Week

Today after a quiet lunch in Madison, Mississippi, I went shopping with my wife at a second hand bookstore and picked up, for the princely sum of $1, a copy of of one of my favorite books, Dubliners.

The outcome of this pleasant adventure is that I get to share what in my opinion is one of the greatest closing paragraphs in the history of the English language.


A few light taps upon the pane made him turn to the window. It had begun to snow again. He watched sleepily the flakes, silver and dark, falling obliquely against the lamplight. The time had come for him to set out on his journey westward. Yes, the newspapers were right: snow was general all over Ireland. It was falling on every part of the dark central plain, on the treeless hills, falling softly upon the Bog of Allen and, farther westward, softly falling into the dark mutinous Shannon waves. It was falling, too, upon every part of the lonely churchyard on the hill where Michael Furey lay buried. It lay thickly drifted on the crooked crosses and headstones, on the spears of the little gate, on the barren thorns. His soul swooned slowly as he heard the snow falling faintly through the universe and faintly falling, like the descent of their last end, upon all the living and the dead.


-- James Joyce, "The Dead" (from the short story collection Dubliners.)


Quote of the Week

"Data describes humans, but data itself is not human. Stories are human."

                                                                     -- Me


Health Care Reform, by William Shakespeare

The battle over the repeal of Obamacare is in a ceasefire, but it is hardly over. And there is still immigration reform, and a Supreme Court nomination, and who knows what other political melees pending.

This time, rather than expound my own views on politics, I thought I would allow a few words from an old friend.

The quality of mercy is not strain'd,
It droppeth as the gentle rain from heaven
Upon the place beneath: it is twice blest;
It blesseth him that gives and him that takes:
'Tis mightiest in the mightiest: it becomes
The throned monarch better than his crown;
His sceptre shows the force of temporal power,
The attribute to awe and majesty,
Wherein doth sit the dread and fear of kings;
But mercy is above this sceptred sway;
It is enthroned in the hearts of kings,
It is an attribute to God himself;
And earthly power doth then show likest God's
When mercy seasons justice....
Though justice be thy plea, consider this,
That, in the course of justice, none of us
Should see salvation: we do pray for mercy;
And that same prayer doth teach us all to render
The deeds of mercy.

          -- William Shakespeare,
              The Merchant from Venice
              Act IV, Scene 1, ll. 182-200

Here Shakespeare, in one of his greatest speeches, makes a heartfelt case for justice tempered with mercy.

But he is after all Shakespeare. Which is to say, messy. Shortly after the character Portia delivers this sparkling speech, she uses the law to strip the Jew Shylock of half his fortune and force his conversion to Christianity. To make things worse, Portia is not even a judge, but instead a wealthy heiress fraudulently posing as a judge. Any legal decision she renders as a fake judge is illegal, and thus hardly an act of mercy.

Shakespeare's audience would have found this hilarious, but today the humor is tempered by the cruel and anti-semitic treatment Shylock receives. Yes, Shylock is a villain and yes, he does try to kill one of the main characters. But for all their boasting about superior Christian values, the Christians in the play do not exactly live up to their Christian values when they mete out punishment.

Portia admits as much in the first act, when she says, "I can easier teach twenty what were good than be one of the twenty to follow mine own teaching." That is, it is easier to teach others right from wrong than to follow the teaching yourself.

But then, that is the point of mercy, isn't it? "In the course of justice, none of us should see salvation" in Portia's speech means that if God is just, we have no chance of escaping punishment. Justice has very little meaning without mercy, because if all of us were punished fairly every time we did wrong, we would all be in jail -- or worse.

As Shakespeare argues, far from being a sign of weakness, mercy is a sign of strength: "Mercy is above this scepter sway; It is enthroned in the hearts of kings, It is an attribute of God himself."

If I were in charge of health care reform, I would, like Shakespeare, be more concerned with mercy than justice. And should I fail, I should seek mercy myself, and then make a second attempt.


On Illegal Immigration 

Undocumented immigrants are breaking the law by remaining in the U.S. So, many conservatives ask, what is wrong with enforcing the law by removing them?

I've thought a lot about this lately, and here's what I've come up with.

