The Best Choice One Could Make (and the Worst Outcome One Could Imagine)

by Daniel A. Kaufman

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Last Sunday, after the most harrowing several days of our lives, I told my sixteen (nearly seventeen) year old daughter, Victoria, the following:  “You can do everything right.  And things can still go horribly wrong.”

It is an important point and one I had been repeating again and again to myself, as I needed to hear it as much as she did. Now that she has returned home and I remain here, I continue saying it to myself, in search of some comfort that I have yet to find.

To follow are the decisions I have had to make, over the last week, and the outcomes that have ensued.  On reflection, I have no doubt that each decision was the right one, given the circumstances.  Unfortunately, I also have to say, with equal confidence, that the results for the most part have been disastrous.

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Victoria and I came to visit my parents last Thursday.  My mother is 86 and my father, just shy of 91.  Worrying reports from my mother and a Skype conversation, in which my father’s speech was substantially slurred, made me think that I had better make the trip from Missouri to Long Island, New York, where my parents still live in the house in which I grew up.  After a conversation with my wife, Nancy, I told Victoria that I thought she’d better come with me; that I was worried and that at her grandfather’s age, anything could happen at any time.

I never want to scare my daughter, but I also don’t want to lie to her or shield her from things that she will have to confront over the course of her life.  Little did I know that the scare I gave her in explaining why I thought she should travel to my parents’ house with me was nothing compared to the scares that were to come.

At one-thirty in the morning, on our first night in NY, my mother came into the room where I was sleeping and told me that my father had fallen and could not raise himself.  I rushed to their bedroom and found him prone on the ground.  He had not been able to make it from the bathroom to bed.  He is a proud man (unfortunately, to a fault) and insisted on trying to get himself up, exerting an enormous amount of effort, but to no avail.  It is a miracle he did not give himself a heart attack, as he had a pacemaker put in several years ago.  Finally, I got him up myself and into the bed.  It was no easy task, as my father weighs 185 pounds.

That morning, I was summoned by my mother, once more.   My father had fallen again.  For the second time, he insisted on trying to get up and could not.  For the second time, I had to lift him up off of the floor.

At this point, you are probably wondering why I hadn’t already taken him to the hospital.  For one thing, his weakness and confusion weren’t entirely surprising to us, as he had been on a very powerful antibiotic for a bone infection in one of his toes – a medication that is known to have these sorts of side-effects on the elderly – and this was his final week on it.  Our working theory was that it was just a matter of making it through the next few days.  For another, he refused.  As I said, he is proud to a fault, and will not go to a hospital, unless he is forced to. I begged and cajoled and tried every other means of persuasion, but I could not convince him, and as he still had enough of his wits about him to retain his autonomy, I could not force him.

That night, I woke up at about 11 to my daughter screaming.  Coming to the top of the stairs, I found her struggling with my father, who was halfway out of the chairlift that he uses to get from the first to the second floor, as his knees are shot.  Apparently the lift had stopped mid-way, and in his confused state, he thought he had reached the top and tried to get out, whereupon he became entangled with the apparatus.  The noise he had made had woken Victoria, and she was all that was preventing him from falling down the stairs and onto the tile floor, which undoubtedly would have killed him.

In those moments, my daughter demonstrated what she is made of.  Having been woken up in such a jarring way, I was befuddled and at a loss as to what do.  Even if we got him down the stairs somehow, what then? He was too weak to stand. But Victoria had figured it out.  Instructing me to hold him, she ran and got a chair and placed it at the bottom of the stairs.  All we needed to do was to get him down a few steps and into the chair, which we did together.  Later, I found out that she had also hatched a plan-B, in case this didn’t work.  She was going to get all of the cushions off the couch in the living room and lay them down on the stairs, so he could simply slide down gently to the main floor.  For a teenager to be able to think so clearly in the midst of such terrifying madness was remarkable.  I was so proud of her that I thought my heart might burst.  It also occurred to me that she had been subjected to a traumatizing experience, as a result of my – and my wife’s – decision that she should come to New York with me.  The right choice, for sure, but with a punishing outcome.

