There were usually not nearly as many sick people inside the hospital as Yossarian saw outside the hospital, and there were generally fewer people inside the hospital who were seriously sick. There was a much lower death rate inside the hospital than outside the hospital, and a much healthier death rate. Few people died unnecessarily. People knew a lot more about dying inside the hospital and made a much neater job of it. They couldn’t dominate Death inside the hospital, but they certainly made her behave. They had taught her manners. They couldn’t keep Death out, but while she was there she had to act like a lady. People gave up the ghost with delicacy and taste inside the hospital. There was none of that crude, ugly ostentation about dying that was so common outside of the hospital. They did not blow-up in mid-air like Kraft or the dead man in Yossarian’s tent, or freeze to death in the blazing summertime the way Snowden had frozen to death after spilling his secret to Yossarian in the back of the plane.“I’m cold,” Snowden had whimpered. “I’m cold.”“There, there,” Yossarian had tried to comfort him. “There, there.”They didn’t take it on the lam weirdly inside a cloud the way Clevinger had done. They didn’t explode into blood and clotted matter. They didn’t drown or get struck by lightning, mangled by machinery or crushed in landslides. They didn’t get shot to death in hold-ups, strangled to death in rapes, stabbed to death in saloons, blugeoned to death with axes by parents or children, or die summarily by some other act of God. Nobody choked to death. People bled to death like gentlemen in an operating room or expired without comment in an oxygen tent. There was none of that tricky now-you-see-me-now-you-don’t business so much in vogue outside the hospital, none of that now-I-am-and-now-I-ain’t. There were no famines or floods. Children didn’t suffocate in cradles or iceboxes or fall under trucks. No one was beaten to death. People didn’t stick their heads into ovens with the gas on, jump in front of subway trains or come plummeting like dead weights out of hotel windows with a whoosh!, accelerating at the rate of thirty-two feet per second to land with a hideous plop! on the sidewalk and die disgustingly there in public like an alpaca sack full of hairy strawberry ice cream, bleeding, pink toes awry.

~ Joseph Heller

Long before there were effective treatments, physicians dispensed prognoses, hope, and, above all, meaning. When something terrible happens-and serious disease is always terrible-people want to know why. In a pantheistic world, the explanation was simple-one god had caused the problem, another could cure it. In the time since people have been trying to get along with only one God, explaining disease and evil has become more difficult. Generations of theologians have wrestled with the problem of theodicy-how can a good God allow such bad things to happen to good people? Darwinian medicine can't offer a substitute for such explanations. It can't provide a universe in which events are part of a divine plan, much less one in which individual illness reflects individual sins. It can only show us why we are the way we are, why we are vulnerable to certain diseases. A Darwinian view of medicine simultaneously makes disease less and more meaningful. Diseases do not result from random or malevolent forces, they arise ultimately from past natural selection. Paradoxically, the same capacities that make us vulnerable to disease often confer benefits. The capacity for suffering is a useful defense. Autoimmune disease is a price of our remarkable ability to attack invaders. Cancer is the price of tissues that can repair themselves. Menopause may protect the interests of our genes in existing children. Even senescence and death are not random, but compromises struck by natural selection as it inexorably shaped out bodies to maximize the transmission of our genes. In such paradoxical benefits, some may find a gentle satisfaction, even a bit of meaning-at least the sort of meaning Dobzhansky recognized. After all, nothing in medicine makes sense except in the light of evolution.

~ Randolph M. Nesse