双语·当呼吸化为空气 我在妇产科的轮转结束了

不久，我在妇产科的轮转结束了，立刻就转到肿瘤外科。同期的医学生玛丽和我一起轮班。轮班了几个星期，在一个无眠的夜晚之后，她被分配去协助一台“惠普尔手术”。这是很复杂的手术，需要调整腹部的很多器官，以便切除胰腺癌。在这种手术里，医学生一般都要连续站上九个小时，通常只是旁观，顶多帮忙拉拉勾。被选中去协助这种手术，是医学生梦寐以求的事情，因为过程极度复杂，能够主刀的至少也要住院总医生的级别。但这也是会累垮人的手术，是对普外科医生技能的终极测试。手术开始后十五分钟，我看到玛丽站在走廊里哭。惠普尔手术开始时，医生要从小小的切口放进一个小小的摄像头，看有没有转移瘤。因为如果癌细胞大面积扩散，那手术就没用了，需要取消。玛丽站在手术室里，想着要站上整整九个小时，心里一直在默默地祈祷：“我太累了——上帝啊，一定要有转移啊。”的确有。病人被重新缝合，手术取消。玛丽先是松了口气，接着心灵就不断被愧疚侵蚀，越来越深，痛苦不堪。玛丽冲出手术室，她需要一个倾诉的对象，而我恰好出现在那里。
Not long after, my obgyn rotation ended, and it was immediately on to surgical oncology. Mari, a fellow med student, and I would rotate together. A few weeks in, after a sleepless night, she was assigned to assist in a Whipple, a complex operation that involves rearranging most abdominal organs in an attempt to resect pancreatic cancer, an operation in which a medical student typically stands still—or, at best, retracts—for up to nine hours straight. It’s considered the plum operation to be selected to help with, because of its extreme complexity—only chief residents are allowed to actively participate. But it is grueling, the ultimate test of a general surgeon’s skill. Fifteen minutes after the operation started, I saw Mari in the hallway, crying. The surgeon always begins a Whipple by inserting a small camera through a tiny incision to look for metastases, as widespread cancer renders the operation useless and causes its cancellation. Standing there, waiting in the OR with a nine-hour surgery stretching out before her, Mari had a whisper of a thought: I’m so tired—please God, let there be mets. There were. The patient was sewn back up, the procedure called off. First came relief, then a gnawing, deepening shame. Mari burst out of the OR, where, needing a confessor, she saw me, and I became one.

医学院的第四年，我看着很多同学一个个选了要求不那么高的专业（比如放射科或皮肤科），并申请了住院医生。我对此困惑不已，搜集了好几个顶尖医学院的数据，发现趋势都一样：读完医学院之后，大多数学生都倾向于选择有利于“高品质生活方式”的专业，上班时间比较人性化，工资比较高，压力比较小。他们在申请医学院时写就的雄心壮志，要么打了折扣，要么消失得无影无踪。临近毕业，我们按照耶鲁的传统，坐下来，修改我们毕业典礼上要说的誓言。总之就是希波克拉底、迈蒙尼德、奥斯勒和其他几个伟大医学界前辈名言的合集。有几个同学争论说，应该去掉把病人利益置于自身利益之上的句子。（其他人不允许，讨论没能持续很长时间。这些话没有去掉。在我看来，这种自我中心论是完全与医学精神相悖的，但话说回来，也是完全合理的。的确，这世上99%的人选工作都是这样的：薪水、工作环境、工作时间。事实本来就是如此，选择工作的时候，当然要把生活方式放在第一位，哪管什么使命的召唤。）
In the fourth year of medical school, I watched as, one by one, many of my classmates elected to specialize in less demanding areas (radiology or dermatology, for example) and applied for their residencies. Puzzled by this, I gathered data from several elite medical schools and saw that the trends were the same: by the end of medical school, most students tended to focus on “lifestyle” specialties—those with more humane hours, higher salaries, and lower pressures—the idealism of their med school application essays tempered or lost. As graduation neared and we sat down, in a Yale tradition, to rewrite our commencement oath—a melding of the words of Hippocrates, Maimonides, Osler, along with few other great medical forefathers—several students argued for the removal of language insisting that we place our patients’ interests above our own. (The rest of us didn’t allow this discussion to continue for long. The words stayed. This kind of egotism struck me as antithetical to medicine and, it should be noted, entirely reasonable. Indeed, this is how 99 percent of people select their jobs: pay, work environment, hours. But that’s the point. Putting lifestyle first is how you find a job—not a calling.)

