Richard Smith: Rediscovering a BMJ gem

Richard SmithAfter a class I taught recently one of the students came up to me and said, “My mother was fond of you. Her name was Clare Vaughan.” I remembered. I met Clare only once, shortly before she died in July 1996 in her early 40s. My memory of the meeting is hazy: I remember beauty, kindness, stillness, a lovely smile. But what I remembered clearly and have now reread many times is the piece Clare wrote for the BMJ as she was dying. It’s a gem that deserves a special place in the profusion of medical writing, most of it unprecious.

Clare describes being with her five year old daughter when she discovered that her breast cancer had recurred. That daughter must have been born in 1990. Was the student in my class 24? She was probably younger and perhaps has only faint memories of her magnificent mother.

The initial diagnosis, four years before the recurrence, gave Clare, clearly a high achiever, great energy. Everything—mothering, working, teaching, doctoring—had to be perfect. But it was dying, which she describes as “the biggest adventure of all,” that gave Clare insights into her life “in a totally unexpected way.”

She describes herself as a “doer and a fixer.” “Doctors,” she observes, “have this terrible problem: they need to be needed so badly.” She candidly observes that, like many doctors, she was “quicker and brighter and more impatient than most other people.” She had been plagued with anger. A BMJ obituary might use the euphemism that “she didn’t suffer fools gladly.” She hadn’t dealt with these things, but dying allowed her, taught her, to do so.

Should she have more chemotherapy? She decided against. “My heart told me to nurture all the wonderful bits of my life rather to try again…to poison the tumour.” That must have been a hard decision for a woman with three young children and a husband who was “desolate.” But surely it was the right decision. I’d like to think that I will be brave and sensible enough to decide the same when my time comes—perhaps very soon.

Clare describes herself “having a wonderful time fixing treasures for my children…and writing a book about the dreams I have had, the dialogue I have entered into with my tumour.” I’d like to read that book, but I don’t know how much of it she managed to write. She learnt the “joy of receiving” despite her education having taught her “nothing about the grace of receiving.”

Most people when dying, she observed, “get medicalised and pitied and feared and isolated.” She concluded that “advanced cancer is a curious condition” and she believed that we “understood it very poorly.” The appearance since Clare’s death of new, often very expensive drugs that offer a few extra weeks of life may mean that we often don’t even try to understand advanced cancer. We simply try to defeat it. This may often be the wrong choice.

Memorably Clare thought we needed “midwives for dying,” people with “the particular skills of companionship, passage, and journey with a prescribed endpoint.” There are such people; her Macmillan nurse was one. But there aren’t enough of them. We’ve invested instead in oncologists, perhaps another wrong choice.

My main aim in writing this blog is to urge you to read Clare’s piece. Although short, it’s a rich, deserves multiple readings, and can help us think about our own lives and deaths and how our society deals with death. In the Middle Ages preparing for death was one of life’s main tasks. It’s a task we now neglect.

Why, I wonder, did Clare title her piece “Teach me to hear mermaids singing?” She makes clear in her article the importance of poetry for her in those final months, and I went back to John Donne’s poem that contains the mermaid quote. She probably simply meant that dying had taught her to do something as extraordinary as hear mermaids singing. It’s a poem primarily about the falseness of women, but I think that Clare must have loved particular lines:

Go and catch a falling star…
Tell me where all past years are…
Teach me to hear mermaids singing,
Or to keep off envy’s stinging,
And find
What wind
Serves to advance an honest mind.

Note: You may not know this: although you cannot access many BMJ articles for free you often can through PubMed Central. That’s why the link to Clare’s article is via that route.

Richard Smith was the editor of the BMJ until 2004 and is director of the United Health Group’s chronic disease initiative.