Fragments #4 - Camus - The Plague

How then to live life well when the humiliations of human suffering lie in wait for us? By drifting from day to day in numbing routines? Not for Camus. And I still agree with him. By escaping into hollow distractions rather than be face to face with the harsh realities of human suffering? Not for Camus. And I still agree with him. By trusting religious or philosophical interpretations of life experiences that collapse whenever pressed by the intensity of human suffering? Not for Camus. And I still agree with him. By maintaining an idealist confidence in the exchange of ideas and an optimism about the future that inflate unsullied by the absurdity of human suffering? Not for Camus. And I still agree with him. By shriveling into a passionless cynic who indifferently gainsays any resolve to rebel against the sources of unspeakable human suffering? Not for Camus. And I still agree with him.

Fragments #3 - Camus - The Plague

I recoiled from the militant Jesuit priest Father Paneloux, an Augustinian scholar celebrated even among those indifferent to religion for his study of ancient inscriptions and for his trouncing series of public lectures on present-day individualism. The ecclesiastical authorities, toward the end of the first month of plague, organized a Week of Prayer that culminated with a sermon by the fiery tempered Paneloux. The large audiences, alarmed, but far from desperate, hadn’t yet reached the phase when plague would seem to them the very tissue of their existence. With a violent storm pelting the cathedral, the stocky bespectacled Paneloux leaned on the edge of the pulpit and launched at the congregation the gist of his discourse in clear, emphatic tones: “Calamity has come on you, my brethren, and, my brethren, you deserved it.” No one could miss his point – “The just man need have no fear, but the evildoer has good cause to tremble. For plague is the flail of God and the world His threshing floor. . . . Maybe at this very moment his finger is pointing to your door. . . . No earthly power, nay, not even – mark me well – the vaunted might of human science can avail you to avert that hand once it is stretched toward you. Some, including the Othon boy’s father, found Paneloux’s arguments irrefutable. Some felt sentenced. Some panicked. Some rebelled. Tarrou added to his diary – “At the beginning of a pestilence and when it ends, there’s always a propensity for rhetoric. In the first case, habits have not yet been lost; in the second, they’re returning. It is in the thick of a calamity that one gets hardened to the truth, i.e., to silence.” Rieux confessed to Tarrou, “I’ve seen too much of hospitals to relish any idea of collective punishment. . . . Paneloux is a man of learning, a scholar. He hasn’t come in contact with death. But every country priest who visits his parishioners and has heard a man gasping for breath on his deathbed thinks as I do. He’d try to relieve human suffering before trying to point out its excellence.” At Tarrou’s invitation, Paneloux joined the sanitation squads. He spent his entire time in hospitals and places where he came in contact with plague . . . in the forefront of the fight. . . . Paneloux leaned against the wall by the Othon boy’s bedside, his face drawn in grief. The child’s death wail fluttered out into silence as Paneloux sank to his knees repeating in vain, “My God, spare this child!” They had already seen children die, but they had never yet watched a child’s agony minute by minute. They had never had to witness over so long a period the death throes of an innocent child. Once outside, Rieux turned toward Paneloux, “There are times when the only feeling I have is one of mad revolt.” Paneloux said in a low voice, “I understand. That sort of thing is revolting because it passes our human understanding. But perhaps we should love what we cannot understand.” Rieux gazed at him, then shook his head, “No, Father. I’ve a very different idea of love. And until my dying day I will refuse to love a scheme of things in which children are put to torture.” Paneloux had been working on an essay entitled “Is a Priest Justified in Consulting a Doctor?” Humbled by working so close to death, he presented the thesis in a second sermon – “My brethren, a time of testing has come for us all. We must believe everything or deny everything. And who among you, I ask, would dare to deny everything? . . . The love of God is a hard love. And yet it alone can reconcile us to suffering and the deaths of children. It alone can justify them, since we cannot understand them, and we can only make God’s will ours. That is the hard lesson I would share with you today. That is the faith, cruel in men’s eyes and crucial in God’s, which we must ever strive to compass.” Paneloux soon after began to feel run-down and, though without the specific symptoms of plague, died bedridden gazing at the crucifix that hung above the head of his bed.
I agonized with the short, square-shouldered young journalist Raymond Rambert, on assignment for a Paris newspaper to report on the sanitary conditions prevailing among Oran’s Arab population. When Rieux informed him about the extraordinary number of dead rats that were being found, he exclaimed, “Ah! That certainly interests me.” Rambert soon discovered the story was far bigger than he could have imagined. The officials’ decision to quarantine the city trapped him, one of the many travelers caught by the plague and forced to stay where they were cut off from the person with whom they wanted to be and from their homes as well. Pained by separation from his fiancé, Rambert exclaimed, “But confound it, I don’t belong here!” Longing for happiness and baffled by fruitless interviews with officials, he turned to the criminal element in search of a way to sneak past the guarded gates. Wrestling with his determination to escape over against Tarrou’s commitment to the sanitation squads, he listened to the weary Rieux’s reminder, “There’s no question of heroism in all this. It’s a matter of common decency. That’s an idea which may make some people smile, but the only means of fighting a plague is common decency.” Still fighting to prevent the plague from besting him, Rambert gazed at Rieux and Tarrou, “You two. I suppose you’ve nothing to lose in all this. It’s easier, that way, to be on the side of the angels.” Draining his glass, Rieux said to Tarrou, “Come along. We’ve work to do.” As they walked away, Tarrou turned and looked at Rambert, “I suppose you don’t know that Rieux’s wife is in a sanatorium a hundred miles or so away.” The next day, still fancying he had the power of choice, Rambert called the doctor, “Would you agree to my working with you until I find some way of getting out of the town?” “Certainly, Rambert. Thanks.” When the chance to escape came, Rambert chose to stay, explaining to Rieux, “Until now I always felt a stranger in this town and that I’d no concern with you people. But now that I’ve seen what I have seen, I know that I belong here whether I want it or not. This business is everybody’s business.” . . . Rambert’s fiancé arrived on one of the first trains to enter Oran on the day the city gates were reopened. Rambert felt a nervous tremor at the thought that soon he would have to confront a love and a devotion that the plague had slowly refined to a pale abstraction. If only he could put the clock back and be once more the man who, at the outbreak of the epidemic, had had only one thought and one desire: to escape and return to the woman he loved! But that, he knew, was out of the question now; he had changed too greatly. The plague had forced on him a detachment which, try as he might, he couldn’t think away and which like a formless fear haunted his mind. He hadn’t had time to pull himself together. Happiness was bearing down on him full speed, the event outrunning expectation. . . . He hadn’t time to see that form running toward him; already she had flung herself upon his breast. And with his arms locked around her, pressing to his shoulder the head of which he saw only the familiar hair, he let his tears flow freely, unknowing if they rose from present joy or from sorrow too long repressed; aware only that they would prevent his making sure if the face buried in the hollow of his shoulder was the face of which he had dreamed so often or, instead, a stranger’s face. For the moment, he wished to behave like all those others around him who believed, or made believe, that plague can come and go without changing anything in men’s hearts.

