Illustrations by Matt Rota
Mark Kingwell is a professor of philosophy at the University of Toronto.
I climbed awkwardly into the ambulance, unco-ordinated with fatigue and staggering effects of drink. The paramedic who helped me up gave me a searching look. “Ha,” she said. “I think this must be the first time we’ve had a Simpsons character in the bus.”
Jaundice turns your skin yellow. Also the whites of your eyes. Swollen ankles and midriff fluid – edema and ascites, I would learn to call them – are other outward signs of advanced alcoholic liver disease. For the most part, though, liver failure sneaks up on you. I had been feeling fine, or as fine as I ever did in those days, though I had, yes, stumbled and fallen a couple of times trying to empty the cats’ litter box and struggled with the recycling bins. Mostly I was tired, convinced I just needed to sleep off a routine gin-and-tonic binge.
Yeah, no. In fact I was sleepwalking off a cliff of advanced, life-threatening alcohol-fuelled disease. Advanced heavy drinking, what the therapeutic establishment likes to call substance-use disorder, can be like a plane crash in zero visibility: It’s one g all the way down, as pilots say. You only know you’re in a death spiral when the nose hits the ground.
My wife Molly, out of the country on family business, had begged me to call the ambulance – one of countless acts of life-saving love to come. My daughter had come over to make sure I made it to the emergency department. The Simpsons line was just added cosmic irony. I was forever quoting the series to my students, to the point of being a professorial running gag. Surely, I thought as we bumped along, there must be easier ways to be Homeric?
It was late August of 2021. I would spend the next 18 months severely ill, sometimes close to death. With astonishing speed and luck, I would undergo two complete-organ liver transplants and an almost constant schedule of other procedures, from biopsies and draining of abdominal-cavity fluids to dialysis and invasive esophageal-tube examinations of my insides. I would puke, cough and crap uncontrollably from infections ranging from CMV and C difficile to shingles, mononucleosis, aspergillosis, septic shock and COVID-19. My nose would bleed for days on end. I would lose a third of my booze-bloated body weight, ebbing to a skeletal 130 pounds as muscle tissue wasted away and I could not hold down any solid food. My xiphoid process stood out so far you could hang a scarf on it. (Yes, I had to look it up, too.) I would have to learn to walk again several times over.
They say it takes 100 people to execute a successful solid organ transplant. I met them all, from amazing nurses whose names I never learned to the physiotherapists and specialists who tended to my recovery from abject body-fail. Sometimes residents or interns were the most attentive: Kudos to Dr. Excellent and Dr. Perfect, clever youngsters rotating through general medicine. Dr. Excellent helped me arrange my stupid hospital gown to look semi-respectable – this for a daunting interview with the authorities who would decide if I was a candidate for surgery, despite having got myself here through self-inflicted abuse. Dr. Perfect wasn’t perfect, he just liked the word. “How are you today?” he’d ask. The truth, doc? Achey, sick, like death warmed over. “Perfect, perfect!”
I don’t recall the surgeries themselves, of course, though the prep stages for the second are clear in my memory: the pregame huddle of the surgical team as I lay blanketed on the slab, the jaunty Québécois anaesthetist who aimed his large-bore needle along my forearm like a dart, how routine it all seemed. Toronto General Hospital’s Multi Organ Transplant Program, a global leader in the field, performs more than 140 liver transplant surgeries every year; it is routine for them.
The aftermath of the first surgery, by contrast, was a nightmare of vivid delusion and toxic fantasy, with me intubated and shackled to the bed. I thrashed and raved. I thought I was in a Frank Herbert science-fiction story I had read years ago, trapped in an asylum. I thought the doctors and nurses were harvesting organs, not replacing them, and so I planned an elaborate jailbreak that would have seen me pounding along the rain-soaked Toronto pavement in an adult diaper and a backless hospital gown.
I imagined that the head of surgery had set me a survival test, a mock debate on the relative merits of Lynyrd Skynyrd’s Sweet Home Alabama and Neil Young’s Southern Man. Winning side gets a liver! I called the well-meaning hospital chaplain “a stooge for management,” yelled repeatedly for the police, and abused the freakishly strong ex-Navy nurse who met my spitting and biting – yes, sorry about that, not in my right mind – with absolute patience and grace.
