Hektoen International

A Journal of Medical Humanities

Butterfly day

Marsal Sanches
Bismarck, North Dakota, United States


In some cultures, black butterflies are
considered omens of death.

He did not believe that a black butterfly was an omen of death. It was just some old superstition he remembered hearing from his Brazilian babysitter many years before, sort of a South American banshee. Someone would see a black butterfly inside the house and, a few hours later, receive terrible news: a family member had just passed away.

As an engineer, logic had always guided Jeff’s life. Rationality was his fuel and “you make your own destiny” his mantra for almost all of his fifty-seven years. As a child, he never bothered playing with other kids (“They only like silly games”) and would rather spend hours reading. It was better to be alone. His teenage years had passed without passion or the emotional ebullition of his schoolmates. He could not understand their upside down priorities. Why go to the movies with a girl you would never see again after graduation, rather than studying for exams?

During college, all his energy was focused on studying. He made sure to choose a major that would allow a solid career, and was dismayed when some professors insisted he had a special talent for arts. He could not afford uncertainties. Everything had to be carefully planned, meticulously calculated. All decisions needed a rational explanation. He proposed to his wife after two years of mechanical dating, and not before balancing the pros and cons of marrying a woman he did not feel particularly attracted to, but who seemed reliable and stable, like himself. In any case, a marriage was just a business agreement, which could be easily dissolved if necessary. He had never and would never waste energy mourning the loss of a relationship. “I will just press the delete key and move on,” he once told a therapist that his wife had insisted he see, right before filing for divorce years ago.

The diagnosis had not changed his way of facing the world. It sounded rather matter-of-fact: stage four lung cancer. His first reaction was to ask the physician how much time he had. Years? Months? Weeks? The doctor just shook his head and smiled, sadly. What were the chances? What were the options? The physician had again smiled, condescendingly, it had seemed, and suggested that he get his affairs in order.

After leaving the office, he vaguely remembered the doctor mumbling something about keeping him comfortable, but by that time Jeff had barely been listening. The physician did not know what he was doing or saying. He would never give up. He would face this new challenge with his head up, no self-pity or useless outbursts of anger. Nothing like running after a God he had never spoken with, either. His bargain would be with science. New treatments were constantly advertised, and there was always an ambitious and brilliant doctor conducting a new clinical trial on some kind of revolutionary treatment. That was what the Nobel Prize was for, to encourage the bright ones to exceed themselves. And doctors often performed miracles. He knew it. He trusted medicine, had faith in it. And he still had time.

The following months passed quickly. Countless hours were spent in procedure rooms, laboratories, and radiology suites. He often turned down the chance to spend a few hours with his adult children because of research appointments. He did not need delays and could not afford to waste time with long-faced people who had not spoken with him in years and now seemed to be hovering around, pretending to be sympathetic. Just vultures waiting for their share.

Most of the research staff he had encountered, on the other hand, did not have long faces. They sounded rather optimistic, reciting the long list of potential side effects and adverse reactions in a monotone voice, sometimes with estimated risk percentages, which he almost enjoyed. Now they were talking. At least he had numbers to make his decisions.

He had to admit that the numbers would at times seem a little discouraging. One of the research assistants had mentioned something like an average increase of six months in the survival rate in previous studies when compared to placebo. That sounded like gambling. The words “randomized” and “double-blind” did not inspire much confidence either, but he said nothing. Instead, he tried to act nonchalant and returned his eyes to the pile of forms he had to fill out and consents he had to sign. This was a ritual he had grown used to, the same procedure in every study he applied for.

Still, all he had received so far were gentle refusals. The most recent one had not been any different. The study coordinator who called him that morning, with all the freshness and brightness of her early twenties, had been rather straightforward: he did not meet the inclusion criteria for that study. She hoped Jeff understood.

He did understand. He knew how these things were. He accepted it. There should be other trials somewhere. New York. Houston. Los Angeles. He knew it. He would not give up. If the shortness of breath allowed him to proceed and the wheezing improved at least a little, he would continue to fight.

Yet, he could not figure out why, after noticing the big black butterfly comfortably resting in his porch, right at the transition between the wall and ceiling, he was now feeling so anxious. Anxious like a kid on his first day in kindergarten. Anxious like someone about to leave on a long road trip without a map or a compass.

He had run out of time. Butterfly Day had arrived.



MARSAL SANCHES, MD, PhD, is an attending psychiatrist at CHI St. Alexius Health and a clinical associate professor at the University of North Dakota School of Medicine in Bismarck, North Dakota. Born and raised in Brazil, he has lived in the Unites States since 2009. He has a great interest in medical education, the interface between humanities and medicine, and medical psychology. Dr. Sanches strongly believes in the power of narrative fiction as a healing strategy and a resource to reduce burn out among health care professionals. He also finds it a little odd to talk about himself in the third person.



Summer 2018  |  Sections  |  Fiction


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