What Christopher Hitchens Taught Me About Empathy

If you know who Christopher Hitchens is, chances are you think the title of my post is a little strange. Empathy isn’t a term that’s typically associated with this outspoken contrarian.

If you’re not so familiar, allow me to offer an introduction through this interview video clip. With a glass of scotch in one hand, cigarette in the other, Hitchens shares some of his opinions on Mother Theresa and Bill Clinton. On Mother Theresa, who he’s been known to refer to as “The Ghoul of Calcutta” he says:

I wanted to call my book about her The Sacred Cow but instead I called it The Missionary Position because I was afraid The Sacred Cow would offend some people.

Bill Clinton, he describes as “a rapist, a war criminal and a pathological liar”. Whether there’s evidence in his claims or not is not the point I’m trying to make, it’s that being a bit of an asshole was a core part of his identity.

In June 2010 Hitchens woke up feeling like death. I don’t need to describe it for you, because he wrote about it on the very first page of his book Mortality

I have more than once in my time woken up feeling like death. But nothing prepared me for the early morning in June when I came to consciousness feeling as if I were actually shackled to my own corpse. The whole cave of my chest and thorax seemed to have been hollowed out and then refilled with slow-drying cement. I could faintly hear myself breathe but could not manage to inflate my lungs. My heart was beating either much too much or too little. Any movement, however slight, required forethought and planning. It took strenuous effort for me to cross the room of my New York hotel and summon the emergency services.

From this moment he was transported “from the country of the well across the stark frontier that marks off the land of malady”. He went to hospital thinking that he was having a heart attack and ended up with a referral to an oncologist for a cancer biopsy. That night, despite the physical and mental distress, he kept his appearances on The Daily Show and another event talking with Salman Rushdie.

Following further investigation, Hitchens received his diagnosis

Working back from the cancer-ridden squamous cells that these first results disclosed, it took rather longer than that to discover the disagreeable truth. The word “metastasized” was the one in the report that first caught my eye, and ear. The alien had colonized a bit of my lung as well as quite a bit of my lymph node. And its original base of operations was located - had been located for some time - in my esophagus. My father had died, and very swiftly, too, of cancer of the esophagus. He was seventy-nine. I am sixty one. In whatever kind of a “race” life may be, I have very abruptly become a finalist.

When I read this book, it makes me think about what it would be like to have Christopher Hitchens as a patient. How I would respond to him. How my colleagues would.

This was a man who had a very strong personality and was far from someone who just shouted empty rhetoric. He was so adamant that water boarding (simulated drowning that was controversially used in interrogations that in the Iraq war) was not torture that he volunteered to undergo it, suffering post-traumatic stress disorder as a result, followed by a very public reversal of opinion. He was also incredibly intellectual and outspoken about his opinions. I imagine that he’d be quite an intimidating patient to have in front of you and one that you might not necessarily like all that much. But do you have to like your patient and feel connected to them to provide them with quality care? I don’t think you do. In fact, I’d go so far as to say I think it can get in the way sometimes if you do.

Being an empath and being able to hold an empathetic position are different things. Being an empath is really feeling what other people are going through. Holding an empathetic position, being empathetic, is recognising and acknowledging how others are feeling and experiencing a situation.

In other words, empathy is not just for the touchy feely bleeding hearts brigade. Being empathetic is about understanding the patients’ world view. I think it’s quite easy to recognise when someone who looks different to ourselves has a vastly different culture from our own, but it can be harder to recognise in people of a similar background. So lets go back to imagination land of having Christopher Hitchens as a patient and trying to understand his world view.

He’s just been hit in the face with his own mortality. A suspected heart attack would be a shock on its own, but cancer involves yet another set of assumptions. And not just any cancer, but the type that killed his father. The diagnosis (metastatic Stage IV oesophageal cancer) is one that is bad from the get go.

Hitchens might have been considered palliative in the objective sense, he may have understood that he was dying, but he was still willing to pursue chemotherapy and experimental treatments, even when it meant spending time away from his family. Why might that be? Others with cancers that are more likely to respond to chemotherapy are much more hesitant, why would he do this to himself? It’s not like it was a pleasant experience:

I was fairly reconciled to the loss of my hair, which began to come out in the shower in the first two weeks of treatment…But I wasn’t quite prepared for the way that my razor blade would suddenly go slipping pointlessly down my face, meeting no stubble. Or for the way that my newly smooth upper lip would begin to look as if it had undergone electrolysis, causing me to look a bit too much like somebody’s maiden auntie. (The chest hair that was once the toast of two continents hasn’t yet wilted, but so much of it was shaved off for various hospital incisions that it’s a rather patchy affair.) I feel upsettingly denatured. If Penelope Cruz were one of my nurses, I wouldn’t even notice…

We know that Hitchens had a somewhat reckless lifestyle filled with booze, cigarettes and working relentlessly. Yet despite this, up until this point he had somehow always got through things with a clean bill of health from his doctor. He described himself as having a ‘strong constitution’. He was young, only 61 years old, with a family he wanted to be around for. He was younger than his father when he died, and his mother who died as a result of a suicide pact. He had every expectation that he would live for at least ten or so more years.