Fragments #2 - Camus - The Plague

I appreciated the broad-shouldered Dr. Bernard Rieux, an unassuming 35-year-old physician given to absentmindedness whose demonstrated loyalty to his poorer and most at-risk patients oriented me to recognize medical students, residents, and practicing physicians who still held to the intent to be humane and to exercise a social conscience. Soon after the morning he stepped on something soft – a dead rat – Rieux, torn between conflicting fears and confidence, was the first among his colleagues to utter the word ‘plague’. It took city officials several meetings to be convinced to act. Once the epidemic was diagnosed, the patient had to be evacuated forthwith. Then began a tussle with the family, who knew they would not see the sick one again until dead or cured. “Have some pity, Doctor!” – Rieux had nothing to look forward to but a long sequence of such scenes renewed again and again. . . . He needed no longer steel himself against pity. One grows out of pity when it’s useless. . . . He admitted to a close friend, “I have no idea what’s awaiting me or what will happen when all this ends. For the moment, I know this – there are sick people and they need curing. Later on, perhaps, they’ll think things over and so shall I. But what’s wanted now is to make them well. I defend them as best I can. Against whom? I haven’t a notion. When I entered this profession, I did it because it was particularly difficult for a workman’s son like myself. And then I had to see people die. I saw that I could never get hardened to it.” At midnight before going to bed, Rieux sometimes turned on the radio to hear well-meaning speakers call out fervently to the quarantined city, “Oran, Oran, we’re with you!” But he reminded himself, “They are too remote.” To diagnose, to register, and then to condemn -- he was not with the patient to save life; he was there to order the patient’s evacuation. “You haven’t a heart!” a woman once told him. . . . Had he not been so exhausted, had his senses been sharper, the odor of death might have touched his sentiments. . . . “A man can’t cure and know at the same time. So let’s cure as quickly as we can. That’s the more urgent job.” . . . As the survivors celebrated the plague’s receding after killing thousands, Rieux chose instead to draft a chronicle so that he would not be among those who hold their peace but would bear witness for the plague stricken victims. The mothers, husbands, wives, and lovers who had lost all joy now that the loved one lay under a layer of quicklime in a death-pit or was a mere handful of indistinctive ashes in a gray mound -- who gave a thought to these lonely mourners? Rieux knew what the jubilant crowds did not know -- that the plague bides its time dormant in bedrooms, cellars, trunks, and bookshelves until rousing its rats again to send them forth to die in a happy city.
I returned again and again to the good-humored but estranged son of a successful prosecuting attorney Jean Tarrou, a youngish traveler of private means new to Oran who seemed an addict of all normal pleasures without being their slave. A faithful diarist given to understatement, he had a habit of observing events and people through the wrong end of a telescope. He set himself to recording the history of what the normal historian passes over . . . seemingly trivial details which yet have their importance. He struck up a friendship with Rieux, accompanying him on home visits and giving him a safe conversation partner. Sitting across from Rieux at his office desk, Tarrou spoke frankly, “In a fortnight, or a month at most, you’ll serve no purpose here. Things will have got out of hand.” He continued as Rieux nodded, “The sanitary department is inefficient – understaffed, for one thing – and you’re worked off your feet. . . . Why not call for voluntary help? . . . I’ve drawn up a plan for voluntary groups of helpers. Get me empowered to try out my plan. . . . I have friends in many walks of life; they’ll form a nucleus to start from. And, of course, I’ll take part in it myself.” Rieux replied, “I need hardly tell you that I accept your suggestion most gladly. But I take it you know that such work of this kind may prove fatal to the worker.” . . . Tarrou continued to make detailed journal entries, though working long hours with the sanitation squads and shielding the overworked Rieux left him thinner, his eyes and features blurred with fatigue, his shoulders sagged. . . . He understood the plague as metaphor as well as physical horror. As he explained to Rieux, “I had plague already, long before I came to this town and encountered it here. Which is tantamount to saying I’m like everybody else. Only there are some people who don’t know it or feel at ease in that condition. . . . I only know that one must do what one can to cease being plague stricken, and that’s the only way in which we can hope for some peace or, failing that, a decent death. . . . All I maintain is that there are pestilences and there are victims, and it’s up to us, so far as possible, not to join forces with the pestilences. . . . I came to realize that all our troubles spring from our failure to use plain, clean-cut language. So I resolved always to speak – and to act – quite clearly. . . . I grant we should add a third category: that of the true healers. But it’s a fact one doesn’t come across many of them and anyhow it must be a hard vocation. That’s why I decided to take, in every predicament, the victim’s side, so as to reduce the damage done.” Two days after an official communiqué fed optimism that the plague was ending, Tarrou’s diary ended with shaky handwriting – “Feeling very tired tonight.” Ganglia swelled under his burning skin. There was a rumbling in his chest. Rieux could only watch his friend’s struggle. He had before him only a mask-like face, inert, from which the smile had gone forever. This human form, his friend’s, was foundering under his eyes in the dark flood of the pestilence, and he could do nothing to avert the wreck. He could only stand, unavailing, on the shore, empty-handed and sick at heart, unarmed and helpless. And thus, when the end came with a short hollow groan, the tears that blinded Rieux’s eyes were tears of impotence. Tarrou had “lost the match”, as he put it. But he endured the experience without flinching and lucid. Rieux received word the next morning of his own wife’s death, a tuberculosis victim who died alone in a sanitarium miles from the quarantined city.

Fragments #1 - Camus - The Plague

We cannot be reminded too often that where one thinks about spirituality, ethics, theology weighs heavily on what one concludes. It is one thing to think about such matters while sitting in a dorm room, in an office, in a library, in a restaurant, in a classroom, in front of a beautiful sunset, . . . . It is quite another to think about such matters while sitting in a city hospital emergency room, in an unemployment office waiting room, in a juvenile courtroom, in the middle of a group of terribly abused children, in an AIDS clinic, . . . . It is still another to think about such matters while living and working in those settings. I know. For many years, I had done my thinking while sitting in dorm rooms, in offices, in libraries, in restaurants, in classrooms, in front of nature’s beauty . . . while living and working at a safe distance from the nauseating realities borne by so many. But no longer by the time I began teaching the ‘Human Suffering’ graduate course (1980). Instead, I began preparing my lectures and assessing my students’ essays while volunteering at St. Jude Children’s Hospital, while attending support group meetings for victims of neurological diseases, while participating in a childcare service for parents with disabled children, while assisting in the creation of a gynecology clinic for women with mental disabilities, while being introduced to the breadth and depth of human suffering present day and night at Memphis’ Charity Hospital.

