Fragment -- #60

[2/98] Rejoicing with those who rejoice and weeping with those who weep are difficult aims to achieve with full integrity. Envy, jealousy, . . . inhibit rejoicing. Insecurity, fear, shock, . . . inhibit weeping.

Fragment -- #59

[2/98] Words without power (i.e., substance or significance) are without power due to their source and their center. Therein is one reason for my attention to a Quaker-like emphasis on silence. Meaningful and powerful words emerge from an ‘engaged silence’ approach to life. Therefore, what happens in ‘silence’ is critical. One only speaks out of what is experienced in silence.

Fragment -- #58

[2/98] A key difference between C. S. Lewis and me (not to speak of numerous obvious differences!) is that I went through the trauma (spiritually and theologically) of a spouse’s chronic/degrading illness/death before and then simultaneous with my graduate education and subsequent thought formation whereas Lewis developed his thought and became ‘larger than life’ via his writings before his experience with his cancer-inflicted wife revealed to him the ‘house of cards’ weakness of his by then internationally acclaimed thought. (The writings that had made Lewis an anchor for faith for so many around the world – e.g., Mere Christianity, Miracles, The Problem of Pain, . . . – were written before Lewis married Joy Gresham in 1956. Her health was failing when they married. She died of cancer four years later. Lewis died in 1963.) His A Grief Observed – in which he admitted the hollowness of the views he brought to the experience of his wife’s illness/death -- is, for me, his most helpful writing. He had little to say after his wife died. (Question -- What effect did his World War I experiences as a soldier have on him?) I continue very intentionally to add to the initial experience with tragedy in my first wife’s illness/death (e.g., Down syndrome victims as with Ginny Elkins, Charity Hospital patients, abused children at K-Bar-B, cancer patients, University of Miami/Overtown cocaine-abusing women, Appalachia poverty, . . .). One consequence is my hesitancy to share with others my thoughts/views.

Fragment -- #57

[2/98] Are certain individuals innately gifted with the ability to handle confrontation? Perhaps to a degree, in that some personality types (e.g., more introverted or more structured) have additional anxieties about confrontation. However, everyone will be confrontational about what matters most to them. Otherwise, the subject does not matter so much after all. Variables that work against taking a stand are fatigue and loss of vision.

Fragment -- #56

[1/98] What is ‘after modern’? ‘Post-modern’ implies some meaning for and involvement with ‘modern’. At issue is paradigm decay. All paradigms – being human constructs -- must be subject to questions and criticism in order to avoid idolatry. The erosion of a paradigm does not in and of itself undermine the paradigm until a certain threshold of decay is recognized. ‘Post-modern’ points to deficiencies in the understandings of ‘modern’, but does not yet provide direction re what is beyond ‘modern’.

[Note: As several journal entries re ‘post-modern’ indicate, I struggle with the term – both ‘post’ and ‘modern’. ‘Post’ strikes me as too detached, too categorical, too dismissive. Otherwise, how could ‘pre-modern’ fundamentalists be emboldened by ‘post-modern’ postures against ‘modern’? Otherwise, how could political operatives such as those who have been driving the Bush administration be so unrestrained by facts and true debate, choosing instead to ‘create reality’? And is not every dominant paradigm ‘modern’ in its time/place? Perhaps ‘Imperial/Colonial’ or ‘Scientific’ or ‘Cartesian’ or ‘Capitalist’ or ‘Holocaust’ or . . . would be more to the point re the ‘modern’ in ‘post-modern’. Some innovations in method and interpretation since the eleventh century in Western Europe continue to be revised and used; others have been tested and discarded. And since the end of World War II, a monopoly on political voice/power has steadily slipped away from the presumptive Western nations. I would argue that the future of humankind depends on an unconditional commitment to critical reasoning. Would ‘post-modern’ proponents agree?]