而我呢，会选神经外科。这个选择我已经考虑了一段时间了。究其发端，是一天晚上，刚刚走出手术室，在一间病房里，我带着默默的敬畏，听一个儿童神经外科医生与病人父母的谈话。他们的孩子长了个很大的脑瘤，那天晚上刚送到医院，说是头痛。医生不仅跟他们详细讲述了临床上的一些信息，也充满人情味地表达了对这种不幸的同情，并为他们提供了指导。恰巧，孩子的妈妈是一名放射科医生。肿瘤看上去是恶性的，妈妈已经研究了扫描结果，现在她坐在日光灯下的塑料椅上，完全崩溃了。
As for me, I would choose neurosurgery as my specialty. The choice, which I had been contemplating for some time, was cemented one night in a room just off the OR, when I listened in quiet awe as a pediatric neurosurgeon sat down with the parents of a child with a large brain tumor who had come in that night complaining of headaches. He not only delivered the clinical facts but addressed the human facts as well, acknowledging the tragedy of the situation and providing guidance. As it happened, the child’s mother was a radiologist. The tumor looked malignant—the mother had already studied the scans, and now she sat in a plastic chair, under fluorescent light, devastated.

“好了，克莱尔。”医生轻轻开了口。
“Now, Claire,” the surgeon began, softly.

“有看上去那么糟糕吗？”母亲打断了他，“你觉得是癌症吗？”
“Is it as bad as it looks?” the mother interrupted. “Do you think it’s cancer?”

“我也不知道。但我知道，我知道你也知道，就是你的生活即将改变——已经改变了。这是一场长途旅行，你明白吗？你们必须相互陪伴支持，但需要的时候你也要好好休息。这种病要么让你们更团结亲密，要么让你们彻底决裂。所以，现在你们要给彼此前所未有的支持和陪伴。我不希望你们中任何一个整夜待在床前或者守在医院不走，好吗？”
“I don’t know. What I do know—and I know you know these things, too—is that your life is about to—it already has changed. This is going to be a long haul, you understand? You have got to be there for each other, but you also have to get your rest when you need it. This kind of illness can either bring you together, or it can tear you apart. Now more than ever, you have to be there for each other. I don’t want either of you staying up all night at the bedside or never leaving the hospital. Okay?”

他继续说起手术计划，可能的结果和预后，现在需要做的决定，需要开始考虑但不用立刻就做的决定，还有他们暂时完全不需要担心的决定。谈话结束时，一家人并不轻松，但看起来似乎可以面对未来了。我一直注意着两夫妻的脸，一开始毫无血色、呆滞迟钝，几乎是神游天外，后来神情越来越振作和集中。坐在那儿的我突然意识到，那些集合了生命、死亡与意义的问题，那些所有人在某个时候都必须要面对的问题，通常都发生在医院里。当一个人真正遇到这些问题，这就变成了实践，有着哲学和生物学上的双重意义。人类是生命体，遵循自然法则，很遗憾的是，这些法则就包括一条：熵总是在增大的，生命是无常的。疾病，就是分子的顺序打乱了；生命的基本要求是新陈代谢，而死亡，就是新陈代谢的终止。
He went on to describe the planned operation, the likely outcomes and possibilities, what decisions needed to be made now, what decisions they should start thinking about but didn’t need to decide on immediately, and what sorts of decisions they should not worry about at all yet. By the end of the conversation, the family was not at ease, but they seemed able to face the future. I had watched the parents’ faces—at first wan, dull, almost otherworldly—sharpen and focus. And as I sat there, I realized that the questions intersecting life, death, and meaning, questions that all people face at some point, usually arise in a medical context. In the actual situations where one encounters these questions, it becomes a necessarily philosophical and biological exercise. Humans are organisms, subject to physical laws, including, alas, the one that says entropy always increases. Diseases are molecules misbehaving; the basic requirement of life is metabolism, and death its cessation.