It was then that I first read The Plague. The 1947 novel rang true in the places I found myself. It set the table for my deepest questions and for my protest against the temptations to become reconciled to the extremities of human suffering.

Albert Camus (1913-60) – athlete, actor, playwright, journalist, novelist, essayist – received in 1957 the Nobel Prize for Literature. He was raised in Algerian poverty, his father a World War I casualty. Tuberculosis imposed on him at age seventeen the ordeal of a protracted illness. Sifting carefully for many years through the ideas of celebrated European thinkers sharpened his resolve to protest against every idea, every value, every thought system that depended on deceitful rhetoric or denied “the vast indifference of the sky”. Camus and his wife Francine first visited the Algerian port city Oran in 1939 -- he a newspaper reporter focused on the living conditions of North African Arabs and she a mathematics teacher. They returned in 1941, the year he joined the French Resistance “by the automatic reflex of humiliated honor” and began writing The Plague. When the Allies invaded North Africa in 1942, Camus was staying at a boarding house owned by his wife’s cousin in the mountains of Central France recovering from yet another tuberculosis attack. His wife had returned to Oran for the beginning of the school term. The tightened German occupation kept them from reuniting until the liberation of France.

Camus never wavered from the premise that the “ambition which should be that of all writers is to bear witness and shout . . . for those who, like we, are enslaved.” He did so most forcefully in The Plague, an allegory about Oran, a town without intimations; in other words, completely modern. (Italics indicate quotations from the novel.) The townsfolk were wrapped up in themselves. Their chief interest is in commerce, and their chief aim in life is, as they call it, ‘doing business’. They disbelieved in pestilences. City officials and the cultural elite remained blind to the pending devastation implicit in the report of rats dying in the streets, blind until the human victims ceased to be isolated to slum dwellers. Cornered, irritated, exiled, abandoned, shaken to the core – the quarantined citizens and visitors came to know the incorrigible sorrow of all prisoners and exiles, which is to live in company with a memory that serves no purpose. They finally saw that plague was the business of them all. Hope focused on the attempt of medical researchers to create a serum. The test recipient – Philippe Othon, the young son of the police magistrate. Philippe nonetheless died in excruciating pain.

How does one feel, live, think when defenseless against plague? Four characters drew me into the story.

A Non-Religious View of Dietrich Bonhoeffer #3

In prison, Dietrich soon began moving – sometimes at a dizzying pace – into radically new ideas. As my wife’s crippling fight with multiple sclerosis ‘imprisoned’ her . . . and me, I pored over Letters and Papers from Prison and imagined returning again and again to Dietrich’s prison cell for conversation about such ideas as:

I sometimes feel a real craving for an evening of music. . . . The mind’s hunger for discussion is much more tormenting than the body’s hunger for food. (9 November 1943; 25 December 1943)

There are two ways of dealing psychically with adversities. One way, the easier, is to try to ignore them; that is about as far as I have gotten. The other and more difficult way is to face them deliberately and overcome them; I’m not equal to that yet, but one must learn to do it, for the first way is a slight . . . piece of self-deception. (5 December 1943)

It’s possible to get used to physical hardships, and to live for months out of the body, so to speak – almost too much so – but one doesn’t get used to the psychological strain; on the contrary, I have the feeling that everything that I see and hear is putting years on me, and I’m often finding the world nauseating and burdensome. . . . I often wonder who I really am – the man who goes on squirming under these ghastly experiences in wretchedness with cries to heaven, or the man who scourges himself and pretends to others (and even to himself) that he is placid, cheerful, composed, and in control of himself, and who allows people to admire him for it . . . (15 December 1943)

But isn’t it characteristic of a man, in contrast to an immature person, that his center of gravity is always where he actually is, and that the longing for the fulfillment of his wishes cannot prevent him from being his whole self, wherever he happens to be? . . . He may have his longings, but he keeps them out of sight, and somehow masters them. And the more he has to overcome in order to live fully in the present, the more he will have the respect and confidence of his fellows, especially the younger ones who are still on the road that he has already traveled. (19 March 1944)

The time when people could be told everything by means of words, whether theological or pious, is over . . . . We are moving toward a completely religionless time. . . . It means . . . that there remain only a few ‘last survivors of the age of chivalry’, or a few intellectually dishonest people, on whom we can descend as ‘religious’. Are they to be the chosen few? Is it on this dubious group of people that we are to pounce in fervor, pique, or indignation, in order to sell them our goods? . . . If we don’t want to do all that, . . . what kind of situation emerges for us? (30 April 1944)

And we cannot be honest unless we recognize that we have to live in the world etsi deus non daretur. And this is just what we do recognize – before God! . . . The God who lets us live in the world without the working hypothesis of God is the God before whom we stand continually. Before God and with God we live without God. . . . The world that has come of age is more godless, and perhaps for that very reason nearer to God, than the world before its coming of age. (16 July 1944)

I remember a conversation that I had in America thirteen years ago with a young French pastor. We were asking ourselves quite simply what we wanted to do with our lives. He said he would like to become a saint . . . . At the time I was very impressed, but I disagreed with him, and said, in effect, that I should like to learn to have faith. . . . I discovered later, and I’m still discovering right up to this moment, that it is only by living completely in this world that one learns to have faith. One must completely abandon any attempt to make something of oneself. . . . By this-worldliness I mean living unreservedly in life’s duties, problems, successes and failures, experiences and perplexities. . . . How can success make us arrogant or failure lead us astray when we share in God’s sufferings through a life of this kind? (21 July 1944)

Dietrich forsook escape in 1939. He shared fully in his fellow conspirators’ resolve to strike – violently, if necessary -- at an evil head of state. He maintained his cover and theirs in prison. He dared to let go every idea that had collapsed under the weight of horrific evil and human suffering. He sketched in isolation the electric new ways he had begun to see. He hung naked from the gallows, dead at thirty-nine years of age.