Fragment -- #55

[12/97] It seems to me there is a size beyond which cities cease to be ‘human’ or ‘natural’ (as self-interest, lack of accountability, anonymity dominate actions and encounters). Is ‘community’ (as I am coming to understand such from a ‘non-religious’ perspective) inherently in tension with a large-city social structure?

Fragment -- #54

[4/1997 journal entry] The approach to ‘spirituality’ I am seeking has to do with what energizes a person, with what gives orientation, with that without which one begins to shut down existentially and ethically.

Fragment -- #53

Fragment -- #53
[3/1997 journal entry] Most individuals still seem to be unaware of (or, in other words, take for granted) the paradigm within which they interpret life experiences. The paradigm is thus not subject to questioning. Once aware of one’s own paradigm (and, therefore, aware that others also interpret life experiences within some paradigm), most individuals continue to use a paradigm as long as the paradigm permits them to feel sufficient balance (1) through the greatest number of life experiences or (2) through the most difficult life experiences.

Fragment -- #52

[10/1996 journal entry] A reality that transcends the human is essentially without or beyond language, forms, institutions. I would argue that symbols (1) must serve to awaken a spiritual experience (past or present) and (2) should arise from within the experience of those sharing in that to which the symbol points and which the symbol opens. Corollaries are (1) that such language, forms, and institutions should be permitted to fade/die as well as be born and (2) that no competitiveness should occur about such symbols. As examples of such symbols, see Bonhoeffer’s reference to the gift of Barth’s cigar and his references to ‘the parcel’ in the prison correspondence

Fragment -- #51

[9/1996 journal entry] Why am I drawn toward silence as a centering spiritual exercise? (1) A Berdyaev-type analysis of ‘God’ language. (2) An Otto-type approach to ‘the sacred’. (3) A Habakkuk-type experience of being painfully/disturbingly conscious of the tragic, offensive, violent, hopeless, . . . .

[Note: The reference here is to Nicolai Berdyaev (1874-1948) – a controversial Russian philosopher and theologian who lived as an exile in Paris from 1922 to his death. He wrote prolifically. He stood with the French resistance against the Nazi occupation. He is usually classified as an existentialist, though he called himself a ‘personalist’. I first encountered Berdyaev’s thought (especially through The Philosophy of Freedom and Truth and Revelation) in the late 1970s as I prepared to teach a course on trends in current theology. He insisted that ‘spirit’ is that which is impossible to define, that which is situated beyond the limits of thought. He extended my critical analysis of ‘God’ language by sensitizing me to the sociomorphic and cosmomorphic (in addition to the more familiar anthropomorphic) critiques/limitations of ‘God’ language.]

[Note: The reference here is to Rudolf Otto (1869-1937) – an influential German Lutheran theologian and political activist who advocated liberal strategies for international peace and justice and who worked tirelessly for a renewal of Protestant liturgy. I included Otto’s 1917 Das Heilige (published in English as The Idea of the Holy) in the readings for a classics in spirituality literature course I taught. I especially appreciate his description of ‘the sacred’ as, beyond ideas of goodness, a ‘mysterium tremendum’ – ‘mysterium’ leading to silence and ‘tremendum’ leading to awe.]

ethical dimensions of patient care #22

Narrative

Our physician had passed the mid-point in his career. He had resisted temptations to finish his career on the comfortable fringes of his field with those who rallied around ‘Not in my practice!’ He considered patient and practice changes -- e.g., better educated patients, group practice, enthusiasm for ‘natural childbirth’, fathers in delivery rooms, female obstetrician-gynecologists -- through the lens of professional excellence and patient dignity. Though no activist or enthusiast on either side of the abortion issue, he sympathized with the view that being unwanted can be worse than never being born. He dreaded more regulation and scrutiny in the wake of ‘Baby Doe’, while questioning a single-factor ‘Is the heart beating?’ criterion for aggressively intervening in cases involving critically ill newborns. He learned to work under the threat of lawsuits.

