Review: Seeds of Mortality

[This book is winner of the 2004 PEN award for the art of the essay. TMP congratulates Prof. Justman, a member of UM-Missoula's Liberal Studies faculty, on his receipt of this honor. Readers may see <http://www.pen.org/awards/> for further information.]

This is a book about courage more than cancer, language more than medicine. Seeds of Mortality is in many respects a continuation, albeit more personal in tone and scope, of Justman's The Psychological Mystique (1998), a critique of the infiltration of psychology into both American popular culture and education. In that book Justman traced historical precedents of the role of psychology in education (John Locke), manufacturing and marketing (Josiah Wedgwood), and advertising and public relations (Edward Bernays); he also examined the problems that arise when personal and political agendas are disguised behind medical metaphors. In Seeds Justman continues this analysis of the misuse of medical language and of even medicine itself. Seeds of Mortality explores the process by which we construct reality not only through our perceptions, accurate and faulty, but also through our language.

I found Justman's narrative to be an enlightening antidote to the rhetoric of many contemporary pathographies or personal accounts of illness. Seeds is a patient equivalent of physician Abraham Verghese's best-selling memoir My Own Country: A Doctor's Story (1994): Justman explores his illness from the perspective of one patient who has cancer but who does not define his life through cancer. Justman has created a rarity in cancer literature, a pathography that is not self-centered. He has written an articulate, clear, and forceful narrative that proves his thesis, that discussions of illness, specifically of prostate or breast cancer, by patients and physicians should not be egocentric nor political.

The book's title holds the key to its content: the seeds the author refers to are threefold. The seeds of cancer may be harbored within anyone, including the reader, as they were within the author himself. "Inside the body of the unsuspecting forty-year-old, cancer had a life of its own" (8). But the seeds are also the treatment: the potential cure for Justman's prostate cancer is the radioactive titanium pellets implanted within his prostate. Finally, and most importantly to Justman, seeds are also the words used to discuss cancer in both the private discourse between patient and physician or between patient and family and the public discourse which is all too public in Justman's opinion. He does not refer to the parable of the sower, but he contends that these seeds are ill sown.

Justman confronts what he calls "the culture of cancer," the "awareness crusades, rhetoric of battle, campaigns against shame, and support culture" (53) that is producing a nation of Mr. Woodhouses (54). And then there are those individuals who use medical rhetoric for purposes other than describing their own lives with cancer, such as Michael Milken's attempts at redemption (40-45) or Barbara Ehrenreich's political feminism (50-52). Numerous self-help books, support-group material, and cancer-related internet sites are characterized not by concrete specific scientific support, but by rhetorical stratagems and by empty emotional-laden phrases, the rhetoric of victimhood, entitlement, and/or liberation, the rhetoric "that inhibits critical judgment" (53). As Justman points out, critical judgment is exactly what you must have to make the necessary decisions regarding cancer treatment, for "[w]ithout the guidance of judgment, which enables us to evaluate probabilities informed by our experience of things, we too might be condemned to...these ideological chills and fevers" (95). The necessity of making choices is an inevitable part of life, no matter how carefully we choose language to deny these choices.

One such ideological chill or fever is that medicine is primarily a social or public endeavor, not a private one, that physicians should be curing populations and societies, particularly oppressed populations, not treating individuals. Justman traces this view of medicine back to Kant's "idealization of publicity" (173) and to Jeremy Bentham's "antiseptic influence," his belief in the "curative" power of public discourse, and his reduction of social problems to mathematical calculations (109). However, disease is only one aspect of experience, and as Justman notes, because "experience belongs to a single person, so too is the ultimate focus of medical treatment a single person" (168). For physicians to act as if they were "physicians to society itself" (168), to be social reformers, would be to ignore the individual person, and treat only the body, and not even an individual body but the collective body, the society, thus reducing all persons in the community to mere physical carcasses.

This emphasis on social medicine, obscuring or denigrating the role of the private physician treating individuals, leads to the loss of reticence. The choice to remain private, which many in American society seem to overlook or devalue, is our ultimate freedom; our response to any situation is ultimately our choice and ours alone. We choose to reveal what is private, or we choose to keep private that which might distress others. Choosing reticence was considered in the eighteenth century to be part of our social contract; it was called "sense," represented by the character Elinor in Jane Austen's Sense and Sensibility. Elinor never forgets that she is isolated from social interactions, relationships that require from us consideration of others (81-82). Justman, before writing this book, preferred to keep his private life, prostate cancer and radiation treatment included, private. His public account, Seeds of Mortality, is not so much a pathography, as a rhetorical seed implanted to guide the reader into reading more critically the literature about cancer. In fact, we should read this literature as literature, as a discourse that creates and uses its own codes and signifiers, its own "symbols, myths, and rhetoric" (188).

