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On the Move, by Oliver Sacks

On the Move, by Oliver Sacks. Alfred A. Knopf, 2015.

Medicine is dominated by the quants. We learn about human health from facts, and facts are measurable. A disease is present or not present; a reckonable proportion of people respond to a particular drug; the inability to predict gene-environment interactions reflects only a failure to map facts we will eventually be able to determine; and if the observable phenotype varies for an established genotype, the differences must be caused by calculable issues. In this version of things, the case histories that constituted most of medical literature up to the early 20th century reflect a lack of empirical sophistication. Only if we can’t compute something are we reduced to storytelling, which is inherently subjective and often inaccurate. Science trades in facts, not anecdotes.

No one has done more to shift this arithmetical naïveté than Oliver Sacks, whose career as a clinician and writer has been devoted to charting the unfathomable complexity of human lives. “All sorts of generalizations are made possible by dealing with populations,” he writes in his new memoir On the Move, “but one needs the concrete, the particular, the personal too.” The emergent field of narrative medicine, in which a patient’s life story is elicited in order that his immediate health crisis may be addressed, in many ways reflects Sacks’ belief that a patient may know more about his condition than those treating him do, and that doctors’ ability to listen can therefore outrank technical erudition. Common standards of physician neutrality are in Sacks’ view cold and unforgiving — a trespass not merely against a patient’s wish for loving care, but also against efficacy. Sacks has insisted for decades that symptoms are often not what they seem, and that while specialization allows the refinement of expertise, it should never replace the generalism that connects the dots, nor thwart the tenderness that good doctoring requires. A reasonable corollary to the Delphic injunction to “know thyself” is to know thy patient, and few physicians have devoted themselves more unstintingly to such inclusive knowledge than Sacks. Patients want coherence, which can be achieved only when the contradictory essentials of experience are assembled into a fluid account. The doctor must not only listen, but also process what he has heard.

Sacks’ interest, however, is not merely in helping his patients construct their stories, but also in recounting them to the rest of us. The ethics of that undertaking have often been questioned — most notably, perhaps, by the disability activist Tom Shakespeare, who described Sacks as “the man who mistook his patients for a literary career.” Janet Malcolm’s assertion that “every journalist who is not too stupid or too full of himself to notice what is going on knows that what he does is morally indefensible” has a particular relevance to Sacks: When the journalist is a doctor, the exploitation of trust is particularly complicated. Sacks’ decision to write about his own patients as uncanny specimens (in this book, he reproduces a note that describes a dancing patient as “an idiot Nijinsky”) can feel at odds with the careful sensitivity with which he has clearly listened to and observed them.

Sacks has long grappled with this dichotomy, and it surfaces repeatedly in his memoir. He does not play down the anger of some patients who have felt betrayed by his portrayals of them, nor does he deny his frustration with wary ones who resisted being depicted. He also reports patients who felt deeply satisfied to read their tales in print — who believed that Sacks had transformed their lonely struggles into heroic exemplars of dignity. Sacks neither dodges nor pursues these moral quandaries at the root of his work; this memoir is more a history of his career than an analysis of it.

For decades, his oeuvre has pointed to very high boundaries with most people, startlingly low ones with his patients, and rather muddled ones with his readers. His delving accounts of the invalids he treats have until now stood in stark contrast to his restraint about revealing himself deeply, even though autobiographical threads run through such books as A Leg to Stand On, Uncle Tungsten and Hallucinations. A doctor — concerned, engaging, humane, eccentric and unforthcoming — has occupied the foreground in his self-description. With On the Move, he has finally presented himself as he has presented others: as both fully vulnerable and an object of curiosity.

The most attractive and most problematic qualities of his writing turn out to be what are best and worst in him. His immersion in his patients’ brokenness is mirrored here in his acknowledgment of his own brokenness, his belated empathy for his younger self. He was evacuated from London during World War II to a boarding school where he was often beaten by a sadistic headmaster; he had a brother who developed schizophrenia; he realized he was homosexual as a teenager in the 1940s, in those Alan Turing years when prejudice was at its apex. Medical training pressed him toward aloofness. “There has to be, along with fellow feeling and sympathy and compassion, a sort of detachment so that one is not drawn into a too-close identification with patients,” he explains. His life battle has been both to sustain such detachment and to overcome it.

After many years of sidestepping the question of his sexual orientation, Sacks has finally written about being gay, recalling his mother’s horror at the news (he was 18; she said, “I wish you had never been born”), his early love affairs, the prolonged sexlessness of his midlife, and his recent, happy coupledom with the writer Bill Hayes. Sacks’ writing about sexuality is both labored and moving; this is still rough topography for him. In his younger days, he was astonished that someone he had been seeing might be in love with him, and alarmed by the belated discovery that he had “broken his heart.” His transition into celibacy is presented without explication. “After that sweet birthday fling, I was to have no sex for the next 35 years,” he writes. But why not? He explains only that he had trouble with “bonding, belonging and believing.” Sacks has cared for many people — especially his patients — but the kind of love on which marriages are based seems to have been not merely elusive, but bewildering to him (though he has been seeing the same psychoanalyst for nearly 50 years). Sacks did not so much avoid convention as fail to notice it; he understands difficult facets of the human experience with singular clarity, but emotional rules that are legible to most people seem to bewilder him.

