NOT KNOWING

Copyright © 2016 by Jeff Kane

They say that if you’re going to give a talk, you ought to address a subject you know something about. So I’d like to talk about something I feel pretty accomplished at: not-knowing.

I don’t know the answer. After decades of this, they’re finally saying, “Dad, what kind of a doctor are you, anyway? You never seem to know anything.”

I have to answer, “I’m one of the few honest doctors you know.”

After all, my profession is rich in ignorance, if we’d only admit it. The dean of a medical school was addressing his graduating class. He said, “I’m very sorry, but about a third of what we’ve taught you is incorrect. We just don’t know which third.”

What he meant was that the way we understand and practice medicine today is certain to be obsolete in fifty years. Our current style might even be laughable then, in the way we now think of leeches and cathartics. Medicine is a story of continual evolution of knowledge, and it’s the same in the world at large. We can’t get around that, which leaves both knowledge and ignorance troublesome.

As for knowledge, Will Rogers said, “It isn’t what we don’t know that gives us trouble, it’s what we know that ain’t so.”

And as for ignorance, world renowned expert Donald Rumsfeld said, “There are known knowns; there are things we know we know. We also know there are known unknowns; that is, there are some things we know we don’t know. But there are also unknown unknowns, the ones we don’t know we don’t know.”

At least we’ve been around long enough to recognize that we’ll never know everything. That doesn’t stop us from trying, though. In fact, seeking facts like flies seek honey describes the entire history of science. We love learning about the world so much that when we hit a cul-de-sac, a place that won’t reveal its pattern, we feel terrible. And we deal with that feeling by repressing it or denying it.

I had a boss once, the director of a hospital, who would say the most outrageous things. “You really don’t have to treat a lot of cancers,” he’d say. “They clear up by themselves.”

When we suggested diplomatically that maybe we hadn’t heard him right or that he was overgeneralizing to make a point, he’d double down. “I’m right,” he’d say. “Try not treating some patients and see what happens.”

“Are you sure?” “Are you absolutely sure?”

“Of course I’m sure. There is a tiny chance I’m wrong, but I’m sure.”

We see this posture’s full bloom in politics. Better to be sure of what’s not so than admit ignorance. Voters love that Strong Chin of Certainty. If you’re running for office you can say Mount Rushmore is actually a mound of blue cheese. When you’re challenged, all you need to do is repeat it confidently, and you’re still on solid ground. But if you’re asked about an issue and you respond that you don’t know, you’re a dead duck. You may as well pack up your bumper stickers and go home.

Ignorance is bliss? No it isn’t. In fact, not knowing constitutes much of human suffering, especially when we’re sick. I’ve worked with cancer patients and their families half a century now. I’ve seen a lot of suffering. Some is physical, but most is emotional. And most of that—the issue that drives people to tears and beyond—is their discomfort with not knowing. And when we don’t know, we employ our very human tendency to fill in the blank with negativity, fantasizing about all the things that can go wrong. In the cancer support business, we call that “awfulizing.”

Maybe you were told once that there was something amiss in your body, and it might be serious. No one takes that as small talk. I’ve been there. Many years ago an x-ray showed a sharp bony growth crimping my spinal cord at the second cervical level. I was looking at impending quadriplegia. The doctors advised me, “Whatever you do, don’t turn your head. Let’s get you into surgery right away.”

I didn’t turn my head, but I didn’t choose surgery then, either. I went home and performed emotional cartwheels around not knowing for weeks. “What does this mean?” I asked myself. Will I survive? If I do, how will it affect my life? We were building a home then, and we added a wheelchair ramp. What’ll it be like to be unable to move my limbs? Were the friends who didn’t contact me respecting my privacy or frightened by my situation?