The initial transplant surgery – a bloody, 10-hour, 20-plasma-unit slog that included a Code Blue cardiac event – had been done the previous October. The new liver proved ineffective: It saved my life but refused to graft onto my own fleshy plumbing – foreign object, after all, someone else’s flesh. The main symptom of this organ failure was intense, uncontrollable, constant, all-over itching. If this sounds trivial to you, I invite you to imagine a parasitic infestation of subcutaneous insects bent on your systematic torture that do not respond to creams or ointments and are only inflamed to new heights of torment by scratching.
My counsellor warned me that sometimes people suffering from this pruritis – mild-sounding word for a sanity-destroying condition – become suicidal with the torment.
Five months after the first, I suddenly was in line for a second transplant. Just five hours of surgery this time. I woke up in recovery knowing that the devilish itch was gone. The tall surgeons from both procedures were there – Dr. Wonderful and Dr. Cool. “Another new engine,” said Dr. Wonderful, my wife’s favourite, with evident satisfaction. “If you ever need a kidney,” he smiled, “that’s just an oil filter.” (He is wonderful.)
I was readmitted six times after that surgery in early 2022, spending more days in hospital than out. One potentially deadly infection after another. These days I’m better, but I have anemia and chronic kidney disease, plus acidosis and recurring hyperkalemia. I get fatigued easily, and bruise or bleed without much cause. I still itch violently now and then, though nothing like before. And yes, my feet are pregnant-lady numb and swollen. I get headaches like a Treadstone assassin and the dizzy spells of a Tilt-a-Whirl novice. My hands cramp without warning or else shake from the corticosteroids I must take to stave off organ rejection. These suppress the whole immune system, making every outlandish infection more likely for as long as I live.
My incision, like a double-slash broadsword chevron across my midriff, bled and wept for weeks after the second surgery. My brother dubbed me “Oil Can” after Mr. Boyd, the former Red Sox ace and one-time Expo. So: more stitches, more glue, more staples, more bandages. The incision healed eventually, though not before a few scenes of me leaking fluid all over hospital corridors and elevators. Now it just feels like what it is, a rope of congealed flesh simmering its lines of fire beneath my ribs.
Well-meaning friends send messages congratulating me on being “up and about” or “on the mend,” phrases I’ve grown to loathe. Yes, I can walk again, though not very far or for long. I must avoid sick people, or really just all people. Every morning I perform a mental checklist of possible red flags, like a gate-side airliner before departure. Flaps? Nacelles? Hatches? Okay, good to go. For one more day at least.
In early March of this year I passed the first anniversary of my second liver transplant. I also turned 60, and logged 18 continuous sober months for the first time since my 20s. But time has morphed for me as it did for Hans Castorp – or maybe Philip Marlowe. “Time passed again,” the latter says after one drug-induced knock-out. “I don’t know how long. I had no watch. They don’t make that kind of time in watches anyway.”
A common view holds that alcoholism, maybe all addiction, is suicide on the instalment plan. Certainly there is harsh reality in the idea of drinking yourself to death. The key point with addictive behaviour is that your payments are standing orders, not case-by-case transactions. I don’t mean that there is no thought or exercise of will here: quite the contrary. I sincerely wanted every drink I took, and sometimes planned carefully how to get it.
But when one is a willing addict, as the philosopher Harry Frankfurt argued, there is a smooth alignment of first- and second-order desires: I want the drug, and I also want to want it. Your brain, so craving of stimulation, is your worst enemy here. But so is your lively mind, that repository of narratives, moods and metaphors. Every drinker I know is a romantic, partial to visions and scenes: a cold gin-and-tonic on the summer-sunset porch, an icy Gibson in a New York hotel bar, a swig of Glenmorangie standing in a Montana trout stream. Rhapsody in booze.
Alcoholics are not stupid, after all, even if we do stupid things. We drink because we want to, because it’s lovely and comforting. It blunts irritation or boredom, underwrites conversation and conviviality – at first, anyway. But at some point, to quote Raymond Chandler again, “there is nothing so deadly as the trap you set for yourself.” And then the unlucky, the unvigilant or the merely susceptible find that the mirth has all drained away, leaving just the damaging chemistry.
My own plotline, years long, is fairly typical for what the literature calls high-functioning heavy drinkers. (The bare term alcoholic is not favoured of late: too reifying or essentialist.) A fan since my 20s of the smart evening cocktail – I wrote a magazine column and then a book about mixology – into midlife I liked to follow an ice-cold martini, Manhattan, or gimlet (or two) with some big glasses of chilled pinot grigio over dinner. Then, sometimes, a single malt or snifter of Calvados to aid the postprandial digestion.