Shocked, confused, disappointed, offended, threatened, . . . – such reactions to Dietrich’s prison ideas and his brutal execution as a traitor soon surfaced even among friends and students with whom he labored before 1939. Here is what I see. His integrity, firm. His optimism, resilient. His gratitude, unfailing. His ‘religionless’ faith, just beginning to form. His death, humiliating. His defeat, honorable.

I had the privilege of participating in Eberhard’s 90th birthday celebration (August 1999). After returning to the hotel from the Bethges’ home, I shared a glass of wine with the other American in attendance. Thirty years earlier, he had been a founding member of the International Bonhoeffer Society. As we explained our experiences with Dietrich’s life and thought, I began to describe the collaborations I have enjoyed with a small but courageous circle of physicians within the medical sphere who are resolved to practice medicine humanely and with a resolute social conscience. At one point, he broke in with the observation, “I see what you and your physician friends are . . . conspirators!” When I later checked the etymology (i.e., conspirare, to breathe together), I realized even more fully that so we are.

A Non-Religious View of Dietrich Bonhoeffer #2

Dietrich’s June 1939 decision to return to Germany as the darkness of war descended on Europe still holds my attention. The Bonhoeffers were a culturally refined and influential Berlin family. Previous generations had made significant contributions in academics, politics, church life, the military, and music. Dietrich’s father was Professor of Psychiatry at the University of Berlin. His oldest living brother was a noted physicist. Two brothers-in-law were well positioned in the legal field; an older brother, in the aviation industry. The Bonhoeffer men, women, and children did not fail to see the evil potential – especially for Jews and other minorities -- in Hitler’s January 1933 maneuver into political control. The family home quickly became a gathering place for information sharing and for daring conversation of resistance. Dietrich’s confrontational speech on Berlin radio the week after Hitler became chancellor prompted the Gestapo to open a file on him that led to his arrest a decade later.

Dietrich, in the early Nazi years, concentrated on attempts to mobilize into a phalanx of non-violent civil disobedience a remnant of Protestant pastors who were alarmed at Nazi enthusiasm within German Protestant churches. Until the 1936 Olympics in Berlin, Hitler worked to consolidate his power while being careful to avoid internationally sensitive incidents. However, by 1938 the Nazis were secure enough to exploit the protesting pastors’ internal debates by reducing their choices to (1) making a public oath of personal allegiance to Hitler or (2) being imprisoned. The ranks of the pastors broke. Too few remained in place. Many were eventually swept up by patriotic fervor as Germany annexed one neighbor after another. Others huddled tightly to ride out the storm.

Dietrich had invested too much not to feel deep disappointment and loss of direction. He did know that being loyal to the collapsed strategy of non-violent civil disobedience looked futile and self-serving. As he would later observe in a December 1942 essay written for his family and fellow conspirators:

To talk of going down fighting like heroes in the face of certain defeat is not really heroic at all, but merely a refusal to face the future. The ultimate question for a responsible man to ask is not how he is to extricate himself heroically from the affair, but how the coming generation is to live.

But, as late as Spring 1939, Dietrich had not yet joined the ring of high-ranking political and military conspirators hidden within the Abwehr. Instead, with the conscription date – May 22 – for his birth year approaching and with efforts to stall his order to report for military service exhausted, a travel permit finally arrived by which he could accept an invitation from friends in New York City – including Union Theological Seminary’s Reinhold Niebuhr and William Sloan Coffin – who were intent on rescuing him. He crossed the Atlantic on the Bremen, accompanied by his older brother and noted physicist Karl-Friedrich.

A permanent address . . . exceptional libraries . . . the opportunity to do some serious writing . . . an engaging lecture schedule . . . . New York City was a safe place. But it was the wrong place. Dietrich felt keenly the dislocation. A letter written to Reinhold Niebuhr just a few weeks after arriving at Ellis Island reveals that he quickly recovered his sense of place in the world:

My thoughts about Germany have not left me since yesterday evening. . . . The whole weight of self-reproach because of a wrong decision comes back and almost chokes me. . . . I have made a mistake in coming to America. I must live through this difficult period of our national history . . . I will have no right to participate in the reconstruction of . . . Germany after the war if I do not share the trials of this time with my people. . . .
By 27 July 1939, Dietrich was back in Berlin. By October, the German army had invaded Poland. After his application to be a military chaplain was denied in February 1940, Dietrich crossed the threshold into covert resistance. By now he knew well the seasoned conspiracy circle hidden within the German Army’s secret intelligence that would finally on 20 July 1944 make its move to assassinate Hitler. Under this official cover, Bonhoeffer used his international connections for three years trying (without success) to convince the Allies there were reasons not to demand another crushing unconditional surrender. Eventually, circumstantial evidence fell into the long-suspicious Gestapo’s hands that led to his arrest and four others – including his brother-in-law Hans von Donanyi -- on 5 April 1943.

A Non-Religious View of Dietrich Bonhoeffer #1

‘Pivotal’ – an oft-used word with an ambiguous etymology. Some linguists trace the term to pungere (L.) which means to prick or sting so as to penetrate and cause a piercing, even acrid, sensation. A pivot is a short shaft or pin whose pointed end forms the fulcrum or center on which something turns about, oscillates, or balances – e.g., the axle on which a wheel turns, the shaft on which the hands of a clock circle, or the pin on which a compass pointer is balanced. An army wheels around its pivot troops when making a tactical maneuver. Athletic teams have pivot or centering positions. Basketball players plant a pivot foot while stepping with the other foot toward teammates to whom to pass the ball. Dancers rotate on a pivot foot while shifting their weight to the other foot.

I reflected at length during the months after my first wife’s death (1987) about what ideas had held as pivotal through the attempt to be truly present with her to the end. We were twenty and nineteen years old when we married. Except for the first eighteen months of our marriage, to be with her was to see multiple sclerosis -- without the mercy of remissions -- completely incapacitate her over fourteen years before finishing with her.

What did it mean to return, after her death, from such an extreme and prolonged experience? Would I try to forget the humiliation, the offense, the stench, the struggle, the isolation, the tragedy of a human being utterly devastated by an insidious chronic disease? No. I would instead look for ways to stay near to and vulnerable before individuals trapped in extreme experiences. Should my thoughts about ethics and spirituality -- born when I had been so fatigued and alone -- be trusted? Yes. I resolved always to see from ‘below’, from ‘the scrap heap’, keenly attentive to the breadth and depth of human misery. Would I tailor my comments to insure approval from extended family members? approval from acquaintances who lived distant from the brutal realities of illness my wife symbolized? approval from communities of faith for which I had become a stranger? approval from fellow faculty members, pastors, and students who had given me the benefit of the theological doubt during the years before my wife’s death? No. I would instead speak carefully, but openly, with them from the perspective of individuals rendered voiceless and harshly diminished. Or I would not speak at all.