Another ideology masked by the rhetoric in much cancer literature is the paradigm that cancer is not a natural part of life but is instead caused by the environment, one's diet, modern industry, or even capitalism. Justman traces this idea of illness caused by man back to Rousseau and repeatedly censures the rhetoric that denies any connection between cancer and nature. His discussion in these sections of Seeds is remarkably similar to Susan Sontag's questioning of the rhetoric of cancer, but other than briefly mentioning a review of Sontag's work, Justman does not discuss her work, an omission I find puzzling since he has accomplished what Sontag called for, the creation of an alternate metaphor to the war rhetoric embedded in "the fight against cancer."

Justman elaborates upon the metaphor of seeds by linking this metaphor to the larger one of agriculture in his discussion of the image of the plowman, specifically the plowman in Brueghel's "Landscape of the Fall of Icarus." His discussion of this painting illustrates the richness of his chosen metaphor to discuss illness. The metaphor of agriculture, symbolized by Brueghel's plowman, is organic, natural, orderly, and ordinary. The plowman represents a cyclic pattern of life and death and life again, a pattern of hope and of meaning. This image of a cyclic pattern of life almost forces from us the acknowledgment that while we learn from the past, we cannot separate ourselves from the past, nor should we desire to. Although we may gain knowledge that our elders never knew, wisdom comes only with integrating the past into our present, because "to devalue the past is to impoverish the present" (xvi). In a world where postmodernism seems to run rampant, Seeds is not only an account of living a life with, but not defined by, cancer but also of maintaining a respect for tradition. The plowman image also symbolizes life without the modern focus on self, also symbolized by the character of Gerasim in Tolstoy's The Death of Ivan Ilych (154-57). Brueghel's depiction of the plowman continuing his work can be perceived as another example of self-adsorption, "as a comment on man's indifference to man," but Justman sees it as "fidelity to one's calling" (24). And most importantly, the plowman embodies a certain amount of ignorance: Brueghel's plowman is not cold or unsympathetic to others, but merely unknowing of the tragedy of Icarus falling to his death that has happened behind him, an event that no one (except for Icarus himself by not flying so close to the sun) could have prevented (26). There is much that Brueghel's plowman does not know, including the fact that a young boy has just died.

There is much that we do not know. The rhetoric within cancer literature that implies that the past was filled with ignorance and that today we possess complete knowledge is contrary to what any medical authority would say. Physicians commonly use the discourse of caution, not certainty. Justman insists on rhetoric that allows for ambiguity to be acknowledged and uncertainty to be spoken. He maintains that this is precisely what the study of literature, most notably the novel, can bring to medicine.

A good doctor approaches the disease in a spirit of uncertainty--not the paralyzing uncertainty of complete doubt but the sort that keeps you aware of the limits of knowledge. In the world of literature, the questions of what we know and how we know come to the fore in the novel, so much so that the novel itself might be called the narrative form of incomplete knowledge. The reader of a novel is presumed subject to error, uncertainty, and surprise, and the great novelists--high among them Tolstoy--manage these forces with great skill and power (136).

Tolstoy's manipulation of the reader through his use of ambiguity is why Justman spends so much time on analyzing The Death of Ivan Ilych. Tolstoy invites the reader to judge Ilych, only to subvert that judgment in the final pages of the novel. As Justman notes, Ilych's awakened compassion for his family (140) forces the reader to reevaluate assessments of both other characters as unredeemable (146-51) and the story itself as transcending its own darkness (151-53). Justman again uses his agricultural metaphor in describing this turning point in Ilych's redemption as his "seeds of awakening" (138).

Thus, Seeds is also a work of thoughtful literary criticism, worth reading for the elegant analyses of Homer, Tolstoy's Death of Ivan Ilych, Austen, and Dostoevsky's The Brothers Karamazov interspersed throughout the book. I also find Seeds to be reminiscent of Viktor Frankl's Man's Search for Meaning and Lou Marinoff's Plato not Prozac! Applying Philosophy to Everyday Problems (1999) in that all three men fault much of contemporary psychotherapy as needless or mechanistic. Seeds could be read as an example of Marinoff's bibliotherapy or Frankl's logotherapy.

Scholars might find, as I did, the silent footnote system to be rather tedious; however, Seeds is clearly written for a more general audience as well as an academic one. There is one major flaw; Justman does not seem to have critically examined the evidence supporting the role of truly self-reflective writing (the kind that Justman himself has done in this book) as part of an on-going treatment program for chronic and/or life-threatening illnesses. Certainly, "the writing cure," as well as the "talking cure" or the "reading cure" or indeed any cure that promises a relatively quick or easy end to disease, should be not accepted without critical analysis. However, Justman seems to dismiss the rewards of reading great literature and self-reflective writing for others even while he engages in both practices himself. His criticism of the claims of the proponents of self-reflective writing would have been strengthened by a more direct and critical examination of the claims he dismisses.

Justman is that rare combination of scholar and wit, a writer who is academic without being pedantic. His style reminds me of C.S. Lewis's scholarly treatises--concise, clear, and readable. One learns almost without realizing that one is being instructed and not merely reading for pleasure. Seeds of Mortality is written for patients as well as academics, but would also be an excellent addition to courses in literary criticism, medicine and literature, and rhetoric. I have already added it to the list of recommended reading in my Narrative Medicine course.

Seeds of Mortality: The Public and Private Worlds of Cancer