Musings of a Cancer Doctor

Wide-ranging views and perspective from George W. Sledge, Jr., MD

Tuesday, November 15, 2011

On Steve Jobs

My first computer, back in the early 1980’s, was an Apple IIe, and pretty much every computer I have owned since has been an Apple product. I had a brief, disastrous detour into PC-land (a Dell computer that crashed, like clockwork, whenever a grant was due), regretted it immediately, and returned to Macworld as soon as I could. I have an iPod Nano and am writing this on my iPad while sitting on an airplane. I love the style, the ease of use, and the durability of Apple products.


Maybe this is why I am so angry about Steve Jobs. And angry at Steve Jobs. Angry because his brilliant mixture of tech and style, a mix that changed how we interact with the world, is gone forever. And angry because I suspect that his death was unnecessary and premature.


This may be unfair, or at least incorrect. The facts are reasonably straightforward, at least as I can piece them together. He was diagnosed with an early stage pancreatic islet cell tumor, the only kind of pancreatic cancer with any sort of cure rate. Despite the entreaties of friends and colleagues he wasted nine months on worthless alternative approaches before finally undergoing pancreatic surgery. He subsequently had a recurrence of his cancer, underwent a liver transplant, received experimental therapies and eventually succumbed to his disease.


Did this nine months matter? Did he miss his window of curability? I don't know, and neither does anyone else. His tumor may have already shed the micrometastases that eventually grew and killed him, and if so those nine months were irrelevant.


But I do know that cancer doesn't care. It doesn't care if you are rich or smart or powerful, it doesn't share your beliefs on nutrition or meditation and it has no desire to ever give you a second chance if you screw up your chance for a cure. It is an agent of entropy. It maximizes disorder, and our short lives are possible only if we try and preserve ourselves from the entropic catastrophes it foments.


I've not taken care of anyone living up in the Steve Jobs stratosphere. I view this as a function of living in flyover country, and have never regretted losing the opportunity to hob-nob with people who attract camera crews. But my limited experience has been that the inhabitants of the stratosphere don't always get very good medical care.


Partly this springs from personality. Jobs was brilliant, arrogant, and kooky, if Walter Isaacson's fine new biography is to be believed. Throughout his life he periodically went off the deep end with fad diets, so he naturally believed that he could handle cancer the same way. He was quite capable of ignoring those who disagreed with him: was this a literally fatal flaw?


I have had similar experiences with some (though not all, by any means) high-flyers. Because the normal rules of existence don't seem to apply to them, they sometimes seem to believe that cancer's biologic imperatives are options rather than mandates. They think they can perform, through use of their wealth and position, some Kobayashi Maru maneuver, reprogramming life's computer to alter the outcome of their disease.


Curiously, the well off sometimes suffer from lack of access to good medical care. They surround themselves with toadies and yes-men and (viz Michael Jackson and Elvis Presley) the unethical and incompetent. Idiots with medical degrees endorse their magical thinking. Because they can afford concierge doctors they assume that they are receiving better care, when their care is frequently inferior to that received by the average Medicare recipient. This doesn't seem to have been the case with Jobs, however, who received his care at excellent institutions.


The other part of the Steve Jobs story that makes me wonder involves his liver transplant. I am no expert in this area, and neither, apparently, is anyone else: a Medline search of liver transplantation for metastatic islet cell tumors reveals a paucity of data. There are small collections of anecdotes in the medical literature, with nothing solid to go on.


Leaving aside whether the transplant was medically wise or appropriate, or even if it was performed for his cancer (I lack data sufficient to make a judgment on this), Jobs apparently got the transplant by gaming the system. Because transplants are assigned on a state-by-state basis, there are inequities in distribution that have a geographic basis. Californian Jobs got his replacement liver in Tennessee by getting his name on their state registry, as well as many others.


The Apple addict in me mourns the passing of Steve Jobs. The doctor part of me wonders whom he bumped off the transplant list. There are always more candidates for liver transplant than there are livers, and people die while standing in line for their turn.


Isaacson's biography details the many unlikeable aspects of Jobs's personality: his cutting, vicious attacks on employees, his belief in his own infallibility, his lack of concern for the feelings of others, his despicable treatment of his born-out-of-wedlock daughter. Nor was he particularly generous. Bill Gates has done far more from a philanthropic standpoint, and his philanthropy has saved countless lives.


It is not hard to imagine such a man thinking that his life was more valuable than that of some poor guy in Nashville or Memphis. When you bump someone off the list, that person is anonymous to you. But the relatives of the anonymous grieve for their loved ones when they die, and the unknown dead deserved their short time on earth just as much as Jobs. Maybe even more so, since that short time is often all that life gives them.


The excuse I’ve heard about Jobs is that “we transplant the sickest person on our list.” But that is an excuse: the poor guy almost certainly doesn’t have the resources to fly around and be examined at multiple centers. He never gets on the transplant list, regardless of how sick he is.


When a rich man uses his resources to add his name to transplant lists with shorter waiting times, that is class warfare of the most terrible sort. It isn't illegal, but is it ethical? That Jobs subsequently supported efforts to expand the pool of transplant donors in California was a good thing, but he may have taken away a liver from someone who might have been better served by the surgery.


And yet, and yet…the man was a genius. His commitment to excellence, even in the small things, enriched all of our lives (not to mention the lives of those smart enough to invest in Apple in 1998). He will be remembered long after the rest of us have passed into our well-earned and final obscurity. He was capable of real wisdom: read his wonderful 2005 Stanford University commencement address. He was a mixed bag, as are most of us.


So I have ambivalent feelings about the passing of Steve Jobs. Part of why I am in no rush to leave the land of the living is my curiosity--it amounts to a compulsion--about what will happen tomorrow. According to his sister, Jobs's last words were "Oh, wow. Oh, wow." I suspect we will miss several "Oh, wow" moments due to his passing, and that is a shame.