双语·当呼吸化为空气 没人是活该的

没人是活该的。
Nobody has it coming.

我知道，威廉·卡洛斯·威廉姆斯和理查德·塞泽尔曾经承认他们干过比我更坏的事情，但我一点也不觉得安慰。我发誓要做得更好。满目的人间悲剧与痛苦失败，我真怕自己已经看不见人类关系最非凡的重要性了，不是病人和家属之间的关系，而是医生与病人之间的关系。专业技术出色是不够的。人人终有一死，作为一名住院医生，我的最高理想不是挽救生命，而是引导病人或家属去理解死亡或疾病。要是一个病人脑出血，救不了了，送到医院来，神经外科医生与家人的第一次谈话，可能将永久决定他们对这场死亡的感觉，有可能是平和地接受（“也许他该走了”），也有可能是痛苦的遗憾（“那些医生根本不听我们说！他们都没努力去救他！”）。要是手术刀没有用武之地，外科医生唯一的工具，就是言语。
I took meager solace in knowing that William Carlos Williams and Richard Selzer had confessed to doing worse, and I swore to do better. Amid the tragedies and failures, I feared I was losing sight of the singular importance of human relationships, not between patients and their families but between doctor and patient. Tech-nical excellence was not enough. As a resident, my highest ideal was not saving lives—everyone dies eventually—but guiding a patient or family to an understanding of death or illness. When a patient comes in with a fatal head bleed, that first conversation with a neurosurgeon may forever color how the family remembers the death, from a peaceful letting go (“Maybe it was his time”) to an open sore of regret (“Those doctors didn’t listen! They didn’t even try to save him!”). When there’s no place for the scalpel, words are the surgeon’s only tool.

严重的脑损伤会带来超乎寻常的痛苦，而家人的痛苦往往要胜于病患，看不到完整意义的，不仅仅是医生。围绕在床边的家人，看着他们亲爱的人头部面目全非，脑子完全伤成一团糨糊，他们通常也看不到完整的意义。他们看到的是过去，是点点滴滴累积起来的回忆，因为当下遭遇而感受到的更深的爱，全都由眼前这具躯体所代表。我看到的是病人可能面对的未来，通过手术在脖子上开个口子，和呼吸机连在一起；肚子上开个洞，黏糊糊的液体一滴滴流进去；可能要经历很长、很痛苦的恢复过程，还不一定能完全恢复；有时候，更有可能的是，根本变不回他们记忆中的那个人了。在那样的时刻，我抛弃了平时最常扮演的角色，不再是死神的敌人，而是使者。我必须帮助这些家人明白，他们所熟知的那个人，那个充满活力的完整的人，现在只存在于过去了，我需要他们的帮助，来决定他／她想要的未来：轻松地一死百了，还是一袋袋的液体这边进，那边出，尽管无力挣扎，也要坚持活下去。
For amid that unique suffering invoked by severe brain damage, the suffering often felt more by families than by patients, it is not merely the physicians who do not see the full significance. The families who gather around their beloved—their beloved whose sheared heads contained battered brains—do not usually recognize the full significance, either. They see the past, the accumulation of memories, the freshly felt love, all represented by the body before them. I see the possible futures, the breathing machines connected through a surgical opening in the neck, the pasty liquid dripping in through a hole in the belly, the possible long, painful, and only partial recovery—or, sometimes more likely, no return at all of the person they remember. In these moments, I acted not, as I most often did, as death’s enemy, but as its ambassador. I had to help those families understand that the person they knew—the full, vital independent human—now lived only in the past and that I needed their input to understand what sort of future he or she would want: an easy death or to be strung between bags of fluids going in, others coming out, to persist despite being unable to struggle.

要是年少时接触宗教更多一些，我可能会成为一个牧师。因为我所追求的，其实就是一个牧师的角色。
Had I been more religious in my youth, I might have become a pastor, for it was the pastoral role I’d sought.

调整过我的思想重心以后，病人签署授权手术的同意书，意义就不那么简单了。这不再是一套迅速告知手术所有风险的司法程序，就像某种新药品广告里快速念一遍的副作用，而是一次机会，可以和正在承受痛苦的同胞订立盟约：我们在此共聚一堂，一起走过接下来的路。我承诺尽自己所能，引导你走向彼岸。
With my renewed focus, informed consent—the ritual by which a patient signs a piece of paper, authorizing surgery—became not a juridical exercise in naming all the risks as quickly as possible, like the voiceover in an ad for a new pharmaceutical, but an opportunity to forge a covenant with a suffering compatriot: Here we are together, and here are the ways through—I promise to guide you, as best as I can, to the other side.