As age 70 and a third generation of babies approached, his literature seemed to be signaling the time had come to step aside. Articles such as ‘Whither electronic fetal monitoring?’ questioned the technology he had championed. Two lengthy articles about ‘Interpreting the literature in obstetrics and gynecology’ hinted that his generation might not be able to keep up. An article on ‘Retirement patterns of obstetricians and gynecologists’ provided a frame of reference. In carefully chosen conversations, he admitted, “It’s not fun anymore”. ‘Private practice’ had become an anachronism. He was exhausted. He retired in 1991 . . . almost. He continues to staff a uro-gynecology clinic with residents one day each week. I asked him what he thought about today’s residents. He said cautiously, “I’m encouraged”.

Commentary

1991. If 1951-1971 warranted images of modern medicine such as ‘explosion’ and ‘expansion’, 1971-1991 requires a word such as ‘constriction’. Physicians have become ‘providers’, ‘expert witnesses’, ‘gate-keepers’. Physicians’ discretionary space in clinical decisions has shrunk. ‘Managed care’ has put physicians in a position with patients uncomfortably analogous to real estate agents who represent the seller as they work with potential buyers. HIV infection has ended the assumption -- widespread since the introduction of penicillin -- that medicine is a risk-free profession. The consequences of changing the delivery of health care to extend access and contain cost are yet to be determined. It seems safe to conclude that maintaining integrity between patients and physicians is not getting easier.

And ‘ethics’? During the early ‘70s, ‘bioethics’ emerged within the medical sphere as a discipline of study in search of a voice in a conversation already underway. With patient confidence in physicians eroding, the first generation of bioethicists made its most noticeable contribution by providing justification for placing patient autonomy as the cornerstone in medical decision-making.

It is encouraging to see that the subjects of values and virtue have now reentered medical and ethical literature. More is being heard of casuistic reasoning and attention to the ethical significance of patient histories. We are recognizing that reducing decisions to patient self-determination missed the complexity of hard clinical choices and offered little guidance for public health concerns. ACOG’s Ethics Committee is carefully crafting revisions of earlier statements on such subjects as informed consent, physician responsibilities in an era of HIV epidemic, and end-of-life decision-making.

And so we are left to ask, “Can medical students and residents be taught how to be with patients?” I think the answer is ‘yes’ if the question has to do with what is sometimes called ‘minimalist ethics’ -- i.e., where what ought to be done is equivalent to what by law has to be done. I think the answer is ‘yes’ if the question has to do with communication skills or recognizing varying points of view. I think the answer is ‘no’ if the question has to do with ‘ethos’ -- i.e., with integrity, with character, with virtue, with vision. But I must quickly add that ‘ethos’ can be identified, protected, nurtured, recovered, encouraged, healed, prompted, matured in the medical education/practice settings. The ‘ethics’ that transcends a minimalist threshold essentially derives from and is clarified by one’s defining life experiences.

To illustrate: If the obstetrician-gynecologist whose professional career we have profiled today were asked to account for his consistent and impassioned advocacy of doing what is best for the patient, he would at some point contrast his participation in the indignities and death of battle during World War II with his participation in bringing healthy life into the world as an obstetrician.

To illustrate: Another physician (with whom I have worked closely) began a pediatric practice in 1954 but, a dozen years later, devoted his full attention to disadvantaged inner-city critically-ill newborns who were dying two-to-three times as often as advantaged suburban critically-ill newborns. When asked at an award ceremony to account for his resolve, he said simply, “My grandfather’s toes” and then went on to recount how each evening as a young boy he would meet his Yiddish
grandfather -- a 1901 immigrant to New York’s Lower East Side from Czarist Russia -- in front of the dining room buffet. With unequal strides, the two made their way to the living room where the weary blacksmith settled down in his chair. The stocky, spectacled lad would begin his nightly ritual of unwinding the laces from around the hooks on his grandfather's work boots. Pulling off the boots and socks, he would run his fingers over each foot's single chunk of nailless flesh that had once been separate toes and prod his grandfather to recall the painful memories always just a thought away: “Papa, tell me again. What happened to your toes.” “Son, Cossacks chased me. I hid in the forest for a long time. My toes froze off in my shoes.”

