I have a confession.  I’m a retired doctor, but I have a hard time talking to folks about dying.  I don’t think it is an uncommon problem for doctors and it is certainly a common problem among the general population of friends and family that has to deal with death.

The real problem, though, is talking about life to folks who are dying.

I have two friends who have breast cancer.  They did everything they were supposed to do and their cancers came back.  We don’t see either of them now due to distance, but we still talk with one on a fairly regular basis.  This friend who has a very unusual name, but whom I’ll call Sarah, is young.  We worked in the same art studio for years and were having lunch when she told us at 47 that she had suspicious lump that she was to have biopsied.

Sarah’s biopsy diagnosis was cancer and, being a pathologist I helped her through the whole process of understanding the diagnosis, prognosis, and options for treatment.  My usual dealings with this process were across the microscope from the patient’s doctor.  This was much more up close and personal. 

Of course, I spent the last 17 years of career in a county with about 90,000 people.  In contrast to the big cities where I had previously worked, I often knew the person whose diagnosis I was helping to establish.  This was a more emotionally wrenching situation than I had previously experienced, but also much more rewarding.

Sarah had no insurance – artists often don’t – and I had to give her advice on how to work deals with her doctors, the hospital, and encourage her to discuss all options for treatment with her surgeon, the medical oncologist, and the radiological oncologist.  She chose to have a ‘lumpectomy’, chemotherapy, and local radiation.

We worked together for another couple of years and then we moved away.  We went back for a visit and Sarah told us that her cancer had come back.  Her take was, “I was irritated when I first got the cancer.  Now I’m pissed.”  Our good friend has had brain metastases and radiation and now has a definite difficulty finding the right words when we talk.

Our usual greeting, all of us, is, “How are you?”  I say this to Sarah and she replies that she is fine.  She does not like to dwell on her problems, but occasionally she will let go. 

I have to admit to a couple of feelings.  I’m glad it’s not me.  I’m also angry that it happened to her.  Can I claim that she did nothing to deserve the problem?  No.  Sarah liked to leave early on Friday and meet her girlfriends for a drink, or two, or three.  She smoked.  Her husband is a drop dead guitar player who plays in a band and makes a living doing it.  It’s hard to travel to the venues where he plays and avoid alcohol, tobacco, and “other temptations”.

Still, my friend is a genuinely good person.  No one deserves to get cancer.

We can’t talk about the future.  We can’t really talk much about the present.  Sarah left the studio where we worked and tries to work at home, but it is hard.  Her husband, son and her son’s family are supportive, but they have to get on with life. 

We worked on a large collaborative art piece when there were five of us who were working in the same studio.  The work, consisting of a set of five frames, each containing the equivalent of about forty 5X5 inch tiles created using the artist’s own media, was recently bought by the local hospital’s cancer center.  The rest of us donated our part of the sale to the hospital foundation.  The money would have come in handy, but it just seemed like the least we could do for our friend to donate our share.  The work hangs in the hallway leading into the radiation treatment center.

All of this feels good, but it doesn’t make Sarah whole.  There is always the remote chance of a miracle, but none of us count on that.  Not us, not Sarah.  We all know that, despite the fact that she is much younger, we will probably outlive her.  We think about her grandchild growing up knowing a special person as an abstraction.

I’m, also, angry that we live in one of the most affluent nations on earth and we have good people who work every day who can’t afford health insurance; that we rank highest in cost per person for health care and 37^th in quality of health care.  Not only do we rank below every industrialized country in Europe and Japan, we rank below Chile, Bolivia, and Dominica.  We can take comfort, I guess, in the fact that we have better health care than Zimbabwe, Mongolia and Turkmenistan.

Had we had the best system on Earth Sarah might still have had the same outcome, but she would not have suffered the indignity of having to beg for care, and to, perhaps, have gotten inferior care because she was not a person with good insurance.