Not every day, you understand; just most days. Then every day. Soon a glass of wine – or two? – at lunch. Why not, why not? Not every day! No. But then every day. And then maybe, now and then, a morning jolt – a throat-clearer, as Bertie Wooster would have it, a gargler – to clear any cobwebs and start the day? Scotch in my coffee, gin in my tea, rye in my hot chocolate. Yum! Not every day. Of course not. And then every day. Of course.
I took to carrying elegant pewter flasks around with me daily, not just while fishing, filled with expensive whisky. Eventually I ditched the elegance for plastic bottles of cheap vodka to mix with corner-store ginger ale. They were bigger and fitting smoothly in the pocket of my favourite jacket. I became adept at buying and disposing of bottles without ever lodging them in the “official” drinks cabinet of my house. I cackled delightedly when I slipped empties into the recycling bins of my neighbours.
I distinguished secret drinks from “fair” ones, that is, those consumed after five o’clock, and fancied I was clever with it all. My wide cocktail research provided soundtrack, film references and literary allusions from a pantheon of glorious creative drinkers: Amy Winehouse, Bix Beiderbecke, Billie Holiday, Stan Getz, Chet Baker; likewise Hitchens, Hemingway, Chandler, Cheever, Fitzgerald, Faulkner, Capote and Parker. So blissfully aware, some of them, so hilariously insightful about what was happening! (Hemingway never said “Write drunk, edit sober,” by the way.)
We were all kin, I gurgled to myself, creative brothers and sisters of the bottle. Less grandly, and more accurately, I was just drinking way too much and it didn’t seem so bad. I held down my job, indeed was more productive by the year as I moved into middle age. I flew all over the place giving lectures and talks, doing seminars and panels. (Airport bars, business-class seats, hotels and academic receptions are all great places to drink too much.)
I wrote many articles and books. I taught my classes, sat on committees and supervised graduate students. My marriage and friendships held. There were no DUIs, no drunken confrontations, no embarrassing complaints. I had to go to the ER twice in 10 years, once for a bike crash that could have happened to any random drunk and once for dehydration and withdrawal. That just taught me that quitting cold turkey was not an option.
The pandemic lockdown made everything easier, of course, and so worse. Now it was possible to drink all day, every day, with little fear of discovery. Alcohol, like many drugs, elevates tolerance in its habitual users, so that it takes more to make you tipsy but also allows experienced tipplers to feign sobriety as needed – on, for instance, a Zoom call. Nobody knows what’s in your coffee mug, people! There were meanwhile many jokey memes and late-night one-liners about new bouts of clandestine cope-drinking. The COVID Effect fit snugly into the familiar snickering, sorry-not-sorry jokiness that defines cultural norms about alcohol. Hilarious: Screwdrivers for breakfast again …
By the summer of 2021 I was drinking a bottle of spirits a day – all before the “allowed” evening drinks of cocktails and wine. I once heard a sober alcoholic mention the same amount as her daily intake, to my considerable astonishment. But let me assure you that a human being can indeed drink this much every day and still remain more or less functional – for a while.
Because even a wide, forgiving cliff has an edge beyond which fortified genes and dumb luck will not stretch. By the time it happens, a boozer’s mortal death-plunge can feel almost like another moment of care-free oblivion. Who knows that this drink is the potentially final step on a self-slaughter program?
Still: if you’ve turned yellow … check your enzymes.
Despite my evident devotion to demon-drink, juice beyond joy, I never considered myself actually suicidal. True, like any dedicated philosopher who spends time with the fruits of existential thinking, I had thought about it. But ideation is not execution, and I rather considered myself one of that happy clan that Walker Percy called “ex-suicides.” “Since he has the option of being dead,” Percy wrote of this calm hero, “he has nothing to lose by being alive. It is good to be alive. He goes to work because he doesn’t have to.”
I constantly feel lucky to be still present on this mortal plane; but I just as often judge that “luck” is an inadequate framework for my situation. That situation includes, as David Hume would put it, “the circumstances of justice,” including moderate scarcity of available organs. “Moderate” because there are some, but “scarcity” because there are never enough. (Please take a moment to sign your donor card. It’s the easiest way to save a human life we have ever devised, and yet Canadians lag behind other wealthy populations in offering this painless act of giving. You can skip the eyes if you’re squeamish.)
The first successful liver transplant was performed in 1967, by surgeon Thomas Starzl at the University of Colorado. Today, almost 35,000 are done every year, mostly in Europe and the Americas. Then as now the procedure is a mind-blowing combination of high-tech thinking and primitive technique. All surgery, after all, comes down to knives and variations on catgut. But transplants have an added layer of ethical and political significance, lying at the tricky junction of markets and morals.