To illustrate: I spoke recently with one of our third-year Ob/Gyn residents at LSU about the explanation he had given in his residency application’s ‘personal statement’ for becoming a physician. After getting past the shock that someone had actually read his ‘personal statement’, he remembered clearly what he had written: “Open the door, please! Get out of the way! We need to see the doctor right away!” Curious to find out what was happening, I -- only six-years-old at the time -- rushed down to my father’s office as the metal door was dragged open to reveal a haggard, panic-stricken man carrying a lady in her mid-sixties. She was pale and almost lifeless. My father quickly stepped out to greet them and immediately started to take her pulse. “How is she, doctor? How is my mother?” the young man asked anxiously. “Don’t worry. She will be fine. We need to get her to the hospital. I will come with you.” As soon as my father spoke, I could see a change in the man’s expression, from panic and insecurity to calm and trust. I can never forget the relief on that man’s face as his terror resolved in response to my father’s words. Simply by being calm and decisive, my father was able to ease his suffering. I remember telling myself that day, “I want to help people the way my father is doing.”

Such defining experiences -- if remembered -- can sustain a motivation that embraces more than family, friends, neighbors; more than patients for whom a physician has cared for many years. Such defining experiences -- if remembered -- promise to keep us in place when secondary motivations -- e.g., personal gratification, intellectual stimulation, financial reward, even societal reform -- fail.

Concluding Remarks

In a few minutes or hours, we will each be back in our niches within the vast health care sphere. I hope our time together has encouraged each of us to ask again – “Can there be integrity between patients and physicians? between patients and physicians who are strangers? who approach each other with suspicion? who need each other but will never know each other? who are assigned to each other?” Those are the most common -- and, I would argue, the toughest -- ethical questions facing today’s clinician. The reflections I have shared with you today can be reduced to three core propositions.

1. The central ethical issue facing clinicians is how a patient and a physician form a relationship and how they actually relate to/with each other in the delivery of care. Multiple specific issues either are ways into this central issue (e.g., informed consent, confidentiality, patient self-determination) or are ‘outside’ issues that add complexity to this central issue (e.g., allocation of limited resources, HMO expectations/regulations, third-party disclosure).
   
2. Patients and physicians embody the peculiarities of their time and place. However, in every time and place, ‘respect’, ‘trust’, and ‘gentleness’ sustain patient-physician relationships that retain the humaneness without which medicine ceases to be an art or a profession.
   
3. Various metaphors make vivid the ways physicians relate to patients (e.g., healer, counselor, advocate, friend, mechanic, provider, stranger, entrepreneur, adversary). Physicians would do well to view themselves essentially as guests in their patients’ life-stories. A guest enters another’s space with a grateful disposition, expresses respectful interest, departs gracefully.

Thank you for your attention. And thank you, Dr. Wall, for your enduring example.

ethical dimensions of patient care #21

Narrative

In 1955 he moved his family to form with two other physicians a group practice that in time would expand to five partners. Wedded to obstetrics, he soon earned the reputation of being a meticulous and hard-working clinician. He delivered all his patients. Resolved to remain current as the specialty broke new ground, he was among the first in his location to perform laparoscopic tubal ligations. He introduced fetal monitoring. His boys remember going with him to the family farm to practice the fetal monitor on pregnant cows.

During years of social upheaval, he quietly but consistently participated in his hospital’s obstetric service for indigent patients and provided coverage for a nearby home for unwed mothers. Residents rotating with him saw the same high standards of care and the same respect for patients, whether the patients were socially advantaged or not.

