The Mindful Scalpel

During the lifetime of the Buddha, no one knew what the brain was, or where consciousness was located.

“Given . . . that ancient Indian science had detailed knowledge of the human anatomy,” writes the Dalai Lama in The Universe in a Single Atom, “it is surprising that there was no clear recognition of the role of the brain as the core organizing structure within the body, especially in relation to perception and cognition.”

Twenty-five centuries after the Buddha’s final sermon, I’m in a floodlit operating room on the sixth floor of New York University Medical Center, watching Dr. Werner Doyle—a brilliant neurosurgeon and practicing Buddhist—drill through the skull of Mr. S, a sixty-two-year-old epilepsy patient. S’s chronic seizures, Doyle hopes, will be cured by purging damaged tissue from his left temporal lobe.

“I’ll be removing three thumb-tip’s worth of brain,” says Doyle, “and one “pinkie,’ the hippocampus.”

Standing beside me is another neurosurgeon, much younger but equally impressive. Dr. Katrina Firlik is observing this procedure at the invitation of Dr. Doyle. She’s the inspiration for my visit. Her recent book, Another Day in the Frontal Lobe, provides a fascinating window on the art and science of brain surgery. Although Firlik is not a Buddhist, she’s definitely a kindred spirit; her writing glows with insight and compassion.

Firlik, thirty-eight, is the mother of a one-year-old daughter. Her husband, whom she met in college, is also a neurosurgeon, and they live in a densely wooded part of Connecticut near the New York border. It’s hard to believe that this calm, fair-skinned woman has weathered four years of medical school, followed by another seven of specialized training. As Doyle works, Firlik explains the process.

It’s astonishing how many layers separate our brains from the world at large. Doyle has already cut first through the scalp, then through a layer of connective tissue called the fascia; he has severed the “chewing muscle” (temporalis) and pericranium, and opened the skull with a tiny jigsaw. Even after he lifts away a silver dollar-sized disk of skull, we’re not home free; a delicate sheath called the dura mater covers the cerebral cortex.

With infinite care, S’s brain is exposed. The moist surface is covered with blood vessels and pulses with the sleeping patient’s heartbeat and respiration. It’s an incredible, unforgettable sight.

“So that’s the brain,” I whisper in awe.

“Well…” Doyle squints at me above his mask. “That’s a brain.”

Several hours later, over a late lunch in a Japanese restaurant, Doyle’s riposte still makes Firlik laugh. “Your comment was so reverent,” she says. “Werner was bringing it down to earth, back to a surgeon’s perspective.”

The surgeon’s view of the brain, I’m learning, is a perfect blend of respect and pragmatism. The first observation Firlik makes in her book, in fact, is that brain tissue has the texture of soft tofu—a good thing to know when you’re handling the stuff. The book is filled with practical facts and observations about what the (er, a) brain feels like, the way it reacts to disease and trauma, and why much of a brain surgeon’s job involves being a good mechanic.

“The brain takes up 80 percent of the skull; the other 20 percent is blood and cerebrospinal fluid,” says Firlik. “That’s important in disorders that we see—like tumors that push parts of the brain into areas usually reserved for fluids, and in trauma cases, when there’s only so much the brain can swell before it becomes life-threatening. The brain is in a box; it can’t swell up like the arm or the face can.”

My main interest in meeting Firlik is to learn how a thoughtful, empathetic surgeon balances the material component of the mind with its spiritual potential. Does the brain, for example, still keep secrets from those who fillet its lobes?

“Definitely,” she nods. “It’s still being mapped, with increasing accuracy, by fMRI [highly sensitive, “functional” MRI] scans. Take the insula [region of the brain within the cortex]. When I was in medical school, it was all very vague. We knew where the insula is; we knew it must have some connection in the frontal lobe or the temporal lobe. But we didn’t know very much about what it did in terms of emotion and addiction—things that are just now being mapped and clarified.”

“Sort of like the discovery of the New World?”

“Exactly. It marks a shift in what is considered serious research. Early studies of brain function were limited to things like ‘What part of the brain causes speaking?’ ‘What goes on when you move your hand?’ and so on. But now, researching things like addiction, or what lights up when somebody’s in love—things once considered ‘mushy’—are becoming serious. Scientists are willing to explore those fields.”

Though intelligence may be the ultimate aphrodisiac, the brain itself has lately become a sexy organ. Recent research has shown that our brains, like our muscles, respond to exercise. Some of these studies are discussed in Sharon Begley’s Train Your Mind, Change Your Brain, which describes how thought processes and meditation can actually reprogram the brain. The findings are astounding; neuroscientists have discovered, for example, that even thinking about playing the piano can enhance the structure of your brain’s tactile and motor sections. The equivalent holds true when focusing on kindness and compassion. Dr. Firlik continues: “I think the most fascinating thing about the recent studies with monks—which show that the brain can be altered through meditation—is seeing how much the left frontal lobe is involved with happiness, personality, and calmness. Researchers kept noticing that monks who meditate regularly have a lot more activation in the left frontal lobe than the average person. What’s encouraging is that the average person can make their brain look more like a monk’s brain, just by starting to meditate.”

