Mr Suraphol says 'No'

Originally published in BANGKOK POST SUNDAY; Bangkok, Thailand

An American doctor's encounter with a cancer-stricken villager in southern Thailand.

THE platoon of faculty, residents and medical students stood pressed around the bed of the patient like the secret service around the President. The crowd of physicians and students ogled, gaped and stared at the patient like farmers checking a tomato for worms. As if on cue, the medical students begin to form a line in preparation for the ritual communal examination of the patient.

It is Tuesday morning and we are engaged in the timeless academic tradition performed in all teaching medical institutions in the United States as well as in Thailand known as Grand Rounds. Once a week the medical faculty in the Department of Otolaryngology at the Prince of Songkhla University, in Hat Yai, along with residents, students and even, off in the distance, the final arcade of roses in this garden of earnest faces, the nurses, all assemble and move from patient to patient, as they rest in bed to discuss, elaborate and decide on the management and progress of each case.

In some respects it is not unlike a tribal healing ceremony in which the members of a native village perform sacred dances, prayers and incantations under the guidance of the village shaman to deliver demons that have wrested his or her body from a state of balance.

Mr Suraphol, the first patient to be discussed, is sitting up in bed, smiling at the numerous faces circling his bed, like beads on a neck-lace. He is 62 years old but appears younger than his age. On first impression, he seems in fact quite healthy, even robust. The secret of his being here as everyone now knows is discovered when he opens his mouth. By shifting his cheek over to the side with a tongue blade and illuminating the pink lining of his mouth we can see encroaching menacingly on his lower gum, an ulcerating cancer.

In comparison with other patients here it is not particularly large, measuring about 2-3 centimeters. In fact it appears eminently curable, a pleasing change from the more usual cases encountered in Thailand where the advanced stage of the cancers continually tests the surgeon's fortitude and ingenuity. On further examination, a small solitary lymph node is felt on Mr Suraphol's neck, a warning shot suggesting the cancer has spread. This additional portent deflates slightly our gathering optimism, but despite this, Mr Suraphol stands a reasonable even good chance for cure.

The discussion that is augured is not one of whether to operate or not. For this case it is agreed by all that the best chance for cure is surgery with the option of using radiation after the operation. The discussion focuses more on the finer points of the operation such as how much of the jaw bone needs to be removed and how best to carry out the reconstruction.

A fairly active exchange amongst the staff emerges, whirling about the patient ..like a mild hurricane. Mr Suraphol, sitting peacefully in the eye of this circling storm, is smiling and at ease, almost as if he already knew the solution but teasingly chose not to divulge his little secret at this time and spoil the party.

Dr Prasad felt that perhaps no bone needed to be removed from the jaw as the tumor was superficial. Dr Witoon countered that the superior part of the jaw should be removed to be certain all the tumor was excised. Dr Sumed, on the other hand, thought a complete resection of the bone in the region of the tumor was necessary.

Various ideas regarding reconstruction of the jaw were parried like Roman Candles on the 4th of July. One suggestion rocketed sky-ward after the other only to spend itself in an orchid of color, fall earthward and land innocuously by the altar of Mr Suraphol's Buddha crossed legs. He sat on his bed offering only his enigmatic smile in the face of this fusillade of initiatives regarding the fate of his jaw bone.

The pleasant display of rockets and sparklers continued for a time, gradually reducing in intensity and finally abating like the soft flame of a candle extinguishing it-self at the end of its wick. We would operate on Mr Suraphol to-morrow and specific decisions regarding reconstruction would be decided during surgery. A resident stayed behind to discuss with Mr Suraphol our plans while the rest of the team migrated over to the next bed to meet and discuss the next patient.

The following morning I passed Dr Witoon and inquired about the time of Mr Suraphol's surgery. Witoon, even in a land known for smiling, is notable for an unusually jolly manner. His philosophy, whether looking at a pool of bright red blood welling up in the neck after an ill-advised cut during surgery or when narrowly missing a 10-wheel truck speeding at 140 kilometers per hour while driving his thin-skinned Toyota, is quint-essential "Mai Pen Rai (never mind)."

Not to be disappointed, with characteristic precision and accuracy, accompanied by a grin stretching widely across the pocked landscape of Witoon's face, my query was saluted with a short-lived earthquake belly roll followed closely by a high pitched sonic boom of a laugh. Responding in kind with a half hearted chortle and smile of my own I await the more definitive response. Witoon then nonchalantly informed me that there was to be no surgery today.

That wiley, old Mr Suraphol, enigmatic smile and all had elected to follow the dictates of a higher wisdom and cancelled the surgery. He 'would have nothing to do with it. A quiet wind wafting in from the Gulf of Siam had blown lilting melodies, wove tapestries of Karmic wheels, spinning madly in the weave of Mr Suraphol's vivid dreams and advised him that his life was shifting hues from those of autumn to those of winter.

His blue sapphire of seminal force would spend itself now. There was nothing left to do-. Nothing to fight. No reason certainly to undergo surgery.

I probed further into the specif- ics of this turnaround.

"What did he say?" I inquired. "He didn't want to have the sur- gery," Witoon answered.