Yet by 1971 -- the midpoint in his career -- he could identify with the question raised in an Ob/Gyn editorial -- “What happened to the old-fashioned physician and the old-fashioned patient?” He was at a critical juncture. Would he limit his practice to the shrinking number of ‘old-fashioned patients’? Would he shift his practice away from obstetrics by focusing on the gynecologic needs of the women he had delivered in previous years? Or would he pay the personal and professional price to remain in the middle rather than on the periphery of his specialty?

Commentary

1971. When your own kids are leaving for college and you start delivering the babies of babies you delivered, it is time to look up from the exhausting day-to-day work and take a deep existential breath. The task and the profession to respect the patient -- to observe and listen closely -- remained central to being a trustworthy physician. But patients and physicians had changed. Hospitals had changed. Medicine had changed. Society had changed. Maternal and infant mortality and morbidity had dramatically declined. Ironically, so had patient and physician satisfaction. Respect and trust could no longer be taken for granted. Harm? Strangers do not notice and adversaries do not hesitate.

What had happened? What centrifugal forces were pulling patients and physicians apart? Social mobility? A more educated population? The move to protect individual rights? A sexual revolution? All these and still other factors contributed. But the most plausible interpretation points centrally to the tension between two honorable goals -- i.e., on the one hand, doing what is best for each patient and, on the other hand, insuring adequate care for the greatest number of patients. One strategy -- some might say, the traditional strategy -- would have a physician care for as many patients as possible without compromising the standard of care for each patient. Many physicians followed this strategy. Of course, moneymaking motivated some. And ethnic or economic prejudices could still go unchallenged. But many physicians genuinely struggled with the tension between individual and societal responsibilities.

However, all around them medicine was being reshaped by developments that drew attention away from individual patients. Such serious public health concerns as population control and indigent patient care had to be addressed. Research and experimentation -- propelled by wartime successes -- changed public expectation as ‘miracles’ moved from kidney dialysis to transplanted hearts, from polio vaccines to ‘the pill’. Statistical significance and randomized controlled trials reshaped medical education, medical literature, and clinical decision-making patterns. Government legislation and programs so defined the issues that Dr. Roy Parker, in his 1975 presidential looking forward to the year 2000, predicted, “The future of [obstetrics and gynecology] resides in the government”. The trend toward utilizing nurse midwives and other non-physician ‘extenders’ for routine tasks promised to increase the reach of obstetric care.

Obstetrics and gynecology had enjoyed startling advances -- as does a rapidly growing tree according to one observer. By the mid-‘60s, academicians estimated that the best medical education became obsolete in five years. The specialty expanded in fetal medicine, geriatric gynecology, endocrinology, gynecologic oncology, . . . . A chronology of editorial opinions highlights the gradual reformation taking place:

1959: In attempting to stay near the front of the [knowledge] race, there has been a tendency to forget or neglect some qualities of man as desirable as knowledge -- i.e., wisdom, dignity, and faith. Specialization is an evil, but an unavoidable one. We know more and more about less and less. We must avoid the easier method of treating the disease and neglecting the patient.

1963: All efforts not ultimately directed toward more competent and compassionate patient care are valueless.

1965: Programmed learning is in sharp contrast to the traditional pattern of education in medicine that utilizes a close association between student and preceptor for the transmission of skills from one generation to the next.

1966: Devoted to the concept of the responsibility of a particular physician for an individual patient, we are initially repelled by the impersonal, even amoral, nature of statistics and the collective approach. . . . [We should] try to comprehend the ways of the ‘monster’ and, by becoming to a degree part of it, attempt to guide its progress and so preserve some of what seems essential in the traditional ideals of medicine.

1969: Individuals want, need, and trust their physicians; at the same time, the patient generally favors and supports social reforms adverse to the physician and his ability to function as a personal doctor.

1971: Is this to be a point in time when we are expected to acknowledge our responsibility to the community in which we live – and, as a result, perhaps find ourselves doing what needs most to be done -- even though it may not be what we individually would have liked most to be doing?

