Life presents immeasurable challenges as we stroll down its enigmatic walkways. Hopefully, the challenges do not become too difficult until we are sufficiently introduced to reality and the resources we will need to understand, adjust, and accept. By challenges, I refer to the more serious variety—loss, illness, trauma, and the like. Let us begin with an analogy, which Freud noted “decide[s] nothing, but . . . can make one feel more at home.”

Take the practically folkloric tale of the baby left on the doorstep. Now here is a precarious way to be welcomed onto the planet. Does such a thing actually happen in this day and age? I submit to you that it does.² But let’s look at this from the point of view of the newly embodied consciousness. First, there is the prob-lem of immediate survival—will some benevolent soul open his or her door in time, before the small, fragile flame is extinguished? Next, yet another hardship awaits; one is likely to be whisked away by Child Protective Services and spend critical developmental years in a series of foster homes.

Forgoing the odds of encountering “good enough” nurturance in a state-run foster home, let’s assume our doorstep protagonist encountered a bit of good fortune. His stars temporarily aligned, and he was raised in a decent, middle-class home by a married couple. In fact, they raised him well enough that he excelled in academics and obtained an advanced degree. He exceeds everyone’s ex-pectations and is rewarded with a job in a government think tank, where his knowledge of economics and philosophy is valued and relied on. Despite overcoming slanted odds, he nevertheless finds himself apart from others. He finds it hard to relate to them outside of work, and they, in turn, find him difficult to “warm up to.”

His source of self-esteem—his vital energy—derived from his impressive intellect, as well as his ability to work long hours with little need for “leisure” time. This stabilizing energy was abruptly cut off when our protagonist, Mr E, developed a severe, progressive disease that set about shutting down his kidneys. Without work to sustain him, he found himself with an excess of time to spend around his now elderly mother.

It takes a certain intellectual courage for a man to frankly recognize that he’s nothing more than a human tatter, an abortion that survived, a madman not mad enough to be committed; and once he recognizes this, it takes even more moral courage to devise a way of adapting to his destiny, to accept without protest and without resignation, without any gesture or hint of a gesture, the organic curse imposed on him by Nature.

—Fernando Pessoa¹

Perhaps it was she who had originally fostered his interest in philosophical debate, for they both began to engage in an unrelenting, bitter exchange of sentiments. There was to be no true resolution to their debate, as Mr E ended it decisively one evening with a point his mother could not rebut. He then placed her body, not on a doorstep, but in an alley in a plastic trash bin. Focusing primarily on the manner in which Mr E chose to deposit his mother, the court sentenced him to life in prison.

When I encountered Mr E, his end-stage renal disease was well advanced. He required regular, 3-days-per-week dialysis—a medical intervention he concluded was an indignity and a torture. The fact that nursing staff had so far managed to convince him to make the routine trips to an outside hospital should qualify them for the highest honors in nursing. I began seeing Mr E for his chronic treatment refusals, depression, and talent for alienating himself from peers and staff. But what seemed to upset medical staff the most was his refusal to adhere to his renal diet. Since the term “nonadherent” is really not a fair description, I shall be blunt. Mr E used his renal diet “do not eat list” as his main menu. Blocks of cheese rich in calcium. Chips chock-full of sodium. Sausage stuffed with . . . well, you get the idea.

Years of subjecting himself to routine dialysis treatments had taken a toll on Mr E.^3,4 He had grown weary of the tedious, never-ending purification of his blood. Yet what seemed to displease him most were the austere limitations placed on his diet—eating being one of his last enjoyable refuges. Labs reflecting failing renal function held no sway in Mr E’s court. He was openly blamed for worsening his own condition.

There were even some who were not the least bit upset by his dialysis refusals. Their view: why even give him the option of having dialysis? But alas, in no area of medicine do we refuse treatment for those suffering the consequences of their own bad judgment.⁵ If this were the case, a very generous proportion of us would forfeit all future health care. Let him who is without any physical vices cast the first “double down.”⁶

One of the main reasons I enjoyed listening to Mr E was his ability to argue points on an intellectual level that kept one’s mind in constant vacillation. It was not uncommon to find one’s head nodding in semi-agreement. He was, after all, a philosopher’s philosopher. Not only that, but he had a life sentence—and was doing everything he could to shorten it. This alone made him fascinating, as he carried about him a blatant aura of indifference to life itself. He knew he was not long for this world, yet he had the attitude of an annoyed patron waiting for the valet to hurry up and bring his car around . . .