I saw clearly that no life or set of ideas had been more pivotal for me than Dietrich Bonhoeffer and his prison correspondence. I remember carefully opening the 16 November 1993 letter I received from Eberhard and Renate Bethge. I had met them the previous April when this still vigorous couple made presentations for a Boston University symposium on the theme of friendship. I had subsequently spent several delightful October days with them at their home in Wachtberg, a few kilometers south of Bonn in Germany.

Renate was the favorite niece of Dietrich Bonhoeffer, a controversial German theologian and conspirator against the Nazis who was executed (along with several other political prisoners) by the Gestapo at Flossenburg concentration camp just days before the European war ended. The Gestapo also executed Renate’s father and two uncles – in addition to her ‘Uncle Dietrich’ -- in those last days. Her husband Eberhard was Dietrich’s closest friend during the war years. A sympathetic prison guard smuggled to Eberhard and Renate letters Dietrich wrote during his two years in Berlin’s Tegel Prison. They devoted the balance of their lives to making Dietrich’s life accessible to subsequent generations.

I had not ceased examining Dietrich’s life and thought since a 1976 graduate course assignment to read his prison correspondence. In that assignment, I had found what soon became the most reliable point of reference as I searched for a ‘face to face with the world’ approach to ethics, spirituality, and theology. Dietrich’s courageous decisions and radical ideas were never eclipsed as I tested – first during doctoral studies and then for twelve years as a history professor -- the existential strength of the ideas of the most seminal thinkers in the story of western civilization.

Still, when I first met the Bethges in Boston, I was prepared to sever my ties to Dietrich if they thought I was violating his story or misappropriating his ideas. My heart still races when I recall Renate’s observation in her 16 November 1993 letter to me -- “I felt and feel an understanding between us, which I don’t often feel, even with people quite near to us. One feels that you have not ‘learned’ Bonhoeffer, but that you have lived with him and so can sovereignly integrate him into your own thoughts.”

Leaven #21

We take exceptional care of people.

‘Exceptional’ – unusual . . . rare . . . far beyond ordinary . . . remarkable . . . noteworthy . . . excellent.

One way to measure truly exceptional patient care is to assess caregivers’ effort to relate to their patients as ‘people’. Listen closely to the words we use to identify/classify patients. Some words convey honor and respect. Others do not. Who/what pressures us toward diminishing language about patients?

Here are some suggestions/reminders for speaking with patients in ways that may advance our mission to ‘take exceptional care of people’. We could ask --

Where do you call ‘home’? Are there individuals to whom you feel especially close? Are you a member of any groups or organizations that have significantly influenced your beliefs and values, your hopes and dreams?

Has a particular religion influenced what you believe and value? (If so) what would you want us to know about your religious experience that would help us take better care of you? (If not) what would you want us to know about the source/s of your beliefs and values that would help us take better care of you?

What gives your life meaning and purpose? What effect do your beliefs and values have on how you view being sick? (or injured?) What effect is your illness (or injury) having on your attitude toward life? Do you have any special memories -- including painful ones -- that you think we should know about as we care for you?

Do you have family members or friends who are especially supportive at this time? Do they live near enough to be present while you are in the hospital? Would you like for us to meet them?

Are you concerned that being in the hospital will interfere with your ability to participate in any routines that are especially important to your well being? How can we help you continue these routines while you are in our care?

Do you feel encouraged? discouraged? Do you have specific hopes and goals that we should know about as we care for you? Would you want us to look for any special literature or other resources that might be encouraging to you while you are in the hospital?

Do you have any questions or concerns that may be keeping you from having confidence in those of us who are caring for you in the hospital? If so, please share them with one of us. Having your trust is critical to our efforts to care for you.

Patients who feel honored and respected as people are more likely to have (or recover) sufficient balance and focus to communicate well (which requires listening carefully, thinking courageously, and speaking clearly) and to participate appropriately in decisions about their care.

Perhaps only a photographer would see a provocative image in our routinely standing in the hospital’s elevators with our backs to the hospital’s mission statement (as well as vision statement and values statement) posted on the elevator’s back wall. Do we ever work with our backs to the mission to ‘take exceptional care of people’? What are the consequences for the ethical dimensions of care if we do?

Think about it. Perhaps talk to a coworker.

Leaven #20

“I’ve never seen such a diverse group at a ‘Brown Bag’ discussion!”

Several nodded agreement as we watched an overflow audience disperse a few minutes before 1:00 PM.

What drew to Steinberg Amphitheater Washington University physicians, residents, and medical students as well as Barnes-Jewish nurses, social workers, therapists, chaplains, managers, administrators, support staff members, et al? and also a noticeable number of guests -- parents, patients, teachers, advocates, et al? I suspect the diversity had to do with our shared stake in the intersection of three realities – i.e., teenage sexuality . . . human papillomaviruses . . . a new vaccine.

Try to recall or imagine the temporary sense of ‘community’ in the amphitheater. The ethics questions stirred by the new vaccine have public health as well as personal/private dimensions.

Entering the amphitheater, we quickly pushed past being a crowd -- pressing together . . . waiting patiently . . . limiting the refreshments we picked up . . . making room . . . noticing acquaintances . . . pointing out seats . . . chatting about why we had come. The session’s first question revealed more of our common ground –

“How many of us are here because we and/or individuals very dear to us are wrestling with decisions about the new vaccine?”

The show of hands indicated the subject we had gathered to discuss blurs the line that usually separates givers of care from receivers of care. Four panelists oriented us to (1) the demographic and clinical data that should anchor our decisions, (2) the central ethical issues associated with the new vaccine, (3) a cervical cancer patient’s counsel, and (4) a mother’s angst. As they spoke, it became apparent the desperately poor – those at greatest risk in our city and in developing countries -- were underrepresented . . . and no middle school or teenage girls – those recommended/targeted for the vaccine -- were present.

Several definitions of ethics can take you into reflection/discourse about ‘the ethical dimensions of patient care’. The Brown Bag discussion seemed implicitly based on this definition of ethics -- i.e., ethics has to do with determining what ought to be done, all things considered. Not surprisingly, the participants varied in what they took into consideration re the new vaccine and in the value they assigned what they took into consideration. During our short time together, we listened . . . commented . . . (re)shaped our views --

“The vaccine’s benefits seem obvious, but do we have sufficient information to assess the risks?”

“How do I relate statistics about teenage sexuality and HPV incidence to my child?”