住院医生生涯到这个时候，我的工作效率有所提高，经验也更加丰富，我终于可以稍稍松口气，不再为了自保而疲于奔命。现在的我已经完全承担起了为病人创造福祉的责任。
By this point in my residency, I was more efficient and experienced. I could finally breathe a little, no longer trying to hang on for my own dear life. I was now accepting full responsibility for my patients’ wellbeing.

我想到了父亲。医学院时期，露西和我都去过他在金曼的病房，跟着他查过房，看着他安慰病人，同时又告知他们各种不确定性。有个女病人，做了心脏手术，还在康复期，父亲问她：“你饿吗？我给你弄点吃的，你想吃什么？”
My thoughts turned to my father. As medical students, Lucy and I had attended his hospital rounds in Kingman, watching as he brought comfort and levity to his patients. To one woman, who was recovering from a cardiac procedure: “Are you hungry? What can I get you to eat?”

“什么都行，”她说，“我饿死了。”
“Anything,” she said. “I’m starving.”

“嗯，那龙虾和牛排怎么样？”他拿起电话，给护士站打过去，“我的病人想吃龙虾和牛排，现在，马上！”他转身看着她，面带微笑，“在路上了。不过可能看起来像火鸡三明治。”
“Well, how about lobster and steak?” He picked up the phone and called the nursing station. “My patient needs lobster and steak—right away!” Turning back to her, he said, with a smile: “It’s on the way, but it may look more like a turkey sandwich.”

他那么亲切和蔼地与病人交流，春风化雨般在病人心中建立起信任，真是让我备受启发和鼓舞。
The easy human connections he formed, the trust he instilled in his patients, were an inspiration to me.

三十五岁的女病人坐在重症监护室的床上，脸上全是恐惧。妹妹快过生日了，她出去买礼物，突发癫痫。扫描之后发现，她的右前额叶被一个良性的脑瘤压迫。要说手术的风险，这种肿瘤是风险最小的，长的位置也很容易处理；做个手术，她的癫痫症状就八九不离十地消除了。另一个选择，就是终身服用有毒性的抗癫痫药物。但我看得出来，光是“开颅手术”这几个字就够让她心惊肉跳的了。她独自一人，在一个陌生的地方，被迅速从熟悉、热闹的购物中心带到外星球般的重症监护室，到处都是哔哔响的仪器和闪烁的警报，还弥漫着一股消毒剂的味道。要是我用公事公办的口吻，细数所有的风险和可能出现的并发症，她很有可能就拒绝手术了。我当然也可以把她的拒绝记下来，填在表上，想着我尽到了责任，完成了任务，可以开始新的工作。我没有这样做，而是征得她的同意，把她的家人都召集到病床前，一起平心静气地讨论各种选择。随着谈话的深入，我看得出来，她那种不知所措的巨大恐慌，逐渐变成一个艰难但可以理解的决定。在我与她共处的当下的空间里，她是个人，不是个亟待解决的问题。她选择了手术。手术很顺利。两天后她回家了，癫痫再也没有发作过。
A thirty-five-year-old sat in her ICU bed, a sheen of terror on her face. She had been shopping for her sister’s birthday when she’d had a seizure. A scan showed that a benign brain tumor was pressing on her right frontal lobe. In terms of operative risk, it was the best kind of tumor to have, and the best place to have it; surgery would almost certainly eliminate her seizures. The alternative was a lifetime on toxic antiseizure medications. But I could see that the idea of brain surgery terrified her, more than most. She was lonesome and in a strange place, having been swept out of the familiar hubbub of a shopping mall and into the alien beeps and alarms and antiseptic smells of an ICU. She would likely refuse surgery if I launched into a detached spiel detailing all the risks and possible complications. I could do so, document her refusal in the chart, consider my duty discharged, and move on to the next task. Instead, with her permis-sion, I gathered her family with her, and together we calmly talked through the options. As we talked, I could see the enormousness of the choice she faced dwindle into a difficult but understandable decision. I had met her in a space where she was a person, instead of a problem to be solved. She chose surgery. The operation went smoothly. She went home two days later, and never seized again.