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a short story by Mukund Gnanadesikan
A faint smile flickered across Alex’s face as she spoke these words. Its quick transit evoked in my mind the image of a solitary sun ray on the outline of a ghost. Still, she seemed glad to see me, or as happy as her beleaguered constitution would allow.
“How are you?” I asked her, though her pallor and the parenteral nutrition being piped into her body gave stark clues to the answer.
She pointed to the line and shook her head. “I appreciate your care. Really, I do. But what you’re doing is pointless. Isn’t autonomy a thing in medical ethics? You know what they say about horses and water.”
I’d tried to sway her with education, telling her about venous thrombosis, infections, and osteoporosis that are part and parcel of parenteral nutrition. If she’d just relent to nourishment, those risks would fall away. For weeks, logic failed to move her from her obdurate stance, so now I pulled a chair to the bedside and sat.
“They don’t specifically mention hay and grass, though, do they?”
She laughed, revealing straight teeth that had been yellowed from repeated purging.
“Good job, doc. With that kind of focus on technicalities, you could be a defense lawyer like my dad.”
“Yeah, no thanks. I’m not cut out for the courtroom, given my voice and speech patterns.”
She scooted up in bed, her forearms straining to move a few inches.
“So, you understand insecurity on a personal level. Now imagine it multiplied by ten. That’s me.”
I’d worked as a psychiatrist on eating disorder units for years. What she said could have described any number of my patients. But Alex was different in a way I could not define. Perhaps because of this, she had been on the unit for four months with no progress. Every day at morning rounds, I felt the eyes of the dietitian and the nursing staff on me. With each passing week, it became harder to meet their gaze, knowing I was failing them as much as their patient.
I had talked to the unit medical director, Dr. Aaronson, who encouraged such discussions as a vital part of professional development. He was a classical psychoanalyst, intent on the vagaries of transference and countertransference, insistent on unconscious meanings of eating behaviors even though research weighed against using such an approach to treatment. I was a believer in cognitive-behavioral approaches in conjunction with aggressive re-nourishment, and usually my approach worked. For that reason, most of my conversations with Dr. Aaronson consisted of short pleasantries.
When I’d approached him a week ago about Alex, he ran his finger over his handlebar mustache and stared at me for a while before speaking.
“You can’t save them all,” he said. “It’s as true here as anywhere else. Why do you expect the best result all the time.”
I countered that I didn’t have a God complex, that I had realistic expectations based on an understanding of disease pathology. I might have been trying to convince myself when I said those words, though. In truth, I felt obliged to seek the best outcome for every patient I saw, even as I knew I would sometimes fail. I came early and stayed late, and both staff and patients appreciated my earnest approach. Why should I lower expectations?
“You’re right,” I said. “I do appreciate what it’s like to be unhappy with who you are. But is it worth dying for that disenchantment? Because I fear that’s the hill you’re headed down.”
The bluntness of my speech surprised me. The tear that rolled down my cheek was even more unexpected.
“We’re all dying sometime,” Alex murmured, her eyes gazing past me at the sun setting over the mountains. “Self-determination says I should be able to decide when.”
“Very philosophical of you.”
“I am, after all, a philosophy major,” she said.
“That’s Kant, right? I wonder what Kant would say about the impact your death has on others, though. And didn’t he say something about suicide only being justifiable if one can no longer live virtuously?”
She offered a non-committal frown.
“You’ve done your homework, I see.”
I took this as an opening to advance.
“I know that it would leave a mark on me, on the staff,” I said. “I also know you’re not about inflicting pain on others, but alleviating it for yourself.”
“You playing the guilt card? Really doctor?”
I could tell her I didn’t want her to feel guilty for what her death might do, but that was untrue, and I don’t lie to patients. Not overtly, anyway.
“I am responsible to you and to others.”
It was a deflection, but an authentic one.
“Why would I choose to eat again?”
She had never raised the question before, even rhetorically, so I considered this to be a glimmer of hope. I needed a thoughtful answer in order to further sway Alex.