“Will mandating the vaccine ironically result in widespread neglect of regular screening exams?”

“Is a middle school girl nearer a teenager or a young child re ‘informed consent’ for the vaccine?”

“The ads . . . – why should I trust drug companies that aim to make huge profits on the vaccine?”

A plurality told their hesitant neighbors in the amphitheater they would vote to mandate the vaccine for middle school girls. An impressive majority indicated a willingness to have their taxes raised if doing so would make the vaccine accessible to the desperately poor.

What ought to be done re the new vaccine – all things considered – as a pediatrician? a gynecologist? a teenager? a parent/guardian? a public health official? a legislator? a pharmaceutical representative for one of the companies marketing the vaccine? a . . . ?

Think about it. Perhaps talk to a coworker.

Leaven #19

“I’m completely burned out.”

‘Completely’ got my attention. Empty . . . spent . . . no longer with outstretched hands . . . -- this social worker had nothing left to give.

She was carrying a heavy case load of cocaine-abusing women who lived in the most violent section of Miami. They had been assigned to her after they were enrolled in a project federally funded to test a proposed way to assist such women break free from their destructive behavior.

The social worker was not alone. Just minutes into our first conversation, Emmalee -- an exceptional neonatologist who was the project’s principal investigator -- made it clear she was far beneath the glitter often associated with high-achieving academic physicians. She had neither time for nor interest in soft platitudes. She knew better and intended to determine quickly if I did.

“Dr. Brown, I am losing the vision for what we are doing. I am stumbling as a leader. My staff is floundering. I am exhausted. Can you make a difference?”

In the late-1980s and early in her career, Emmalee focused on the alarming number of babies being admitted to the NICU she attended who tested positive for cocaine. When discharged, their mothers took them home to an inner-city wasteland depressed by grinding poverty, organized around an illicit drug ‘industry’, devastated by sexually transmitted disease epidemics.

Fifteen months into the project’s five-year funding cycle, two medical school collaborators had abandoned Emmalee’s leadership team. Hurricane Andrew had slammed Miami, leaving the city in utter chaos and scattering the enrolled mothers. Turf battles with other researchers had intensified. Her original staff was turning over.

Working with Emmalee and her staff over the next several years as the project’s internal evaluator as well as ethics educator shook my foundations. Going to and being present with the 120 enrolled mothers who had been toughened by surviving such oppressive/threatening circumstances forced our biases/fears into the open and carried a real element of personal danger. We regrouped frequently to review each mother’s progress, to refresh our resolve, and to refocus our efforts around six mission/purpose questions – i.e., What sort of project are we? . . . What are our roles on the team? . . . For whom do we do what we do? . . . What values guide what we do? . . . What are our (and each mother’s) objectives? . . . How do we (and the mothers) define ‘progress’/‘success’?

Did you notice the ‘re-‘ words in that paragraph? Many more are imbedded in our discourse – e.g., revise . . . replenish . . . replete . . . recharge . . . rejuvenate . . . rekindle . . . remind . . . require . . . receive . . . reset . . . reverse . . . revitalize . . . reinvigorate . . . recalibrate . . . rehabilitate . . . restore . . . remember . . . recall . . . remake . . . return . . . retool . . . reconsider . . . renew . . . request . . . repeat . . . recreate . . . report . . . remain . . . repair . . . respect . . . .

Being ‘completely burned out’ is the devastating extremity of a protracted deterioration that requires radical (i.e., to the root) interventions if a caregiver has any chance to recover.

When we say or hear “I’m completely burned out”, we should listen to the tone – lament? frustration? anger? fatigue? defeat? . . .? -- and we should listen for the ‘re-‘ words. Recovery is still possible as long as we are using ‘re-‘ words.

Think about it. Perhaps talk to a coworker.

Leaven #18

“So what are your deliverables?”

I attended a Cardinals game several weeks ago with a new friend. He works in computer programming and software development. As we exited Busch Stadium, he asked -- "So what are your deliverables?"

The question caught me off guard. My mind was still on the game. I was not familiar with the word ‘deliverables’. I first linked his question to the pitchers’ 200+ ‘deliveries’ I had just witnessed. Then a phrase cluster began to form – “We deliver” . . . “the delivery truck” . . . “a well-delivered lecture” . . . “labor and delivery” . . . “delivering bad news” . . . My new friend wanted to know what I produce, what I contribute, what I complete where I work. Some of us can answer quickly, specifically, concretely. For others of us, our ‘deliverables’ are not so easily measured. We all begin each day intending to deliver.

I have attached what I hope in time will be considered a 'deliverable'! The diagram is still a work in progress. I would appreciate your testing it when you have the time to do so. Here is the story.

The impetus for the diagram came two months ago during our ethics consultation team's monthly continuing education discussion. We are using articles about ethical decision-making that have been published in the literature specific to various specialties (e.g., Ob/Gyn, Surgery, Internal Medicine, Emergency Medicine, Neurology, Psychiatry, Nursing, Social Work). The reading for the June meeting’s discussion was an American College of Obstetricians and Gynecologists article. Several of the ethics consultation team members expressed familiarity with the article’s 'principles of medical ethics' language (i.e., 'non-maleficence', 'beneficence', ‘patient autonomy’, ‘justice’), but a lack of familiarity with the article's opening references to 'virtue ethics', 'care ethics', 'feminist ethics', 'communitarian ethics', 'casuistic ethics'. All agreed with one member's observation -- "The article does not explain or demonstrate how such approaches integrate with or relate to the four principles of medical ethics."

I only had a sketchy hand-drawn draft of this diagram by the July meeting. Since then, I have discussed a more complete draft with many individuals and groups variously positioned in the hospital -- e.g., attendings, fellows, residents, medical students, researchers, nurses, social workers, physical therapists, patient care leaders, chaplains, interpreters, patient safety specialists, medical school instructors. The responses have been very helpful and encouraging. As you consider the diagram, I suggest you --

Think of situations in which you have used varying combinations of the identified reasoning patterns to make decisions. The diagram’s short explanations for the reasoning patterns open the complexities in the personal experiences we bring to our professional responsibilities.

See the ‘stretching/reaching toward’ image in the etymology of ‘intention’. The use of 'intention' has brought to the surface what may be widespread reservation about the word 'principle' (e.g., "the word 'principle' is cold, calculating, mathematical -- like a geometry axiom", "the word 'principle' is easy to stay detached from", "the word 'principle' is abstract").

Notice the focus on ‘patient/s’. Caregivers take into account their other patients as they attend to any one patient.