By 1971 the curtain had been pulled back on female and fetal health. Medicine was in public view. But the public -- suspicious of social institutions and traditions -- had seen a darker side to their medical ‘gods’. The 1962 thalidomide scandal sparked congressional hearings over regulating drug companies and monitoring informed consent. Then came the 1966 exposé of twenty-two research projects authored by Dr. Henry Beecher (a University of Kansas graduate). And finally, news broke of the US Public Health Service’s Tuskegee research on syphilis.

Hospitals began displaying copies of ‘The Patient Bill of Rights’. The 1972 Canterbury Case shifted the focus of informed consent from what a physician should disclose to what a patient needs to know to make an informed choice. The widely-read Our bodies, Our Selves advised women to be wary consumers of health care. Another title put it more bluntly -- Rid Yourself of Your Gynecologist. 1973 saw the formation of a President’s Commission to address the perplexing questions modern medicine had created but alone could not manage. As Dr. William Bartholome of the University of Kansas School of Medicine explained in a 1971 letter – “There is need to involve not only the medical profession, but lawyers, sociologists, moralists, and society at large to resolve complicated medical issues”. Dr. Bartholome had just released a film that recreated a 1969 Johns Hopkins case in which he had been the resident who was told to pull the feeding tubes on a baby with Down syndrome and an intestinal blockage.

ethical dimensions of patient care #20

Narrative

He had always wanted to be a physician. It took him thirty years, beginning in ‘dust bowl’ poverty. The youngest of three children in a homesteading family on the southwestern prairie, his determination guided him through eight grades at a one-room school and on to the state university. He did poorly his first college year -- too far behind in learning, too many hours working to pay his way. Then the war . . . and the draft. He took advantage of every educational opportunity military training offered. Shipped to England, he co-piloted a B-17 crew on bombing runs over Germany. Shot down and missing in action, he struggled to survive in a POW camp. He was below a hundred pounds and fighting hepatitis when Patton’s Seventh Army liberated the camp.

Once reunited with his family and sufficiently mended, he returned to the state university, graduating with a medical degree in 1951. After finishing post-graduate rotations in obstetrics, cancer surgery, endocrinology, and gynecology, he practiced in a small town for a year as the only physician trained in obstetrics and then moved to join two other physicians in a practice that would be his professional home for the next forty years.


Definitions

We humans are clearly bent on being together -- usually by choice, at times by necessity. And yet the result of our being together seems ironically to dehumanize those we are near. Whether spouse, child, friend, colleague, or stranger, . . . whether patient or physician -- it is a profound and difficult achievement to be with another person and do no harm, but instead to show respect and to justify trust. These terms -- do no harm, respect, trust -- take us to the core of the patient-physician relationship our young physician envisioned with his first patient in 1951 and his last patient in 1991.

Harm means to injure, to wound, to humiliate. Harm has already begun where there is disrespect and erosion of trust. Harm results when power is misused by one or the other in a relationship. Power -- an ever-present and shifting reality when patients and physicians are together -- ranges in nuance from impact, influence, creation, strength across a spectrum to force, control, abuse, exploitation, destruction.

For a concrete image of respect, just break the word down into its Latin parts -- re + specere. To respect is to look at closely again and again, to listen carefully again and again. And so the premium assigned to such traits as patience, altruistic interest, confidentiality, modesty, attention to subtle disclosures.

For a vivid image of trust, consider a rather common scene back in the 1950s. A workman who is assigned to repair phone or electric lines straps on spikes to the inside of his work boots. He ‘walks’ up the pole, digging in the spikes and slinging upward the thick security belt he has looped around the utility pole and hooked to his tool belt. Near the top of the pole, he leans back from the pole. Hands free, he begins to repair the lines. Leaning back from the pole and depending on the security belt – that is trust.

