In this sad world of ours, sorrow comes to all; and, to the young, it comes with bitterest agony, because it takes them unawares.

— Abraham Lincoln, Letter to Fanny McCullough, December 23, 1862

In war, those with their lives yet to be lived are also those most urgently needed to fight. It is one of the tragic ironies of conflict. In the U.S. Civil War, the average soldier was 26 and approximately 620,000 soldiers died. In World War I, over 2 million German soldiers died, and 40 percent of German combatants were between 21 and 25 years old. In the Vietnam War, 58,193 American servicemen died — approximately 24 percent of those killed were 20, and roughly  17 percent of those killed were 21. We comprehend the risk in sending young soldiers off to battle: the abrupt cessation of so much potential and promise. It is no less tragic than the death of sons and daughters in any other context, but at least we understand the possible outcome.

But what of the young who do not fight, who expect to live full lives off the battlefield? Alas, forces beyond their control operate surreptitiously; a few dangerous mutations cause a cell to run awry, errant motorists drive recklessly, malfunctioning plane hardware fails mid-air—– all of these cut life short in unexpected ways.

In my brief career, I have already seen patients from infancy to young adulthood fall victim to the cruelty of nature. As physicians we don’t feel the shock of such events in the same way as the patients’ friends and family. We see the patients, we take care of them, we escort them to their end, and then we move on to take care of the next casualty or convalescent.

Dr. Jon Marc Finamore, a 30-year-old colleague and close friend, upended that sense of detachment for me. Jon and I were in the same class in residency and that created a sense of camaraderie. We shared night and weekend calls along with the traditional weekday rotations. We signed out to each other, always commiserating over one frustrating experience or another. During our time off we mulled over a couple of beers with our other friends, running through stories and talking about our future aspirations in medicine.

It was easy to be friends with Jon; sure, he was kind, but his unwavering jovial manner persisted throughout the most difficult moments of our training, always making a dry, hilarious, and self-effacing joke.

When on-call with him, I can think of multiple instances where he would pitch in to help even if it was not his primary responsibility. On one Thanksgiving a couple of years ago, I was covering consult calls in the hospital and was quickly overwhelmed, all while trying to escape home for festivities that evening. When it was clear I would be stuck, Jon, without asking, started seeing some of my patients. He simply took on some of the burden for me. I got out on time.

These sorts of gestures were evident elsewhere, too. In a social setting, he would turn to our quieter comrades and ask if they were okay with a particular bar or movie and if they had any preferences, such that no one steamrolled anyone else. He looked after everyone but himself, attentive to the smallest amounts of discomfort or dissatisfaction. Even at his bachelor party, while trying to negotiate the wants and needs of his residency friends and everyone else, he asked a few of us if we were fine going to a particular pub everyone else had suggested.

If this was true of Jon with his friends, it was doubly true of Jon with his patients, who were as dedicated to him as he was to them. We sometimes substituted for each other in clinic, if one of us worked nights that week. I saw many of Jon’s patients, some of whom were Spanish-speaking (Jon spoke Spanish), and many of them seemed disappointed when I walked into the exam room. Where was Jon? When would he be back? Could I make sure they see him next time?

And despite his easy-going way, Jon also took his studies seriously. He carried around a notebook with him wherever he went, documenting what he learned and saw. When I took over at the VA hospital after his rotation there, I entered the workroom and saw his diagrams of nervous system motor, sensory, and visual pathways drawn on printer paper sitting on the desk. He never let a moment go to waste; he endlessly fed his curiosity.

Amidst this scintillating and effervescent life, something happened to Jon during our third year of residency. His wife, Erica Finamore, Features Editor at Food Network Magazine and The Pioneer Woman Magazine and Jon’s eventual champion, writes in a beautiful and moving essay for Cosmopolitan about this sudden change. Jon was unable to speak Spanish. He could not find the words. Moreover, he slept almost 19 hours a day, had trouble with recall of facts and figures. He and Erica went to the emergency room, where the doctors there ordered an MRI of Jon’s brain.

The news was not good. Imaging revealed a large brain tumor, known as a glioblastoma multiforme. The malignancy wreaks havoc on the mind and the body. Life expectancy, depending on the genetic mutations of the tumor, ranges from 1 to 3 years. The mutations within Jon’s tumor were all bad; it was as aggressive as it could possibly be. He hadn’t done anything to cause this. It was probably a sporadic mutation. Nature rolled the die for him and this was the outcome.

I cannot possibly imagine what he felt that evening when he looked at the MRI of his brain and knew his diagnosis. As a neurologist, Jon was au fait with his fate from time zero. He had seen his own patients wilt under the weight of this disease as it took away speech, strength, cognition, and eventually all the pneuma of life, with seizures, hospitalizations, chemotherapy, radiation, and surgery as pit stops along the way.

Jon began that journey with rounds of various treatments, only to find that the tumor grew. The price to extend life even just a little bit was steep for Jon and Erica, but the time itself was precious. And throughout this, Jon remained the same selfless person he had always been. Though he took medical leave, we saw him regularly. We went to movies, played video games, went out to dive bars or restaurants. If Jon hadn’t seen someone in a while he would ask how they were. He offered to pay for our meals and drinks and movie tickets. When we discussed his illness, he was surprisingly sanguine. There seemed always to be another option for treatment, and as long as a backup to a backup to a backup existed, he found reason for hope. About a year and a half into his illness he told me: “Everything is great now, everyone is great, I love it all.”

