An essay in honor of me appearing on Ryan Holiday’s The Daily Stoic podcast.

If Marcus Aurelius got cancer, I like to think he’d be reasonably stoic about it. Since my tongue cancer diagnosis, I’ve found myself reaching for his and other stoic philosophers’ work as a companion to adversity. You’ll see stoic ideas threaded through the essays my wife and I have been writing about my fatal cancer diagnosis: “Every day I’m trying to make a good and generative day, and I remind myself that there are many things I can’t control, but, as both Frankl and the Stoics emphasize, I can control my attitude.”

One way to see the virtues of this attitude is by process of elimination: What’s the alternative? Wallowing in bad days in which I accomplish and achieve nothing important? Getting angry about things I can’t control, and things that will remain the same whether I’m angry about them or not?* Lamenting that which cannot be, and will not be no matter how much I wish it so? Nothing will bring my tongue back. Bemoaning my fate will not avert it (though I’m also not passively accepting fate: as described below, I appear to be in a clinical trial for a novel, promising drug that targets squamous cell carcinoma of the tongue). The likelihood of another decade of life is not literally 0.0, but it’s under one percent and would require a series of near-miracles via clinical trials. Bess and I are pursuing that path; realistically, though we’re doing everything we can do, “everything” will almost certainly not be enough to achieve substantially longer life.

There’s a term for the people who get excessively upset about things beyond their control: children. Or emotionally immature adults (a subject I know too much about). I’m not saying I’m an emotionless robot or that you should be one; when I got the news on July 21 about the fatal recurrence and metastases, Bess and I spent the weekend crying and talking and crying some more. Premature death is bad and efforts to prevent it are good; stoicism is not lying down and accepting whatever happens. During that weekend we felt a lot. During the past two months, we’ve felt a lot—including gratitude that I’ve made it two months, since, on July 21, it wasn’t clear that I would. But there is a time for feeling things and a time for doing things (Aurelius tells us that “you have within you something stronger and more numinous than those agents of emotion which make you a mere puppet on their strings”), and I try to focus on doing the things that need to be done (like writing this essay), because most good days are composed of doing things. As long as I have the health and energy to act, I will act. Bess seems to have figured out how to get a lot of things done while feeling things strongly, which seems like playing on a hard-mode setting, but what she’s doing appears to be nonetheless effective for her. She says she’s always operating in feelings mode—and has described herself as “a large sack of feelings on legs”—which initially baffled me, but now I see is just an integral part of who she is and how she is in the world.

In some obvious ways, life changes because of a fatal diagnosis. Treatment and treatment options become high priorities. Planning for the far future, like 401(k) contributions, are dropped. Many of the micro social jockeying and status awareness (or anxiety) almost disappears. The time horizon shrinks. When we’re young, most interactions that could lead to friendships, business opportunities, etc., assume that there are decades in front of both parties, and that assumption doesn’t hold for me. What I do with the time granted to me has changed. But some things remain the same: whether there are a few months left or six decades left, the goal is still to win the individual day in ways that are still congruent with a full life.

I’m deliberately vague about what a “good day” is, and what “winning” the day looks like, because different people are going to have different definitions. For me, right now, the good days are the ones I get to spend with Bess, and the ones I—or more often both of us—spend writing (we are each other’s ideal readers). The bad days are ones when I let the feeling of obligation guide me, or when I let up on what I’ve called the “moratorium on banalities,” or ones when I give up and don’t try to be generative. Either fortunately or through the direction of will, I’ve had few days when I’ve given up and not tried to be generative. Some days, I’ve been legitimately too tired or sick to act: recovery after the May 25 surgery took a long time. Chemotherapy is brutal and debilitating. A medication called olanzapine inadvertently made me sleep for like 14 hours, and then left me feeling like a zombie for days. But those are the exceptions. Given my proclivities and obsessions and training, the good days most often entail finish an essay, which is what I’m doing now.

The bad days are, for many people, probably more similar to each other than the good days. They’re the days when nothing generative happens. They’re the days when we don’t use space-repetition software to memorize. They’re the days that disappear in the fog of distraction, or a haze of smoke from whatever someone might literally be smoking. Or the days that disappear in other kinds of mental hazes caused by ingestible substances, or doom scrolling, or media consumption. They’re the days you check Facebook or Instagram or email too much, and then watch a little TV, and then it’s back to the social media grind, and then it’s dinner time, and then you’re tired, and then it’s bedtime.

I’m not saying people shouldn’t take breaks or vacations. Both are good and have their place; Marcus Aurelius wrote: “No retreat offers someone more quiet and relaxation than that into his own mind, especially if he can dip into thoughts there which put him at immediate and complete ease.” When Bess reads this part, though, she chimes in: “Clearly Marcus Aurelius didn’t have generalized anxiety disorder. Who are these people whose own minds offer them quiet and relaxation? How did they get these minds? Where can I get one? Can I have one right now?” But I have a very long break in front of me, the eternal break, and so right now I’m not much searching for breaks from writing. For me, writing offers some of Aurelius’s quiet and relaxation in the mind.

