Long before there were effective treatments, physicians dispensed prognoses, hope, and, above all, meaning. When something terrible happens-and serious disease is always terrible-people want to know why. In a pantheistic world, the explanation was simple-one god had caused the problem, another could cure it. In the time since people have been trying to get along with only one God, explaining disease and evil has become more difficult. Generations of theologians have wrestled with the problem of theodicy-how can a good God allow such bad things to happen to good people? Darwinian medicine can't offer a substitute for such explanations. It can't provide a universe in which events are part of a divine plan, much less one in which individual illness reflects individual sins. It can only show us why we are the way we are, why we are vulnerable to certain diseases. A Darwinian view of medicine simultaneously makes disease less and more meaningful. Diseases do not result from random or malevolent forces, they arise ultimately from past natural selection. Paradoxically, the same capacities that make us vulnerable to disease often confer benefits. The capacity for suffering is a useful defense. Autoimmune disease is a price of our remarkable ability to attack invaders. Cancer is the price of tissues that can repair themselves. Menopause may protect the interests of our genes in existing children. Even senescence and death are not random, but compromises struck by natural selection as it inexorably shaped out bodies to maximize the transmission of our genes. In such paradoxical benefits, some may find a gentle satisfaction, even a bit of meaning-at least the sort of meaning Dobzhansky recognized. After all, nothing in medicine makes sense except in the light of evolution.
There were usually not nearly as many sick people inside the hospital as Yossarian saw outside the hospital, and there were generally fewer people inside the hospital who were seriously sick. There was a much lower death rate inside the hospital than outside the hospital, and a much healthier death rate. Few people died unnecessarily. People knew a lot more about dying inside the hospital and made a much neater job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep Death out, but while she was there she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital. There was none of that crude, ugly ostentation about dying that was so common outside of the hospital. They did not blow-up in mid-air like Kraft or the dead man in Yossarian’s tent, or freeze to death in the blazing summertime the way Snowden had frozen to death after spilling his secret to Yossarian in the back of the plane.“I’m cold,” Snowden had whimpered. “I’m cold.”“There, there,” Yossarian had tried to comfort him. “There, there.”They didn’t take it on the lam weirdly inside a cloud the way Clevinger had done. They didn’t explode into blood and clotted matter. They didn’t drown or get struck by lightning, mangled by machinery or crushed in landslides. They didn’t get shot to death in hold-ups, strangled to death in rapes, stabbed to death in saloons, blugeoned to death with axes by parents or children, or die summarily by some other act of God. Nobody choked to death. People bled to death like gentlemen in an operating room or expired without comment in an oxygen tent. There was none of that tricky now-you-see-me-now-you-don’t business so much in vogue outside the hospital, none of that now-I-am-and-now-I-ain’t. There were no famines or floods. Children didn’t suffocate in cradles or iceboxes or fall under trucks. No one was beaten to death. People didn’t stick their heads into ovens with the gas on, jump in front of subway trains or come plummeting like dead weights out of hotel windows with a whoosh!, accelerating at the rate of thirty-two feet per second to land with a hideous plop! on the sidewalk and die disgustingly there in public like an alpaca sack full of hairy strawberry ice cream, bleeding, pink toes awry.
Here's the thing about Hazel: Almost everyone is obsessed with leaving a mark upon the world. Bequeathing a legacy. Outlasting death. We all want to be remembered. I do, too. That's what bothers me most, is being another unremembered casualty in the ancient and inglorious war against disease.I want to leave a mark.But Van Houten: The marks humans leave are too often scars. You build a hideous minimall or start a coup or try to become a rock star and you think, "They'll remember me now," but (a) they don't remember you, and (b) all you leave behind are more scars. Your coup becomes a dictatorship. Your minimall becomes a lesion....We are like a bunch of dogs squirting on fire hydrants. We poison the groundwater with our toxic piss, marking everything MINE in a ridiculous attempt to survive our deaths. I can't stop pissing on fire hydrants. I know it's silly and useless--epically useless in my current state--but I am an animal like any other.Hazel is different. She walks lightly, old man. She walks lightly upon the earth. Hazel knows the truth: We're as likely to hurt the universe as we are to help it, and we're not likely to do either.People will say it's sad that she leaves a lesser scar, that fewer remember her, that she was loved deeply but not widely. But it's not sad, Van Houten. It's triumphant. It's heroic. Isn't that the real heroism? Like the doctors say: First, do no harm.The real heroes anyway aren't the people doing things; the real heroes are the people NOTICING things, paying attention. The guy who invented the smallpox vaccine didn't actually invent anything. He just noticed that people with cowpox didn't get smallpox....But then I wanted more time so we could fall in love. I got my wish, I suppose. I left my scar....What else? She is so beautiful. You don't get tired of looking at her. You never worry if she is smarter than you: You know she is. She is funny without ever being mean. I love her. I am so lucky to love her, Van Houten. You don't get to choose if you get hurt in this world, old man, but you do have some say in who hurts you. I like my choices. I hope she likes hers.