The next morning my father fell again.  For the fourth time, I had to get him up, and finally, I was able to persuade him to go to the hospital.  But he would not allow me to call an ambulance.  I had to book a private car, which took us to the emergency room, where I stayed with him for eight hours, until he was finally admitted.  During that time, his confusion grew, he reported to me what were clearly hallucinations, and he began slipping from English to Hebrew mid-sentence.  When I returned to my parents’ house that night, I asked my daughter to sleep in the bed with my mother, so that she wouldn’t be alone.

At five-thirty AM, I received a phone call from the hospital.  My father was in a highly agitated state and was having difficulty breathing.  They wanted permission to intubate him.

I woke my mother and daughter, and we consulted with one another, while the hospital held on the phone.  To their credit, they did not rush us.  My father had signed a Living Will which clearly indicated that he did not want to be kept artificially alive.  But it wasn’t obvious to me whether this situation fit that description. We did not know why he was in this condition, and if he was not intubated, he would die a horrible death, by way of suffocation or a massive heart attack.  I couldn’t let him die that way, minutes after I’d been woken up from a deep sleep, not understanding the situation, and I figured that once he was intubated and the doctors figured out what was going on, we could make more informed decisions, including withdrawing life-sustaining treatments, if appropriate.  Victoria and my mother agreed, and I gave the hospital permission to intubate him.

Of all the decisions I have had to make this week, this is the one that haunts me the most and with regard to which my title is most apt.  For of all the choices I made, it is the one the rightness of which I am most certain, but it also is the one that has had the most devastating results.

My father spent several days in the ICU.  It was determined that his condition was likely the result of a lung infection that had been developing for some time and which, in a person so old, can have these sorts of profound and disturbing effects.  The infection was brought under control.  My father was extubated.  He was eventually moved from the ICU to a regular room.

But he is not better or even moving in that direction.  He cannot walk, cannot feed himself, and is completely delusional.  In short, everything he didn’t want, everything he signed that Living Will to avoid, everything to which he was consciously and constitutionally opposed … all of it has happened.  Now, that may change.  Things are still in flux.  But for now, it’s how things are, and with every day that passes, they are more likely to stay that way.  And it is the direct result of my having made what was clearly, demonstrably, obviously the right choice at the time.

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When I teach Kant’s moral philosophy to my introductory-level students, I tell them that his exclusive focus on intentions – on motives – and his rejection of the moral relevance of outcomes is due in good part to the fact that there are too many variables on which the outcomes of our actions depend, over which we have little or no control.  It is easy to make fun of this part of Kant’s ethics; easy to concoct thought experiments that make it seem absurd; easy to wave one’s hand in the direction of the family hiding Jews from the Nazis and inquire whether they should lie about it to the SS officer who stops by; easy to say that it’s just about making excuses and refusing to take responsibility for the consequences of our actions.  Indeed, I’ve been dismissive of this aspect of his moral philosophy myself, from time to time.  But this chain of events has led me to reconsider. In this situation, the best choice led to the worst outcome, and the best outcome would have resulted from the worst choice.  This is humbling and makes it possible to see the wisdom in Kant’s position or at least a position like it.  After all, what I am calling the “best” choices still take the potential outcomes into account. But it is simply hubris to think that we can know what is going to happen as a result of the things we do or even reliably predict it.  The best we can do is will and choose as rightly as we can, recognizing that things could go terribly wrong nonetheless, as they have in my father’s case.

My friend and colleague Massimo Pigliucci has chosen to pursue a Stoic way of life, in good part because of the Stoics’ wisdom concerning the dichotomy of control, and wisdom it certainly is.  What I have not found yet is a way to derive comfort from it; to turn that which I understand into a source of consolation.  Surely, it is too soon to expect that I would, and I can only hope that it won’t be too long before I do.

For now, all that I can do is pray, in whatever way an atheist like me can: for my father, and for our family; that at a minimum, he should not suffer, and that at best, he should be made whole again, so we can be together once more, even if only for a little while longer.