Fundamentally, stoicism tells us to control what we can control, and accept that many things are beyond our control. The squamous cell carcinoma is largely beyond my control; with the October 20 surgery and the radiation in December and January, it seemed as defeated as the Gauls by the Romans. I wish I’d investigated the strange and painful patch on my tongue sooner, but I can’t turn back time and so try to thrust that issue from my mind.

I can control aspects of what I do next, but not what everyone else does next. One doctor at a clinical trial center, for example, decided that I’m not eligible for her trial because my cancer hasn’t progressed far enough on chemotherapy, and I needed to “fail” it before I was eligible. That seems like a misreading to me (Bess and I will have a lot more to say on this subject in our essay about clinical trials), but her view is out of my control, and, moreover, we’d gotten traction with another oncologist at another medical center who was and is gung-ho.

When Bess and I have been pursuing clinical trials, we’ve tried to master the process despite knowing that we may master the process and yet not achieve the desired outcomes. Finding the maximally good clinical trial is literally a life and death issue, which is concomitantly stressful. The present likely outcome is death: recurrent and/or metastatic head and neck squamous cell carcinoma (R/M HNSCC) is almost always fatal, and current treatment options are palliative. So the stakes are very high and only part of the process is under our control.

Some new treatments might do substantially better, which is welcomed in a world where a “successful” treatment might help 30% of patients live a few extra months. R/M HNSCC is refractory to treatment, and the version infesting me grows particularly fast and, from the start, has shown “perineural invasion”— it occupies nerves and uses them to spread. My getting into one of the better clinical trials depends on those other people, like oncologists, primary investigators, anonymous drug company reps, or site coordinators.

It’s been challenging to navigate the bureaucracy and system. In a slightly different world, the trial I appear to be in now may have closed or rejected me. The first time Bess and I inquired about the trial I’ll be starting, it was closed to new patients—a seeming defeat. Then, we got word that the trial happened to have new spots open a few days before my appointment to establish care at that hospital. If it was still closed to me, I’d continue to work the issue, but I’d also try to accept with as much equanimity as I can what is and what can’t be changed. Bess has had less success with equanimity, and, while her own struggle with acceptance manifests as her single-mindedly working towards getting me into the right trial, now the question has shifted from the active “will I get into one?” to the passive “will it work, once the drug is infused?” Without as much to do, Bess doesn’t conceal well how much she struggles with accepting my fate, and what that means for her own.

I’m writing this particular sentence Sept. 8; in one critical way, it’s not been a great day: CT scans show some tumor size increases, despite chemotherapy. One hopes that chemo will shrink the tumors. But what am I going to do differently with this news? Nothing. I’m going to keep going, and doing everything I can to facilitate the trial happening, and to spend time with Bess. I’m going to keep trying to string together as many positive days in a row as possible.

I can’t control that I can’t chew, swallow, or speak normally, but I can try to mitigate these deficits as best I can—I can get speech therapy in an attempt to maximize my intelligibility and verbal legibility. I can write down the phonemes that most trouble me and attempt to find alternate ways to vocalize them. I can’t chew, but I can use a Vitamix or other blenders to create slurries that I can swallow and taste. I can practice the swallowing techniques that minimize choking and improve my ability to swallow foods that are more whole than they’d otherwise be.

Few of us are maximizing the things that are within our control, including me. We can and should try to do better. We should try to be more resilient.

Stoicism may be a philosophy, but it came before the science/philosophy split, and before “philosophy” became a byword for ineffective talkers. “Wordcels,” in modern Internet meme parlance. Stoicism is about living and doing, to the greatest possible extent. I was reading the Albert Camus entry in The Stanford Encyclopedia of Philosophy and came across this, about Camus’s The Myth of Sisphyus:

What then is Camus’s reply to his question about whether or not to commit suicide? Full consciousness, avoiding false solutions such as religion, refusing to submit, and carrying on with vitality and intensity: these are Camus’s answers. This is how a life without ultimate meaning can be made worth living.

I’m doing my best to achieve full consciousness and to carry on with vitality and intensity, most notably via writing and love. I can taste coffee again, which helps achieve a life of vitality and intensity. When I was closest to saying no to life and yes to the void, it was because I couldn’t achieve full consciousness or carry on with any vitality or intensity. For me, there is some minimum viable mind-body state that I dipped below in May and June. To get above that minimum again is good.

I was talking my sister, Rachel, and said to her a variant of what you’ve been reading in this essay: “I’m trying to be stoic about it: doing everything I can, while accepting that much is outside my control.”

“You’re doing a hell of a job,” she replied, “I wish I had the mental resilience you exhibit.” (Okay, this was via text, and I’ve added the periods.) She went on: “I told you this when I saw you, but it inspires me.”

“The alternative—falling apart, screaming, crying, I don’t know—what’s the point?” I said. “It just makes what days I have worse. Life goal is to have as many strings of good days as possible. Even if I don’t have a lot of good days, I want still to max out those I get.” (I use periods in texts, which I’m told makes me overly serious, or sarcastic, or otherwise off-putting.)