Changing what the brain looks like, Firlik clarifies, doesn’t mean changing its size or shape. “But if you were to put somebody in an fMRI scanner, different areas, or a larger area, might ‘light up’—showing that more brain is now being used for language, memory, or emotional intelligence.”

Neuroplasticity isn’t a new concept; it has been known since at least the 1970s that if large portions of one hemisphere were to be removed from children with extreme types of epilepsy, they could develop relatively normally. “But we’d thought that neuroplasticity was specific to young, developing brains,” says Firlik. “What’s new and exciting is that the adult brain is more plastic than people ever thought. Recent fMRI studies have shown that in adult blind persons, for example, certain functions of the brain—like those related to the tactile task of reading Braille—expand into real estate formerly occupied by visual processing. Other studies have shown that focused attention—mental activity alone—is enough to enhance activation of certain regions of the brain.”

“Does this change the way you see your work?”

“It makes me more excited about it. Because understanding how this works may help us enhance recovery more fully and more quickly.” There’s a clinical trial now in progress, Firlik adds, that is designed to boost neuroplasticity by implanting electrodes on the brain surface of stroke survivors.

“Since the brain’s connections are electrochemical, a low-grade electric current acts as a stimulant. It’s not enough current to make the hand move—it’s more like fertilizing the brain in that area, giving it more power. Early data have shown that this has enhanced recovery more than just physical therapy and rehabilitation alone. This is one of the first technologies we have to improve neuroplasticity. And if we can learn to enhance motor function, it’s conceivable we might ultimately be able to enhance happiness—or even compassion.”

Her comments make me recall something the Dalai Lama said in 1996, during a far-ranging discussion about technology. I’d asked him if human reliance on technology could ever exceed sensible limits. “If a machine is ever created that can instantly make a good heart, a warm heart,” the Dalai Lama observed, “without any need for meditation or practice . . . then I will immediately tell our Chinese brothers and sisters, ‘Please! You buy this!’”

One intriguing issue brought up by this discussion is karma; specifically, the old puzzler of when karma is created. While much classical Buddhist philosophy focuses on the way the cause-and-effect action of karma spans lifetimes, Buddhism also teaches that karma is renewed at each moment; that we generate our karma from instant to instant, and that we can derail the cycle of samsara through mindful thought and action.

Neuroplasticity seems to support this understanding. I found this fascinating summation in the Wall Street Journal by UCSF neuroscientist Michael Merzenich: “We choose and sculpt how our ever-changing minds will work. We choose who we will be the next moment, in a very real sense, and these choices are left embossed in physical form on our material selves.”

But when, developmentally, does that kind of control—and responsibility—become possible?

“It’s probably different for different individuals,” Firlik posits. “But there was some interesting work done with teenagers, showing that even into the teen years they don’t have full ‘myelination’ of their frontal lobes.” Myelin, she explains, is the outer sheath of nerve cells. “The frontal lobes are critical for insight, judgment, and decision making. Maybe part of the reason why young teenagers make silly choices for themselves is because their brains are still developing.”

One question that does come up frequently marks a place where Buddhists and brain surgeons often diverge. What is consciousness? Is it an emergent property of brain tissue and chemicals—or is it, as some contend, a self-arising phenomenon?

“In modern neuroscience,” the Dalai Lama has written, “there is a deep question about whether the mind and consciousness are any more than simply operations of the brain. . . . Though heavily contingent upon a physical base,” he continues, “including neural networks, brain cells, and sensory faculties—the mental realm enjoys a state separate from the material world. From the Buddhist perspective, the mental realm cannot be reduced to the world of matter, though it may depend upon that world to function.”

Asked to reflect on this issue, Werner Doyle gave an interesting response. “Neurologists study physical fluctuations—such as those seen in fMRI studies that show different brain areas turning on and off—and correlate this to perceptual phenomena, thinking behavior, and mood,” he remarked. “We notice a correlation—but it’s not necessarily a cause and effect. In this sense, our study of the mind is no different than any other physical phenomenon. Both natural science and contemplative science analyze the universe by taking it apart, with the objective to find where it originates. And they both result in finding that there is nothing there.” The debate (or even a summary of it) is far beyond the scope of this article. But most brain surgeons would likely agree with Firlik’s view that neuroscience has no convincing explanation of consciousness, and no adequate way to study it—yet.