When you are waiting for a transplant from a deceased donor, you are placed on a list and given a number, called a MELD score (Model for End-Stage Liver Disease). Your age, condition and case specifics determine where you sit on this list, plus there are “exception points,” added according to circumstance. But the main issue is how sick you are – whether you are likely to die within three months.
It was in my favour that I had a steady job and relative youth. Against me, not long ago and still in some jurisdictions, was that my life-threatening state was the result of drinking too much for too long. A six-month sobriety period is mandated in some places. According to critics, this moralizes medicine as well as indirectly handicapping poor or Indigenous populations. And indeed there is no evidence that the six-months-sober period increases the chance of a clean recovery postsurgery. I’m almost certain I would have expired in that time, sober enough to reflect on my sins but not enough to survive them.
In the event, a compatible organ became available just a month after I entered the list and I was given it. When it failed, I nearly despaired: could lightning strike twice? But just five months after the first surgery I was called to the hospital as back-up to a scheduled surgery. When I came onto the ward floor, they told me I was, in fact, going into the OR in the morning. Almost before I knew it, I had yet another liver, my third in less than six months.
Every time I look in a mirror or walk down an empty sidewalk I am overcome with an emotion that lies beyond gratitude, though it is suffused with thankfulness. Somebody I’ll never know saved my life tonight, and I am surprised by painful joy.
The worry about distributing scarce organs is, of course, that the system is not fair. In a public-health system, the worry is mitigated by a belief that some things should not be governed by market rules or even variable moral considerations. I shouldn’t be able to buy myself a liver, nor should I be prevented from getting one because I’m suffering as a result of my own choices. Better than a ruthless market, maybe, but not entirely satisfactory.
“Take a closer look at these patients,” one of my doctors told me. “How much of their condition is not self-inflicted? We set them up to fail.” I don’t know about that. Isn’t a tolerant public-health system liable to create what bankers call “moral hazard” – the condition where insurance back-stops and likely government bail-outs make risk more tolerable? Shouldn’t mortal players shoulder their own chances?
Or is it rather the case that medicine is precisely where there ought to be socialization of risk, community sharing of danger? All insurance schemes, public or private, are risk-diffusion mechanisms floated by premiums. Socialized medical insurance walks an especially fine moral line: It is a public good that functions by being neutral at the level of private individuals. It might count as luck to be part of such a system, but within the system luck is banished from the conversation, along with desert and specific worth.
Still, there is a list and you get a MELD score that translates to weeks or months – or death. The process may be neutral, but it is not random. What counts as a valid exception, to raise your placement? On the receiving end, it is impossible not to feel a certain amount of survivor’s guilt alongside the surging gratitude. Why me? Why me?
I’m writing this from the 12th-floor Transplant Day Clinic at Toronto General. I am here getting some new blood, six hours of a needle in my arm to deal with this hard-to-shake anemia.
It’s amazing what you can do while hooked up this way, at least in my line of work. I did interviews and podcasts, talked to colleagues and students, wrote articles and the final chunk of one book, and watched hours of bad action movies while bedridden. Thank God for the laptop and the internet! I even practised my aesthetics lectures from bed, in case I had to teach from here. The nurses, overhearing these detailed orations to nobody at all, feared I had succumbed to transplant-related encephalopathy. No, I told them, just lecturing over here: talking about Schiller and Kant into a mostly indifferent void, as usual.
Random thoughts and images slip and slide across my mental terrain. I see a gallery view of all my roommates in a year and a half of “semi-private” rooms. There’s Big John, who played AA motivational speeches at high volume and knew all the inmate hacks; prissy Mrs. Perkins, who longed for affliction-connection and shared her test results with me all day; Crazy Darryl, who gave me COVID-19; The Goblin, who abused people on his cellphone well into each night; sweet Avery, who had donated part of his liver to save an alcoholic aunt down the hall; the Wailing Sailor of Estoril, who wept and bellowed in basso profundo Portuguese all night; the Hot Rod King, who liked hearing about the boom-box four-on-the-floor Toyota Corolla I drove in high school.
And of course there was the Bitchy Twit from Uxbridge, whose visitors munched Doritos in violation of PPE protocol and who complained constantly until one harried nurse, fed up, finally resisted. “I come in here every day, cleaning up your mess and changing your diapers,” she said, “and you have never thanked me once.” Allow me to do so on behalf of all patients, good and bad.