“It all makes sense, but it’s not common to be rational in a situation like yours. It’s admirable.”

“I don’t even know if it’s rational per se, so much as me trying to live the best life I can, given the circumstances.”

What’s rational? I don’t fully know. Philosophers tie themselves in knots trying to define it; most of us think we know it when we see it, but otherwise go about our days and lives, trying to take small steps towards a much better world.**

Given what seems like the virtues of stoicism, why is it so hard to implement for so many people—myself included? I’m not sure and the question is a genuine one that I don’t have an answer to. There must be something evolutionarily adaptive about the vicissitudes of random emotions, for the non-stoic reactions and the non-stoic life to be so common. Or maybe it’s counter-adaptive, but vestigial. If the Stoics had known about the amygdala, nestled inside the oldest part of our lizard-brain, responsible for our fight or flight response and a great deal of our fear and decision making, could they have given us some practical guidance as to how to overcome that ancient programming in our minds?

I don’t think stoicism is everything. I can think of some apparent downsides:

* Does stoic philosophy discourage totally feeling one’s emotions? I think there can be a trade-off here; there obvious counterargument is that stoics encourage the feeling of one’s emotions, but not being ruled by them. Feel what you feel, but don’t let feelings rule actions. It’s a subtle but important distinction. “What if you feel you should act on your feelings?” is a tricky one, especially when, sometimes, not accepting a situation can lead to actually changing it (as Bess and I are trying to do with the clinical trial).

* Aurelius doesn’t have a sense of science, the scientific method, or progress. It’s unfair to expect him to, because those notions don’t really get kindled until the Renaissance, but the invention of science is one of the greatest human achievements ever. That achievement occurred after the main stoics were writing.

* Letting stoicism become a dogma instead of a set of adaptable ideas and practices. That’s a risk of almost set of ideas, however, whatever their label.

On July 21, when I got news of the new tumors in my neck and lungs, I didn’t know whether I had only weeks to live. Given the speed of recurrence between the end of radiation in January and the hot PET scan in April, and the speed of the second recurrence between the May 25 surgery and the July 21 CT scans, “weeks to live” was plausible. I rapidly prepared Bess, my family, and friends for my possible demise. The presence of tumors in the lungs scared Bess and me.

Chemo had already been scheduled for July 24, and I went through with it; initially, Bess and I had hoped that chemo would sterilize any cancer cells that remained after the May 25 surgery. Instead, chemo morphed into that palliative effort to buy more time. Have we actually bought that time, or has chemo taken our money and run faster than a crypto scammer? I’ll find out in December, when the first set of CT scans after the clinical trial drug has had time to work—or not. So far, chemo hasn’t shrunk most of the tumors, though it’s likely kept them from growing too rapidly.

Marcus Aurelius died at age 58, of what the notes in my copy of Meditations characterizes as a short final illness of “only a week or so—and the exact cause of his death is not known.” Aurelius’s last entry reads:

Mortal man, you have lived as a citizen in this great city. What matter if that life is five or fifty years? The laws of the city apply equally to all. So what is there to fear in your dismissal from the city? There is no tyrant or corrupt judge who dismisses you, but the very same nature that brought you in. It is like the officer who engaged a comic actor dismissing him from the stage. “But I have not played my five acts, only three.” “True, but in life three acts can be a whole play.”

Early death was more common in the ancient world than it is in the contemporary rich world, and Aurelius, given how much time he spent at war, must have been particularly familiar with it. Yet even today, we are all, sooner or later, dismissed from the city. Yet I disagree that it matters not whether one lives as a citizen in the great city that is life for five years or fifty: fifty is generally better. But I am not going to get all five acts and so have to be content with the acts I’ve had.

The life goal is the same whether there are 30 days or 30,000 ahead, though the means may be differ. All of us know, intellectually, that, given the present level of scientific progress, we’re going to die. Given that, are we living the life we should be living? If not, why not?

I wrote that “Stoic philosophy is a companion to adversity.” Life is about handling adversity, which all of us face, in many forms. In that sense, stoicism is a companion to life.

If you’ve gotten this far, consider the Go Fund Me that’s funding ongoing care.

And you might be interested in me appearing on The Daily Stoic podcast:

Ryan speaks with Jake Seliger about how his cancer diagnosis and having his tongue removed have changed his perspective on life, why he is prioritizing people much more highly than work now, how he is making every single minute count, what he is trying to communicate with his recent outpouring of creativity, accepting death, and more.

I listened to the podcast after I wrote most of this essay, and the podcast starts with Aurelius’s final meditation—a logical place to go, given the topic.

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* Anger is almost always a bid for better treatment: used sparingly and appropriately it can work. All of us have seen the long-term results in people who overused anger and consequently become isolated by it. Sometimes business titans can get away with a lot of anger (Jobs, Musk), but most people can’t most of the time. A lot of us are aware of people who were raised by parents with anger problems. Children can’t defend themselves.

** Stolen from the tagline to Marginal Revolution.