"Does he know he has an excel- lent chance for cure?" I wondered! aloud.

"I explained that to him," Wi- toon responded.

"I'm sure you mentioned that by

waiting his chances of survival go down."

"Yes, he understands that." 'Well, why did he refuse surgery then?'

It seems our erstwhile patient had a different view of the natural order of things. His was not a story of total commitment to perpetuating his own life. Mr Suraphol did not suffer existential angst at the goal line face-off with his own impending extinction. Rather, he saw; the great drama as nothing of the sort.

It seemed he grasped intuitively the idea that regardless of whose universe you believed in, Einstein's or Buddha's, the immutable reality of this existence remained the same: our brilliant and important lives amount to whirling cosmic dust grains in the slowly shifting and indifferent eye of the universe. There was no expectation of festivities or grandstand efforts to delay the final curtain.

The impending chink in the smooth arc of Mr Suraphol's horizon did not seem to faze him in the least. It certainly called for nothing so splashy as a major operation that involved, for one thing, re-moving part of his jaw. No, that was not necessary for our affable voyager. He did not care for fire-works, particularly those involving his own body. Better to leave this samsaric existence in one piece. There may be karmic dividends somewhere down the line. Perhaps in the next life he would return a prince. Or better yet a Tuk-Tuk magnate in Bangkok.

"But the tumour will continue to grow and spread. Right now it is small. If we operate now we have a chance," Witoon explained.

"I understand," replied Mr Suraphol.

"Then you'll have the surgery?"

"No," countered Mr Suraphol.

"In a few months the tumor will be too big to operate on. You will not be able to eat. You won't be able to swallow your own saliva."

"I understand."

"When you return to see us we will not be able to help you. We will have no chance to cure you." "I understand."

"It will be uncomfortable for you," Witoon implored. "I understand."

"Do you understand that you will die!" Witoon finally exclaimed with some measure of exasperation.

Mr Suraphol smiled back knowingly. "I will die anyway. Whether you operate or not I will die. So will you. So will everyone."

The inescapable logic of Mr Suraphol cut in half this caravan of words with the surgical sharpness of a polished scalpel. There could be no disputing this argument. The seed of truth had rooted itself deeply into Mr Suraphol's soul with all the tenacity of a fetus implanting itself in its mother's womb. All the discourse in the world would not shake this humble Thai villager from his oak tree of a conviction.

Mr Suraphol indeed was responding to an inner current of light and sound replete with auras and angelic harmonies that suspended him above the sweat and dirt of his life in the rice fields and belied his simple farmer's back-ground. He well recognized that it was the saksit spirit powers that controlled his day-to-day existence while Lord Buddha and the karmic wheel of law judged the specifics of his transmigration from this life to the next.

Each morning Mr Suraphol would bring incense, water and other offerings to the "spirit house" in a well rehearsed ritual of homage to the spirit overlord (praphuum) of his modest bamboo hut. He also paid his respects to the spirit overseer of his village and of the rice fields. This, of course, did not inhibit his activity in the local temple where he made frequent pilgrimages.

All else was simply giblets and gravy, while the stuffed turkey lay well outside the realm of this body, this cancer and this earnest and sincere doctor standing before him, the well-intentioned Dr Witoon. The noble truths of the Buddha's dhamma were truth enough. Otherwise it was just incense and smoke on Makha Bucha Day.

The next morning Dr Witoon and I were checking some of the patients on the wards. We passed Mr Suraphol's empty bed. Dr Witoon smiled, delivered a quick croak of laughter and then shrugged his shoulders. It was tough for one Buddhist to find fault in the intensely Buddhist logic of our former patient.

Dr Witoon as a surgeon could certainly dispute it and made every effort to do so. But once Mr Suraphol locked in on his decision there was little to say or do beyond appreciating his keenly Thai attitude towards his disease. Anyone familiar with the natural course of head and neck cancer and the pillage it can inflict on the body would pale at the thought of leaving a highly curable cancer untended.

Still, this is Thailand and al-though the great majority of patients are willing to accept treatment there are many who re-fuse intervention on grounds or attitudes not unlike Mr Suraphol's. As much as I recoil at Mr Suraphol's future prospects at the hands of this man eater run loose in the lower left corner of his mouth, part of me respects his decision. I do not advocate it or recommend it, mind you. Only that I can appreciate the otherworldly wisdom that it reflects.

It is also a reminder to surgeons that despite our priestly status in society we still live on this side of the rainbow. No matter the high technology, sophisticated surgical technique and survival rate statistics we brandish like bayonets in the afternoon sun, there will be those individuals slightly less than impressed. Patients who, despite the billowing potency and authority bounding from our voices, still opt to supervise the fate of their own bodies.

Cutting on human flesh can be something of a euphoric with powerful mind altering effects. Among the quick acting antidotes to an overdose are patients who refuse what you the surgeon-priest have to offer. Whether Mr Suraphol's decision was the correct one medically is not the issue. The verdict on that question is clear.

What he did was consistent with his own beliefs and worldview. He was not confused or delirious at the time of his decision. He was as composed as an azalea in spring. In a way, I admire him.