Remember the ‘professional’ and ‘code/s of ethics’ commitments you have made to/before the public as well as to/before your peers. These alignments function as filters/lenses that discipline us toward alignment with the intentions patients are invited to expect/trust when we care for them.

Perhaps this diagram will sharpen our insight into how well-intended individuals can disagree about what ought to be done and reinforce our ability to find the least bruising resolutions to the resulting conflicts.

Think about it. Maybe talk to a coworker.

Leaven #17

“My tears will cool me off.”

St. Louis. August. A couple of minutes before 11:00 AM. Cloudless sky. Slight breeze. Record heat.

I see her when I round the Center for Advanced Medicine on my way to the Ettrick Building across Forest Park Parkway for an 11:00 AM meeting. She looks to be in her early 30s . . . is casually dressed . . . is a bit overweight. She is sitting awkwardly at the corner where Euclid Avenue intersects Forest Park Parkway, looking anxiously across the parkway’s daunting ten lanes (including turn lanes). I wonder if she has fallen. As I approach, the lights change and the heavy/rushing traffic on Forest Park Parkway stops. I notice her struggling to stand. Remembering that pedestrians have been hit attempting to cross the parkway, I slow down to walk at her pace a step behind and to her side.

Her stiff/irregular walking motion is all too familiar. I ask her if I can help. “Yes, thank you,” she responds and steadies herself by holding to my arm. Sweat streaming down her face and neck soaks her shirt. As we slowly cross the parkway, she explains softly while concentrating on each step -- “I have MS . . . This heat is unbearable . . . I am having an exacerbation.” By the time we reach the opposite side of Forest Park Parkway, I have learned she has made it this morning to a clinic appointment at the hospital . . . she has been sent to another location for tests . . . she lives in an apartment a few blocks away . . . she needs to reach the bus stop a few feet past Euclid Avenue before the next bus arrives.

She slumps onto the grass behind the sidewalk in front of the bus stop. I sit beside her. Tears fill her eyes as she stares at the hospital and asks for one thing – “All I want is my life back”.

I listen. Though fatigued, she continues – “I see the way people look at me. I understand their suspicious tone. I don’t want to be on disability. I want my job back. The doctors keep telling me to ‘be patient, be careful’. I wish I had never learned to walk . . . to run . . . to write . . . to play.”

I tell her about the hospital’s spiritual care staff/service. I give her the name of the person who will answer when she calls . . . and I give her my name. I have her repeat twice the information I have written down for her. I ask, “Would you like for me to get you some ice water from the Bread Company (a short distance behind us).” She responds, “No. My tears will cool me off.”

The bus approaches. She struggles again to stand. She makes it to a seat. I watch the bus pull away as I walk to my meeting.

When do we (not) notice? When do we (not) stop? When do we (not) listen? When do we (not) help?

These revealing questions bring to mind a hallway comment I overheard a clearly disturbed/confused nurse make to the nurse with whom she was walking -- “The Good Samaritan story* is eating me alive!”

Think about it. Perhaps talk to a coworker.

* Whether familiar or not with its religious source, you likely know the gist of the story that has given us ‘Good Samaritan Laws’. A traveler is robbed and left on the side of a dangerous road badly injured. Two community leaders traveling separately on the same road see the injured man but hurry past him on the opposite side of the road. Then a third traveler – who belongs to a harshly treated ethnic minority – sees the injured man. Touched deeply by his plight, this third traveler administers first aid and then delivers him to safe shelter. The admonition at the story’s end – “Do what the third traveler did”. The story’s implication – “Do not do what the first two travelers did”. Thus the nurse’s angst. She confesses to her friend that a story to which she turns for guidance does not translate easily/obviously into the complexities of work . . . of life.

Leaven #16

“Code Blue in 126! Code Blue in 126!”

We hear calls for the code team many times every day. When did we last notice long enough to be reminded that a profound drama is unfolding somewhere in the hospital? When did we last pause long enough to recall our own experiences with such crises from the perspective of the patient? . . . or the family members and friends? . . . or the nurses, therapists, physicians who have been caring for the patient? . . . or the code team members?

“Code Blue in 126!” echoed through the hallways of the 54-bed community hospital that serves the rural/poor population living in the Appalachia region where I worked for the nine years prior to coming six months ago to Barnes-Jewish. Our physicians anchored the hospital’s medical staff. Listen as the physician with whom I worked most closely during those years tells the story --

I am making rounds at the hospital one morning when the overhead speakers blare out the alarm. Remembering our practice has a patient in room 126, I rush down the hall. Several anxious nurses have already gathered around the patient when the code team arrives. The patient is lying on the floor. She is not wearing a hospital gown. The patient in distress is one of our nursing assistants.

“She simply collapsed without warning!” Her co-workers do not know of any significant medical problems or recent symptoms. She is in cardiopulmonary arrest – no pulse, no respirations. The defibrillator monitor confirms the assessment. The code team responds quickly, professionally, and according to protocol. But we are not very hopeful. We know CPR and Advanced Cardiac Life Support are rarely successful. But this time is different. Chest compressions, assisted ventilation, IV medications, two shocks . . . and her heart begins beating normally. She regains consciousness.

While giving her time to stabilize in the ICU, we arrange for her to be flown by helicopter to the referral medical center sixty miles away where her critical coronary artery stenosis is diagnosed. They treat the blockage with angioplasty. She returns home and eventually to work at our hospital. Two years later, I beam from ear-to-ear as I have my picture made with her while holding her newborn grandson whom I have just delivered.

Every time I see her, I remember why I wanted to practice medicine.

“Why medicine?”

For more than twenty-five years, I have been asking this question in conversations with medical students, nursing students, social workers, chaplains, therapists, nurses, physicians, medical educators, support staff members, administrators, et al. With very few exceptions, I have heard – usually early in the conversation -- some variation on “to make a difference”.

The “Code Blue in 126!” story illustrates a cherished but too infrequent series of patient encounters – i.e., our ‘I made a difference’ stories.

Why do we tell these stories? to whom? where? How do we view/present the patients when we tell these stories?

Think about it. Perhaps talk to a coworker.

Leaven #15

“What has happened to me?”

A young physician – whose parents were activists for human rights both in their native India and in the United States -- asked this painful question a few weeks before completing her residency training in a Tennessee program. She was responding to one of several selections I had highlighted while reviewing the personal statements she and her fellow residents had written for their residency applications four years earlier.

“I am passionate about the socio-economic issues that contribute to suffering. . . . Inspired by Albert Schweitzer and by organizations such as Doctors Without Borders, I chose to study medicine. . . . My path as a physician will lead me to work with the underserved in this country and abroad. . . . My goal is to establish sister clinics here and in the developing world and to provide longitudinal care in an integrative fashion.”