At one point, I was given cheese sandwiches and dishwater soups for lunch and dinner 18 days in a row. Then I discovered that there was secret menu and I could ask for a burger. Breakfast is the best meal in hospital; everything comes in packages. Also, if you pour the soup on the stiff mashed potatoes together with your tiny paper packets of salt and pepper, they’re almost good. (Thank you, Big John.)
Wordplay. In a get-well card, one of my former students quoted William James. “Is life worth living? It all depends on the liver.” Ahaha. Boston Brahmin goes Borscht Belt. After one predialysis procedure, I have several elaborate tubes dangling from both sides of my neck; I call them “medlocks.” I recall an old Bugs Bunny cartoon where a medieval jousting tournament features Sir Loin of Beef and Sir Osis of Liver. Ha ha ha.
I am sitting with the transplant team and they are all calling me “doctor” because I have a PhD. I kind of hate this – it’s respectful but also a bit provincial, most often used by people who want something from me. Now we sound like characters in that Rock Hudson movie where he plays a neurosurgeon. Doctor? Yes, doctor. Opinion, doctor? No, doctor. You, doctor? Er, doctor?
In an earlier meeting, Dr. Excellent tells me to consider the prospect of transplant. Suddenly I am Captain Picard on the bridge of the Enterprise, the picture of crisis-calm. “Very well,” I say bravely. “Tell me the other options.” He looks at me a little funny. “There are no other options.” Oh.
In a later meeting, I confess that I am experiencing some postop “epistemological slippage,” delusions and distortions of time. The other doctors pause and then burst out laughing. Yes yes, all right: just a humanities PhD over here. But it’s no stranger than “idiopathic aplastic anemia,” which is what they’re busy telling me I have. Sheesh.
There is no privacy or dignity in a hospital. There is no free sleep, either. You will be woken at an early hour and chased from bed to be weighed and poked for blood. There are, however, moments of sublime silence. Four a.m. at St. Mike’s, the dull glow of dawn at Toronto General, the bulky city coming to slow life around you, the hospital revealed as its own kind of cathedral. Until the shift changes and you are once more reduced from full sentient person to abject meat-puppet.
As far as I know, nobody took a selfie of my liver during surgery, as in a recent Coronation Street storyline. Nor, I hope, did anyone win a bet by bumping me up on the surgical schedule. I did have to sign a pledge that I would no longer drink. Unlike English football star George Best, who viewed his post-transplant liver as an invitation down to the local boozer, most of us find abstinence no contest compared with illness.
For the record, some non-alcoholic beer is not bad; but the wine is terrible and the gin-and-tonic mixes might as well be, uh, tonic. The word “mocktail” is silly. Why not just specify alcoholic drinks? Who knows – they may well be heading the way of cigarettes.
I know what I’m doing. I’m hoping narrative will shape experience, bend reality into digestible mouthfuls – ironizing all that looming contingency. We’re all control freaks when it comes to life-story. Any loss of familiar stories and scenes, remembered or repeated, is devastating – even deadly.
But suppose we recover, or return? Now we are revenants, twice-born survivors – not zombies or clones but animated replicants with new parts. We don’t pretend to understand the past, and we can’t presume to predict the future. But we also don’t comprehend the present. George Orwell had it right: “To see what is in front of one’s nose needs a constant struggle.”
It is mid-August. I am in the hospital – again or still, it doesn’t matter. I am talking to my father from my hospital bed in Toronto to his hospice bed on Vancouver Island. He is very sick, fading fast. But he sounds sharp and even chipper, as he has on every bed-to-bed call we’ve shared over the past year. A heavy drinker himself at times – no surprise there, maybe – he avoids judgments and advice. He’s mostly interested in the details of my treatment, the pericardiocentesis and bone-marrow biopsies, shifting symptoms and elaborate drug regimes. I think he’s afraid I will die before him.
We talk about the writers he loves, Graham Greene and Evelyn Waugh, the tortured English Catholics. I ask him how he is feeling, and he laughs hollowly down the line. “This too shall pass,” he says to me, and pauses. “Is that from the Bible?” It isn’t, I tell him, though it sounds like it should be. It’s actually from a Persian adage about the inevitability of change. Abraham Lincoln liked to quote a version of it.
My father mocks me for dissolving into pedantry, then laughs a goodbye across the ether. He died the next day, aged 89, of acute kidney failure. I wrote his obituary from my hospital bed. Later, when I was feeling better, I spread his ashes near the lake where my parents met as glamorous young 1950s revellers.
First installments, new plan.