The primary mark of a good memoir is that it makes you nostalgic for experiences you never had, and Sacks captures the electrifying discoveries he made, especially those in his early career, with vivid, hard-edge prose. He is compelling describing his romance with motorbikes, which he rode across vast distances in his youth, crisscrossing much of North America and Britain, and his obsession with the most extreme kind of bodybuilding; in his late 20s, he could readily squat lift 600 pounds. He conveys the consuming intensity of his writing practice; the sudden insights and ensnaring perils of the drug addiction that nearly killed him; and the expatriate’s permanent yearning for the country he isn’t in, missing the United States while in England and vice versa. He expresses the endemic sadness of remembrance toward the end of life, when the bad recollections remain sad, and the good ones are infused with the melancholy of their transience. He does not disguise the persistence of his guilt about those whom he introduced to drugs, or whom he did not love enough or see enough or help enough. Neither does he renounce his vendettas against those who willfully hurt him, including a supervisor who criticized his manuscript, fired him and then plagiarized from it, and the authorities who sacked him and expressed disapprobation for his choosing to play with autistic patients rather than apply a reward-and-punishment model, an apparent whimsy now borne out as sound practice.

On the Move sometimes stumbles in a way typical of celebrity autobiographies — which is to say that being already interested in Sacks will give you patience with details of how his housekeeper cooked fish or his long swims around City Island that other readers may find unexciting. Parts of the book are bracingly innocent; parts are snobbish, with extended descriptions of his good reviews, banal disquisitions on famous friends (his cousin Abba Eban, the poet Thom Gunn, W.?H. Auden, Francis Crick, Robert De Niro, Stephen Jay Gould, etc.) and a slightly pompous sequence about meeting the queen when she made him a Commander of the Order of the British Empire. Sacks assumes sometimes that we know more of his past than we do, and sometimes that we know less. Parts of this undertaking read dismayingly like the book one might write for one’s grandchildren.

Though he is not at ease in the world, Sacks wants its notice; his face has appeared on the cover of several of his books, as it does, rather fetchingly, on this one. The poignancy of this shy exhibitionism permeates this book. He describes one of his patients as having a “compulsion to be seen and shown, to exhibit himself, but also to hide from sight”; he could be describing himself. The most touching part of the book is the exposition of his relationship to his Aunt Lennie, who seems to have given him a confidence that his quietly accomplished parents failed to instill. “Len’s belief in me had been important since my earliest years,” he writes, “since my parents, I thought, did not believe in me, and I had only a fragile belief in myself.” Later, he muses: “It was not easy to believe that anyone cared for me; I sometimes failed to realize, I think, how much my parents cared for me. It is only now, reading the letters they wrote to me when I came to America 50 years ago, that I see how deeply they did care.” The writing of this book must have helped in that healing, which gives it considerable pathos.

As a young man, Sacks wrote to his parents that he could repay their benevolence by “leading a fairly happy and useful life,” and he appears to have kept that promise. He is enamored of humanity despite often finding individual people difficult, “splendidly inclined to what he characterizes as “childish, ingenuous enthusiasm.” In writing about fellow scientists — especially the Nobel laureate neuroscientist Gerald Edelman — he demonstrates undimmed intellectual vigor, and drives toward an agnostic theory of life as awash in both conscious and unconscious choices, and thus permanently suffused with possibility. This position entails the rejection not of particular facts, but of the tyranny of facts altogether. He angered members of the medical establishment early in his career because, he writes: “I had cast doubt on predictability itself. I had cast contingency as an essential, unavoidable phenomenon.” He has always been, he writes, “haunted by the density of reality.”

To clinicians, Sacks generally seems a very good writer, and to lay readers, he often seems a remarkable doctor, but the extent of his distinction in either area has been subject to question. His writing sometimes has a tinge of exposé, and there is no evidence that his clinical skills outrank those of other neurologists. To dismiss him on either of these fronts, however, misses the central fact that translating between those two arenas has great value of its own. Sacks’ ability to enact and celebrate intuition in medicine and precision in art is singular. In comparing himself to the poet Thom Gunn, he writes, “Thom, even then, was lapidary and incisive; I was centrifugal and effusive.” Edelman’s vision of an essentially “individual, personal world” gave Sacks “the feeling of having been liberated .?.?. from a world of shallow, irrelevant computer analogies into one full of rich biological meaning.” This freedom in turn led him to conclude, “Individuality is deeply imbued in us from the very start, at the neuronal level. .?.?. We are destined, whether we wish it or not, to a life of particularity and self-development, to make our own individual paths through life.”

Sacks’ first major book, in 1973, was Awakenings, which inspired a documentary, a play by Harold Pinter and a feature film. The title is telling. Though he explicitly addresses the reviving of patients long caught in Parkinsonian catatonia caused by encephalitis, the real accomplishment of this and his subsequent books has been the larger awakening to the idea that medicine itself sits rightly at the intersection between literature and science.