Beyond this, Hitchens held firm beliefs that life outcomes were a result of science and genes, not faith and destiny. He had a strong trust in the advancements of science and medicine and the clinicians that were providing him care. He could accept bodily effects and living in a different location to participate in clinical trials because it meant access to the most skilled physicians, potential for recovery and making a contribution to science, even if it did result in his death.

These are my first raw reactions to being stricken. I am quietly resolved to resist bodily as best I can, even if only passively, and to seek the most advanced advice. My heart and blood pressure and many other registers are now strong again: Indeed, it occurs to me that if I didn’t have such a stout constitution I might have led a much healthier life thus far. Against me is the blind, emotionless alien [cancer] cheered on by some who have long wished me ill. But on the side of my continued life is a group of brilliant and selfless physicians plus an astonishing number of prayer groups. On both of these I hope to write next time if – as my father invariably said – I am spared

Making an assessment on someone’s quality of life is hard to do from the outside. It’s multidimensional, subjective and changes over time. It is impossible to consider quality of life without being empathetic to their situation. If we look at some of the aspects of quality of life that were considered by Hitchens prior to diagnosis much of his enjoyment of life revolved around drinking, smoking, eating and travelling which were all lost as his disease progressed. He was willing to tolerate these physical impacts of cancer treatment because it fit with his worldview.

Nobody wants to be told about the countless minor horrors and humiliations that become facts of “life” when your body turns from being a friend to being a foe: the boring switch from chronic constipation to its sudden dramatic opposite; the equally nasty double cross of feeling acute hunger while fearing even the scent of food; the absolute misery of gut-wringing nausea on an utterly empty stomach; or the pathetic discovery that hair loss extends to the disappearance of the follicles in your nostrils, and thus to the childish and irritating phenomenon or a permanently runny nose. Sorry, but you did ask…It’s no fun to appreciate to the full the truth of the materialist proposition that I don’t have a body, I am a body.

It became much more difficult for him when that cancer treatment began to threaten his connection to the world. It did so not just through making his head more cloudy than he was used to, but through peripheral neuropathy:

I am typing this having just had an injection to try to reduce the pain in my arms, hands, and fingers. The chief side effect of this pain is numbness in the extremities, filling me with the not irrational fear that I shall lose the ability to write. Without that ability, I feel sure in advance, my “will to live” would be hugely attenuated. I often grandly say that writing is not just my living and my livelihood but my very life, and it’s true…I feel my personality and identity dissolving as I contemplate dead hands and the loss of the transmission belts that connect me to writing and thinking

When I read this book the first time, this part made me take pause and reflect on my own practice as a pharmacist. I’m not sure I’d previously given a side effect like peripheral neuropathy the respect it deserves. I hadn’t appreciated how debilitating it must be for someone prior to reading this. How it robs them of their independence to do even the most simple things, like button a shirt or brush their teeth. It led me to wonder how many times I’ve sent a patient away after ‘counselling’ them on their medicines without really considering what’s important to them. How medicines contribute to people’s feeling of lost control.

Six months after his diagnosis Christopher Hitchens wrote this:

I see that I write that “I personally want to ‘do’ death in the active and not the passive, and to be there to look it in the eye and be doing something when it comes for me”. I cannot quite sustain this jauntiness in light of what I now know. Should the best efforts of my physician friends be unavailing, I possess a fairly clear idea of how Stage Four oesophageal cancer harvests its victims….

…The terminal process doesn’t allow for much in the way of “activity,” or even composed farewells let alone Stoic or Socratic departures. This is why I am so grateful to have had, already, a lucid interval of some length, and to have filled it with the same elements, of friendship and love, and literature and the dialectic, with which I hope some of this book is also animated. I wasn’t born to do any of the things I set down here, but I was born to die and this coda must be my attempt to assimilate the narrative to its conclusion.”

Christopher Hitchens died in hospital 18 months after his diagnosis following a bout of pneumonia. To close his book, his wife wrote:

When he was admitted to the hospital for the last time, we thought it would be for a brief stay. He thought – we all thought – he’d have the chance to write the longer book that was forming in his mind. His intellectual curiosity was sparked by genomics and the cutting-edge proton radiation treatments he underwent, and he was encouraged by the prospect that his case could contribute to future medical breakthroughs

Decisions about how medicines are used by someone approaching the end of life are not straightforward. Whether someone’s in that circumstance because of cancer, old age or a terminal condition, it doesn’t matter. What matters is that these conversations happen and that their medication regimen is adjusted to continue to optimise their quality of life, not worsen it. These conversations and the resulting decisions are complex and they simply cannot occur effectively without considering the patient’s world view. Being empathetic isn’t a ‘desirable quality’ for healthcare providers, it’s essential to getting the job done.