“I tend to be very practical-minded,” she says. “I’m frequently looking at scans, and damage to the brain, so I have a very hands-on view of consciousness. I think it is definitely generated by connections in the brain. Unlike language or memory, with their clearly defined networks, no one’s figured out whether consciousness is a network at all, or some other property of the brain. But I don’t believe it’s something mystical or supernatural. I think it’s grounded in the brain substance itself.”

And yet one of the things that drew me to Firlik was her very spiritual view of the brain’s intricacy and impermanence. In Another Day in the Frontal Lobe, she offers a reflection on the ultimate fate of consciousness, comparing the mind to a Tibetan sand mandala:

Nature can fragment over time. The brain is a part of nature. Degradation and disease are natural processes. Even so, it’s hard to develop a calm acceptance of the fragmentation of the human mind. It’s hard to find any beauty in it. . . . I sometimes wonder if a good deal of suffering could be curtailed if a brain, like a Tibetan sand mandala, could be swept up and sent out to sea, in a thoughtful and respectful ceremonial fashion, before the intricate design has a chance to fragment too far, before it is degraded by the equivalent of drafts, clumsy feet, and curious hands.

Dealing with impermanence and its consequences is an unavoidable part of Firlik’s practice, and part of what draws her to Buddhism.

“A key idea in this philosophy,” she writes, “is that suffering is a natural part of human life, and the only sure way to overcome suffering is to develop control over your own mind. . . . You can enjoy the here and now because your thinking is clear, you don’t have to look through the smoke of the mystical, and your mind is not the passive victim of whiplash in the turbulence of external events.”

Treating patients with brain fragmentation, Firlik witnesses the full spectrum of human reactions, from suffering to equanimity. In her Greenwich office, she shows me MRI scans of two of her patients. One is an elderly man in a comatose state, with bleeding extending into the brain stem. Despite his near-brain-dead state, his family has insisted—in opposition to every doctor’s recommendation—on keeping the patient alive.

“Here is a situation where the brain function has degraded to such a degree that it’s already been ‘swept up’: the sand is sitting in a pile, devoid of its former beauty. But it’s very difficult to get that concept across to the family, who see a warm body that looks like their loved one.”

The flip side of this experience was an eighty-year-old patient who seemed, from her brain scan, to have a fatal brain tumor. Firlik recommended a biopsy, to confirm the scan so that treatment could begin. The patient and her family thought about it and refused. The woman was otherwise healthy, and felt she’d lived well. She had no interest in a slow decline.

“I was doing rounds in the hospital that evening, and decided to drop in and say hello. The woman’s entire extended family was in the room—drinking champagne and toasting. This woman with the fatal brain tumor was the happiest woman I’d seen in the hospital all day. I’d never seen such incredible acceptance. Rather than dwelling on the unfortunate diagnosis, they were celebrating her life.”

If “the primary purpose of Buddhist contemplative practice is to alleviate suffering,” as the Dalai Lama reminds us, the same may be said of brain surgery.

“For me,” Firlik reflects, “surgery is a form of practice. It requires control of your emotions and actions; your mind is clear. You’re fully engaged in the moment. You’re not really thinking, in the intellectual sense; you’re doing. Your body is going through motions that you know very well—like walking meditation.” But not all types of surgery fall into that category, she adds. If the operation is especially difficult, it becomes a mental challenge.

“We call that ‘engaged’ Buddhism,” I joke.

“Engaged surgery.” Firlik tries out the term, which seems to please her. “This is part of why I have a real appreciation for Buddhist thought. It ennobles the brain. The brain is taken more seriously by Buddhism than any other religion. The Dalai Lama’s fascination with neuroscience makes complete sense to me; I really respect him for collaborating with scientists, and for his willingness to say he’ll reconsider some of his central beliefs if he’s proven wrong. That’s very scientific, and very refreshing.” Buddhism and neuroscience alike have cherished views of the mind and consciousness; both will have to revisit their beliefs while the terrain of the brain continues to be explored. If she could, Firlik would challenge the Dalai Lama on the plausibility of reincarnation; the Dalai Lama might question Firlik on her notion that the tofu-textured brain is a “substantial cause” of consciousness. And neither, quite likely, will be fully satisfied with the response. “Trying to understand yourself,” said Alan Watts, “is like trying to bite your own teeth.” The brain may never yield all its secrets, under a sutra or a scalpel. Personally, I go with a reflexive metaphor offered by Werner Doyle shortly before he drilled into Mr. S’s skull. “The brain is like a beautiful ballet,” Doyle proclaimed. “It’s as if the different centers—language, vision, tactile—are all dancers. And though their dance seems to hover on the edge of chaos, it all works together beautifully.” “The brain,” he concluded, “is just like the real world. But how could it be otherwise?”