As a physician, I have a job that permits me to see into people's private lives. I see people who do drugs, who cheat on their wives, who commit fraud of various kinds. Who beat their wives or abandon their children. Who abuse or horribly neglect their elderly parents.

All of them are citizens. Citizens who daily break the law. And none of them are in jail.

If you ask me who has done more wrong, an alcoholic who continues to drive drunk or an illegal immigrant who cuts grass so his family can eat, there is no comparison.

Illegal immigration may be a crime, but it is just one of many. It needn't be singled out as uniquely bad, because it isn't. The idea that we should marshal para-military assets to combat a crime that hasn't been proven to cause serious harm to our society seems excessive at least, totalitarian at worst.

Where is the proof that undocumented immigrants harm our economy? They mostly take jobs no citizens want. They replace roofs, wash dishes, cook fast food, clean houses, babysit children. They aren't CEOs, or stock brokers, or welders, or certified electricians. In fact, by doing work no citizen wants to do, they add to our GDP by producing tangible products that create jobs for Americans. When an illegal helps build a house, an American can sell it. When an illegal picks peaches, a farmer sells the produce. When an illegal mops a floor, an American gets a job making, shipping, and selling cleaning chemicals.

An economy is complicated. One person chops down a tree. Another mills the wood. Another makes furniture from it. Yet another delivers the furniture to a store. Someone else sells it, and someone else delivers a chair to your house. You buy insurance on your house to protect the chair from loss in a fire. The chain goes on and on. So what if the lumberjack is an illegal? All the other people in the chain could be Americans. So the production of one illegal leads to jobs for dozens of other people.

That is how an economy really works. It isn't millions of people in a pit wrestling each other for a piece of meat. It is millions of people working together, each benefitting the other. Illegals sometimes drain resources from that system, but they are also productive, and the products they make add to the process. In fact, the products illegal immigrants make are added directly to the calculation of the GDP. To misunderstand this is to overlook the value illegal workers add to our economy, and the harm that would arise if they were kicked out of the country.

How serious a crime is it to cross a border in search of a job? Isn't there is a difference between stealing bread so your children can eat and stealing someone's retirement savings? Illegal immigrants don't scam you out of your life savings. Good old true-blue Americans do that, every single day. People who insist on throwing all the illegals out pretend such moral distinctions don't exist. They pretend that a person who crosses the U.S. border looking for work because his family is hungry is in the same moral status as a professional swindler.

This is obviously not true. Most of the people who come illegally into the United States are looking for work out of personal necessity. They are not here to steal from Americans. They are here because they rather enjoy eating and are hoping to continue the practice of eating in the future. And they wouldn't mind if their children could have a chance to eat as well.

To come down on such people as if they are spouse abusers or drug dealers or drunk drivers is ridiculous. They are nothing of the sort, and as long as they follow all other laws and are otherwise upstanding members of society, there is no reason they should not be treated with the same dignity our system accords to citizens who disobey the law in other ways.

Mercy is an important aspect of the law. If we were prosecuted to the fullest extent of the law for every illegal act we ever committed, we would all be serving jail time. If drivers got a ticket every single time their speed drifted up to 67 mph, every single driver would be bankrupt from recurring tickets, and the roads would be empty.

Laws have to be enforced intelligently, not blindly. The purpose of law is to maintain social order, but the dirty little secret of society is that good citizens break the law from time to time, and social order is not disrupted. A wise government knows this, and often turns a blind eye to "crimes" that do not harm society deeply, like accidentally drifting above the speed limit or the occasional experiment with illegal drugs, and instead focuses on those that clearly disrupt order, like intentionally running red lights or dealing illegal drugs.

Blind enforcement of the law is tyranny. The goal of government isn't to throw every single transgressor into prison. It is to correct people who drift outside of the lines and get them back on track. And to be tolerant of people who are breaking the law for understandable reasons, and who are not causing significant harm when they do.

I don't think undocumented immigrants are causing nearly the harm some politicians want us to think they do. Yes, they are breaking the law, technically, but many of them bring more value to the economy than they take away, and most of them have good reasons for doing what they are doing. We need to let mercy and understanding take its place in governing, as it is supposed to.