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Moments before W. Lee Warren performs brain surgery, he cradles the head of the anesthetized patient, looks down and prays.
'God, direct my hands to accomplish this task safely. Let ... the scans be wrong, the problem be manageable. ... Let me take care of him in a way that honors you.”
Warren prays, he explains in his book, 'I've Seen the End of You: A Neurosurgeon's Look at Faith, Doubt, and the Things We Think We Know,” because his work is sacred and dangerous, because he needs reminding that there could be things he won't be able to control. He prays because he needs help.
In his previous book, 'No Place to Hide,” Warren wrote of his time as a combat surgeon in Iraq. With 'I've Seen the End of You,” he moves from the battlefield to the operating room of a hospital in Wyoming, where the resources are greater, but when a case involves a deadly brain tumor, the problems are equally weighty. His account is moving yet problematic.
A man of deep Christian faith, Warren rises at 3 a.m. each day to pray, read the Bible and write. He prays often with his wife and children, and always prays for and sometimes with his patients and their families.
The bulk of his time in the operating room is spent fixing ruptured disks and pinched nerves, the bread and butter of neurosurgical practice. Once in a rare while he encounters a patient with a particularly virulent type of brain cancer, known as glioblastoma multiforme.
In 'I've Seen the End of You,” Warren trains his narrative lens on the patients with glioblastoma, a brain tumor as random as it is cruel, with a five-year survival rate of less than 10 percent. While progress over the past few years in the treatment of many cancers is impressive, for glioblastoma patients, Warren reports, the best news has been the development of a drug that extends life by a few months in roughly half of those who take it. Caring for these patients is a sad and frustrating business.
The book's title derives from the brewing intracranial storm of glioblastoma revealed to Warren when he examines the MRIs of those who have come to him complaining of bad headaches, nausea or dizziness. As soon as he sees this on a scan, he thinks, 'I've seen the end of you.”
The story starts with Samuel Martin, 35, a devout Christian with a kind, gentle manner and a faith that never appears to waver. It is Warren's faith that begins to founder while he is treating Martin.
As happens with many deeply religious physicians who manage diseases with terrible outcomes, Warren is caught in a crossfire between his belief that God can heal disease and the incontrovertible fact that glioblastoma is nearly always fatal. Glioblastoma 'is always (BEGIN ITAL)really(END ITAL) growing somewhere,” he writes. 'At some subcellular level it's in there mutating, plotting, preparing to pounce and pile-drive his nervous system into oblivion.”
Warren can no longer deny what he is feeling: 'I did not doubt that God could heal Samuel; I knew he could. I was afraid that he wouldn't.”
Martin's diagnosis and decline occur roughly in parallel with the case of 30-year-old Joey Wallace, a scruffy, belligerent drug dealer. Warren meets Wallace for the first time in the intensive-care unit; a bloody bandage is wrapped around Wallace's head, his ankle shackled to the bed rail.
Wallace's skull was fractured by a Drug Enforcement Administration agent during a meth lab bust. While performing emergency surgery on Wallace to treat a hematoma caused by the agent's blow, Warren discovers a tumor - a glioma - that is not yet malignant. It's an eerie coincidence, one that could save Wallace's life.
Wallace presents a striking contrast to the big-hearted Martin. A swastika tattooed on the back of one hand and a naked woman tattooed on his neck, Wallace has needle marks covering both arms. He is surly to the nurses, churlish with Warren, his life littered with bad choices. Yet of the two men, Wallace is the one who gets lucky.
'Samuel was the good guy,” Warren writes. 'If anyone was a worthless pile of parts, it was Joey.” With this, Warren posits an age-old question about God, faith and fairness, asking in this case 'why nice people so often get malignant cancers ... while their scumbag neighbors run meth labs and survive brain tumors.”
Warren's faith suffered a deeper blow when tragedy struck his own family. His spirit shattered, he was left with a God who heard prayers and answered them with a firm 'no.”
Warren's writing is fluid and evocative. He asks with delicate finesse, again and again, the question of how to give someone hope when, as a physician, he knows there is none. He comes to see that the real question to ask is this: 'How can I help people (including myself) hold on to their faith when life is hard, no matter how God answers their prayers?”
His final epiphany comes with the realization that 'life is a Hobson's choice. You get good stuff mixed in with a lot of pain, or you get nothing. It's your choice, and the choice is to take it or leave it.”
During Warren's periods of doubt, he looks increasingly to Pastor Jon, the wise and comforting hospital chaplain. Pastor Jon shows up for the first time on Page 96 and on 30 subsequent pages - a leitmotif of faith and enlightenment. Pastor Jon even sets Bad Boy Wallace on a spiritual path.
But there's a problem, one that greatly diminished the book's impact on this reader: Pastor Jon, or the individual as drawn by Warren, doesn't exist. He is, as Warren writes in a brief author's note, an 'amalgam of numerous hospital chaplains.” The same holds for some of the patients, who are 'composites of several real people.” And four of the fellow physicians Warren describes are 'wholly fictitious representatives of colleagues.”
He invented composites of his patients, he tells readers, 'in order to illustrate aspects of their care without risk of identifying them.” He no doubt had patients with glioblastoma, and privacy protections under the Health Insurance Portability and Accountability Act (HIPAA) are very real. But it is possible to remove identifying characteristics in a way that preserves privacy while depicting one real person, not a stitched-together version of many. Moreover, HIPAA protections extend only to patients, not to hospital chaplains, and not to colleagues.
As composites, Martin and Wallace and Pastor Jon become mythical figures, as villainous or good as their creator chooses to make them. Composite characters, that is, add up to fiction.
Warren possesses fine writerly chops. He is certainly talented enough to hew closely to a real cast of characters and still make his story shine. Had he trusted himself as a writer a little more and relied on the crutch of composites a little less, he'd have done a greater service to the reader and to himself.
'The stories in this book are true,”Warren writes. Yet the author of a work of nonfiction who asserts that a story is true, then offers details that might or might not be true, runs the risk of losing a reader's faith. Just as Warren poses lofty questions of faith vs. science, his choice here poses a big question to readers: How much trust can they put in an author who makes up more than he needs to?