Weeks, however, turned into months, and months turned into years; and options dwindled and disappeared, as they have for so many others with this tumor. I saw Jon and another friend from residency; we had lunch and watched television. As a show started, he turned to me and asked “Are you okay with this show or do you want to watch something else?”

In the third century b.c.e., the Greek school of stoicism took root in Athens. We still study its intellectual champions and progenitors: Epictetus, Marcus Aurelius, and Seneca among others. The name stoicism, which was derived from the Greek word for the colonnaded walkway where they would gather to discuss their ideas, has come to be synonymous with the exercise of control over one’s emotions or reactions as a way of dealing with the world. At the risk of oversimplification, we might describe their approach to life as a refusal to let the external world affect internal emotions. Seneca, a Roman stoic philosopher from the early first century c.e., paid particularly close attention to death and how stoicism might help us deal with mortality.

As a Roman senator and eventual tutor to the Emperor Nero, Seneca saw death often. In his life he witnessed young Emperor Caligula’s murderous and paranoid rampages, was sentenced to death in a politically-motivated show trial, though that sentence was commuted to exile, and then, in 65 c.e., Nero, another paranoid and psychotic ruler of Rome, forced Seneca to commit suicide. In the midst of this chaos, Seneca obsessed over how we ought to face mortality. In particular, he addresses the concept of unexpected death over and over again. He explains in a letter to his friend Lucilius:

I’ve seen many who kept a calm mind when facing human beings, but none who did so facing gods. Instead, we berate Fate every day: “Why was that man taken off in the middle of his journey? Why is that other not taken off? Why does he prolong his old age, making it troublesome to himself and others?”

Which do you think more fair, I ask you: that you obey Nature, or that Nature obey you? What difference does it make how fast you depart a place that must, without doubt, be departed? We ought to take care that we live not a long time, but enough; for we need Fate to help us live long, but our own minds, to live enough. Life is long if it is full, and it gets filled when the mind returns its own good to itself and passes over into control of itself…. Just as a man of smaller stature can be complete, so a life can be complete in a smaller stretch of time.

There is no such thing as premature death in his mind, as nature does not owe long life to any of us. It is beyond our control; in order to face death, we can only change how we approach it. We must accept that it might happen at any moment. In his book Of Consolation to Polybius, Seneca expresses frustration at our reactions to death in the young:

You may complain, “But he was snatched away when I didn’t expect it.” Thus all are deceived by their own trust and a willed forgetfulness of mortality in the case of things they cherish. Nature promised no one that it would make an exception to necessity. Every day there pass before our eyes the funerals of the famous and the obscure, yet we are busy with other things, and we find a sudden surprise in the thing that, our whole life long, we were told was coming. It’s not the unfairness of the fates, but the warped inability of the human mind to get enough of all things, that makes us complain of leaving that place to which we were admitted as a special favor.

Seneca’s annoyance at the universal human tropes of “why me?” and “gone too early” seem like a backhanded slap popping out from the page. “Why not you?” He replies in a rebuking manner. And I admit begrudgingly that he is indeed onto something. The world owes us very little. For most of human existence our fate was much hardship and early death. It is only of late, thanks to the miracle of modern science and technology, that our lives reach far beyond that once-common and hasty end.

But one bristles at Seneca’s conclusion, too. To be sure, many lives that end feel like they end too early. In one of the Jewish rabbinical commentaries on Ecclesiastes, the rabbinic sages wrote “No one leaves this world with even half his desires fulfilled.” The rabbis wisely pointed out that no amount of life is enough, we all fall short of what we want in some sense. Nevertheless, we can point to lives that seemed well-lived and fuller than other lives even if those other lives were just as well-lived. To take an extreme example, the death of a ten-year-old, no matter how well-lived differs tremendously in its fullness from the death of a ninety-year-old.

The arc of a long and well-lived life also prepares us for death. Early on we ignore or dismiss impermanence. We aspire toward professional goals, seek mates, go on trips, take risks. But as we age, we accumulate bruises and bumps, some of which never go away. We get arthritis, our vision slowly deteriorates, our balance becomes less certain, we have surgeries, we get high blood pressure and high cholesterol, and we have strokes. And our children begin to take our place. Growing old is not pleasant and it can even be enervating, but it provides a contour to our lives. It slowly escorts us to the ultimate end, allows us time to come to terms with our own mortality.

If only Jon could have had these experiences! He should have had a long marriage. He should have experienced the undulations of life, the ups and downs, successes and disappointments that come with it and the eventual rapprochement with his own transience. After all, he didn’t volunteer to risk his life in war. Instead he was pushed off the ledge by the capriciousness of our own existence. Evidently, even if we don’t risk our lives for our country, we are nevertheless born into a struggle. It is a struggle with the same inevitable outcome for all of us no matter what we do. And that denouement came far too soon for Jon. But Jon was a stoic. He embodied the best of stoicism in the way he dealt with his imminent end. And he embodied the best of medicine in a way that all of us wish we could.

In ruminating on Jon’s death, and death in the young, I think of this passage from Shakespeare’s Macbeth. Toward the conclusion of the play, Macbeth slays Young Siward, a courageous soldier. Ross reluctantly tells Young Siward’s father about the tragedy:

Your son, my lord, has paid a soldier’s debt.

He only lived but till he was a man,

The which no sooner had his prowess confirmed

In the unshrinking station where he fought,

But like a man he died.

Practicing Medicine

March 15, 2021