In the cancer world especially, there’s far more unknown than known. Where did this illness come from? Did I do something to bring it on? What treatments should I choose, or decline? Which of the twenty diets my friends suggested should I go for? Might alternative therapies be effective or only make things worse? Should I look for clinical trials? Contact Hospice? If I feel better, does that mean my treatment is working, or would I have felt better anyway? If I feel worse, does that mean it’s not working, or that maybe I’d be dead without it?

Not knowing isn’t simply unnerving. It’s more like we’re fallen off the Good Ship Reality As Usual and we’re flailing around in the waves grabbing for any little piece of flotsam. Sooner or later, facts—or at least reputed facts—drift in, and whatever those facts are, they relieve us to some extent. Even bad news is often better than no news. We might say, “At least now we know what’s going on, so we have a course of action.”

That makes sense, yet at that point the next unknown pops into our normal human mind. Should I think about retiring? Who should I name as my healthcare agent in my advance directive? What’ll happen to my family if I die? Where do we go when we die?

These are worthwhile questions and deserve to be asked, but they don’t deserve to torture us. A man in our cancer group asked another, “So what are you doing about your cancer now?”

“Well, I’m worrying a lot.”

“Oh, good. Is it helping?”

Sooner or later, sick or not, we’ll do well to ask ourselves whether every unknown is bound to trouble us, or whether we can simply accept that not knowing is a natural, normal, predictable flavor of life.

The psychologist Abraham Maslow wrote about the qualities of what he called “self-actualized”, or optimally mentally healthy people. One of those was equanimity in the face of ambiguity, as he put it, or, more simply, comfort with not knowing. Since there’s so much not knowing in life, that would seem to be a handy skill. In fact, the Dalai Lama has said, “I sit in the field of not knowing, and invite you to join me there.” But Your Holiness, which way? How do we get to this palace of equanimity?

We can start with humility about what we think we know. Do we really know what we say we do? Listen to some of the things I’ve said to sick people in the past.

“I just know you’re going to come out of this even stronger than before.”

“I’m sure the surgery will be a huge success.”

“You’ll outlive me.”

Were those statements true? They were wishful thinking. I have no more idea than anyone else how things will turn out. I was hoping my confident positivity would alleviate the sick person’s discomfort with not knowing. Really, though, that never works; I was only comforting myself.

When I’m with someone who’s sick, I realize now there are only four things I can know. First, they’re sick—unless you want to argue about what “is” means. Second, they are mortal, and so will one day die. Third, they are unquestionably alive right now. And finally, I can know my own feelings in response to being with them. Virtually everything else is conjecture.

The more I hang around this planet, the less sure I am of just about everything. I’ve seen people with cancer choose a staggering variety of ways to address their illness, from prayer to chemo to Romanian clinics to incomprehensible diets to doing nothing. Should I tell them to get a grip and choose today’s cutting edge medical science? Well, I don’t do that because it turns out that the results are all over the landscape. In terms of both quantity and quality of life, those who do best are the ones who’ve chosen the route they most deeply believe in, whether it’s chemotherapy or visiting Our Lady Guadalupe.

When I had my spinal problem and got over the initial shock of diagnosis and could once again think somewhat, I figured I’d first try disciplines I’d been teaching, yoga and imagery. If they didn’t work, I’d consent to surgery. Gradually, as I practiced them, my symptoms diminished, and a year later another x-ray showed the bony growth had retreated. Does that mean yoga and imagery cured me?

I don’t know. Is it okay that I don’t know? It better be, since it’s logically impossible for me to know, anyway.

To sum up: not only don’t I know, but I can’t know. Further, obsessively craving to know distracts me from seeing more fully what’s going on now, which includes a greater range of possibilities than I’ve recognized so far. So please excuse me. I’m going to go sit with the Dalai Lama and see if I can get comfortable there. Where is he? I have no idea, so here will have to do.

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Note from Jeff: Folks who are interested in more material in this vein can browse my KVMR podcasts at http://HealingHealthcareBook.com/category/Healthcare-As-Though-People-Matter