As she read those thoughtful, expectant, energetic intentions on the screen in a “What’s ahead?” discussion a colleague and I were facilitating for the program’s senior residents, she softly commented with a slight gasp, “I think I said something like that in my personal statement.” The selection did in fact come from her personal statement. Her focus, however, quickly moved inward. She began to speak – softly, honestly, tearfully – to herself . . . and to her peers.

“Now where am I? I dream of taking care of rich patients, educated patients, compliant patients, healthy patients. What has happened to me?”

What explanation does your experience suggest?

Perhaps her intentions had been altered as she searched for relief from chronic fatigue. Perhaps her intentions had been eroded by too many disheartening confrontations with the gatekeepers empowered by ‘the system’ to decide what medical services will (not) be approved/compensated. Perhaps her intentions had been effaced by the very patients for whom she had envisioned medicine could make a difference.

Her intent to promote a patient’s interests/values seemed to be in tact. Her intent to respect a patient’s informed choice seemed to be in tact. However, she had lost touch – permanently? -- with her social conscience . . . with the association she had seen for so many years between medicine and social justice.

What do you think is ahead for young physicians represented by this resident? Who/where are they five years after residency? What types of practices do they join? What do they consider a ‘good patient mix’?

Nurse or social worker or therapist or physician or . . . -- what passion, what inspiration, what goal brought you into medicine? For what do you dream now?

Think about it. Perhaps talk to a coworker.

Leaven #14

“Entertainment, shock, distance”.

As on Jeopardy -- What question is being answered?

A clue – the physician with whom I worked most closely during the nine years before coming to Barnes-Jewish recalls vividly an experience as a 1^st-year resident on an ER rotation.

I round a hallway corner in the ER and find myself standing suddenly face to face with a physically imposing patient sitting on a gurney to which his wrists and ankles are chained. His steely glare does not arrest me. It is the bullet hole between his eyes. I learned later the bullet had hit him at an angle that allowed it to track along his skull under the skin to the back of his head.

Another clue – the physician* who created my first opportunities more than 25 years ago to shift from being a history professor to being an ethics educator in the medical education/practice sphere recalled vividly an experience as a 3^rd-year medical student on a Psychiatry rotation.

Tremendously thick glasses . . . barely five feet tall . . . obese . . . protruding front teeth . . . long matted hair . . . only blue swim trunks . . . -- this ER patient is shouting aimlessly, “Thou hast not known me, but thou mayest yet know I am the Christ!” He holds up his transistor radio and claims, “I have direct access to God”. I join my fellow medical students, the residents, and the nurses in chuckling about this character who is too comical to disturb us. It all seemed funny then.

48 hours later, I see him again -- sitting in a padded cubicle . . . banging his head against the wall . . . rolling his eyes . . . clawing at his face . . . jamming his fingers down his throat. When he sees me through a small window, he charges toward the door . . . his face twists with pain . . . his eyes glare at me . . . he screams profanities . . . he tries in vain to attack me. I now realize how quickly/easily my health could slip into his illness, my ‘normal’ could slip into his ‘abnormal’. I feel weak . . . nauseous . . . overpowered.

The question being answered -- “Why do we tell ‘You would not believe what I saw/heard’ stories?” (Yes, I know there are more colorful names for this story type!)

I have asked this question many times -- in private conversations with medical students . . . in didactic sessions with residents . . . in staff meetings with nurses and other medical team members . . . during national meeting presentations for medical educators. The answers I receive are without exception variations on “entertainment” or “shock” or “distance”.

How do we tell these stories? How do we view/present the patients when we tell these stories? Where do we tell these stories? to whom?

Think about it. Perhaps talk to a coworker.

*After finishing his commitment to the Navy, Tom Elkins (1949-98) began his academic career with the University of Tennessee Memphis Ob/Gyn Department. He subsequently led the benign gynecology division of the University of Michigan Ob/Gyn Department, chaired the Ob/Gyn Department at Louisiana State University New Orleans, and anchored the gynecologic surgery service for the Johns Hopkins University Ob/Gyn Department. From his medical school days until his premature death, Tom and his family sacrificially demonstrated a special empathy for women’s health needs in Ghana and Nigeria.

Leaven #13

“I need a friend”.

This opening appeal held my attention a decade ago as I read the letter I received from a dying cancer patient I had met a few days earlier at Charity Hospital in New Orleans. I had talked with her while observing our department’s residents as they spoke with the day’s patients being cared for by our gynecologic-oncology service.

She was 27 years old. She lived in a box.

For the previous 18 months, she had lived in a prison cell. But ‘box’ was a metaphor for her life experiences. Our physicians and nurses no doubt had made comments to/about her that had, without intending to harm her, once more stuffed her into some box -- the AIDS box . . . the ovarian cancer box . . . the drug-abuser box . . . the prostitute box . . . the criminal box.

As I read her letter a second time, I remember asking myself -- Who is this ‘I’ who needs a friend? Is her appeal for a friend genuine? What is she asking me to do? Will I look for a way to respond without running any risks? Can I be genuinely present with her?

No one would have known if I had simply discarded the letter. Instead, I risked reaching to this woman. I think my decision had primarily to do with the fact that I had never -- even in my darkest moments – felt stuffed by everyone around me into some ‘box’. Here is the letter I sent to her:

I am honored that you took seriously the invitation to contact me. Your letter arrived two days ago. I have read it several times. Yes, I remember our visit. But please do not let it bother you that our conversation is a bit blurry. You had a lot to think about.

As I tried to explain to you then, one thing I do is to help our physicians -- young and old -- and our patients understand each other very well when hard choices have to be made. I listened closely as you described to the physician and nurse your feelings and your views about your health care history.

As I have thought about our conversation and your letter, I have found myself wondering -- How did she first learn about her illnesses? How did she react to being told about her illnesses? Did anyone try to give her a medical explanation that she could understand? Who first used words like ‘AIDS’ or ‘cancer’? What does she think about when she hears these words? Is it difficult for her to explain to others who ask how she is doing?

You mentioned doing “a lot of soul-searching”. I would welcome the chance to hear from you about this experience.

Please do not feel pressured to comment if my questions make you feel uncomfortable. They are part of my response to your saying, “I need a friend”. If you mean “I need someone who will try to see that there is more to me than my mistakes and illnesses” or “I need someone who will not forget me”, then maybe I can be a friend.

I did not hear from her. She died several days later. I have not forgotten her.

Think about it. Perhaps talk to a coworker.