“In truth, I don’t know. I can’t give you the reasons that resonate for your life. But you’re only twenty years old. Those reasons are out there. And as a philosopher, isn’t the pursuit of meaning a purpose in and of itself? After all, if you find your own mission, it may be possible to pass it forward, like those you study. There is so much you have not yet done, so much that awaits you. Maybe you owe it to yourself and those who care for you to find it.”
“Forget lawyer,” she said. “You should be a motivational speaker for intellectuals.”
“Glad you think so. Anyway, I’m going on vacation for two weeks. Before I left, I just wanted to give you this.”
I placed a copy of Fromm’s “Selfishness and Self-Love” on Alex’s nightstand.
“Is that an original edition?”
“No such luck, I’m afraid, but it’s complete and worth reading. You can return it to me when I come back.”
“I’ll definitely dive right in,” she said. “Though these days I have to read in short bursts.”
I tapped my head. “Brain food. It’s a thing.”
“I’ll remember that.”
I rose to leave. She lifted her free arm a few scant inches above the bed to wave at me.
After two weeks of being used as a jungle gym by my children, I was ready to get back to work.
I raised my hand. “Alex O’Reilly, what happened to her.”
Dr. Aaronson smiled. “Discharged. Damnedest thing. She just started eating again, like a light switch went on.”
I wouldn’t be getting my copy of Fromm back, but the trade was worth it. I was wary of the decision to send Alex back into a world that had nearly broken her, but there was no time to brood on the decisions made by others. New patients demanded my attention. I needed to forget the past and move into the present.
Months and years rolled by, and the rhythm of admissions and discharges persisted through changes in seasons, staffing, and sociopolitical climate. Each day came with a knowledge of predictable challenges and limited capacity to change the world of my patients. Nevertheless, I clung to the delusion of possible influence, one case at a time.
One cold November day, as flurries descended in a swirling wind, I ducked into my local taqueria.
“Tres al pastor.”
I held up three fingers as a safeguard against my Jersey-accented Spanish. Someone tapped on my shoulder.
At first I did not recognize her. It is different seeing someone standing, shoulders back, head held proudly, when your prior vision of them involved supine slouching. Her skin’s sicklu pallor had disappeared, too, replaced by a pinkish-bronze tone.
“Alexis? Fancy meeting you here.”
“Nowadays I eat,” she said. “Your gift really made me think. Thank you.”
“I’m glad to see you like this,” I said. “It’s a happy surprise. You look great.”
A young, moon-faced boy walked up next to her. “We owe it to you.”
“This is my little brother Jimmy,” said Alex. “I told him what you said, and we had a heart-to-heart. Suffice it to say, I’ve got my ‘why’ now.”
She squeezed Jimmy by his narrow shoulders. He leaned his head on her.
“We’d love for you to join us,” said Jimmy.
I appreciated the offer, but for a variety of reasons I never shared meals with present or former patients. I wouldn’t say this though, instead opting for a white lie.
“I’d love to, but fatherly duties call. No rest for the weary.”
A week later I saw Dr. Aaronson in the break room. He took his time sipping artisanal coffee while I gulped two cups of weak Earl Grey tea.
“I had a strange encounter,” I told him.
“Oh yeah?” he said.
“Ran into Alex O’Reilly in Taqueria Mi Pueblo. She was there with her brother. If I didn’t know better, I’d say she was a completely healthy person.”
Aaronson blew on his coffee, then paused to scrutinize my face.
“It was the day after you left that she made the change,” he observed. “Think it was something you said?”
Maybe it was, but Aaronson was a believer in patients choosing their own recovery. I didn’t need to prove myself to him.
“Oh, I’m sure it was nothing,” I said. “I’m nothing but a horse trainer.”
Aaronson grinned, set his mug down, and clapped me on the shoulder.
“You’re learning, son.”
I licked my lips. The taste of satisfaction was one I would swallow at my leisure.
About the author: Mukund Gnanadesikan is the author of the 2020 novel "Errors of Omission". His first early reader picture book, "Clarence and Elroy" was released in June, and his debut poetry chapbook, "Petit Morts: Meditations on Love and Death" is currently available for pre-order from Finishing Line Press. When not crafting poetry or prose, he practices medicine in California.