Concerns about health bring patients and physicians together. There is a certain pragmatism to the relationship. What is the desired ‘end’ and how do we best get there? That is the stuff of ethics -- i.e., figuring out what ought to be done (if anything), all things considered. The patient and the physician both have to reach the minimal thresholds of mutual respect and trust to proceed toward the desired ‘end’ without injuring and humiliating each other. Some considerations on their minds encourage respect and trust. Other considerations permit or force patients and physicians to drift apart, to remain or become strangers.

Commentary

1951. The young physician we introduced a few minutes ago, began to see his patients in 1951. He had become a physician. A childhood dream, tempered by severe life experiences, had become a reality. Granted, he had just recently been adding his share of stories to the lore of student faux pas. But that young physician with his first patient in 1951 had learned to think, to talk, to dress like a physician. He had been socialized into the cloistered fraternity of medicine. He entered medical education seeing as the patient would see. By the end, he had learned the physician’s view of things. Seeing as a physician while not being blind to the patient point of view seemed possible then. He had embraced the proposition, as articulated in a 1932 AMA Commission Report, that the essence of being a physician is “the capacity to observe, to reason, to compare his observations and reasoning with those of others, and the capacity to place himself in his patient’s place -- in a word, compassion”.

1951 was an exciting time to enter the practice of obstetrics and gynecology. Obstetrics at the turn of the century had attracted few physicians. General surgeons did the few cesarean sections. A 1932 Presidential Conference on Child Health report looked back at the turn-of-the-century obstetrician as occupying “a menial place, entirely unenviable, in the medical school and the hospital, with scant respect from the public at large”. The majority of births occurred at home. For every 10,000 live births, 80 mothers died. As recently as 1920, American obstetrics had been called a national disgrace. Then a year later, Congress passed the Act to Promote the Welfare of Maternity and Infancy, requiring states to establish centers for prenatal and infant care. By 1936 -- the year of the Social Security Act -- all states were complying with the 1921 guidelines. 1937 saw the formation of Maternal Mortality boards in state medical societies. With the outbreak of war, Congress enacted the Emergency Maternity and Infant Care Act to cover the wives and children of soldiers. By the time the wartime emergency had passed, the federal government’s role in the promotion of maternal health had taken root.

In 1921 there were just eleven chartered obstetric societies. The 1928 AMA directory listed fewer than ten residency programs for obstetrics and gynecology. Only two generations earlier, advocates of vaginal examinations had to refute prophets of moral doom. In time, a series of breakthroughs -- beginning with the first reported cure of cervical carcinoma in 1900 -- brought definition to gynecology, then a branch of general surgery. A corps of medical crusaders established in 1930 the American Board of Obstetrics and Gynecology, the certifying body for the merging specialties. The ranks of obstetrician-gynecologists grew rapidly, as evidenced by the proliferation of chartered obstetric and gynecologic societies.

By 1944 two out of three births occurred in hospitals. In 1945 the National Federation of Obstetric and Gynecologic Societies was organized to consolidate the specialty, in part to stall federal control of maternal health care. The Federation was reorganized in 1951 into the American Academy (College) of Obstetrics and Gynecology. Members had to be physicians who had confined their practice to either obstetrics or gynecology for five years and who had the endorsement of their local colleagues. Within two months, the Academy (College) had 2000 applicants. Being a Fellow meant:

To establish and maintain the highest possible standards for obstetric and gynecologic education in medical schools and hospitals, in obstetric and gynecologic practice, and in research; to perpetuate the history and best traditions of obstetric and gynecologic practice and ethics; to maintain the dignity and efficiency of obstetric and gynecologic practice in its relationship to public welfare; to promote publications and encourage contributions to medical and scientific literature pertaining to obstetrics and gynecology.

And so, our young physician began his practice at a time when patients trusted their physicians’ decisions, when examinations depended on observation and touch, when case reports in the medical literature provided context for clinical judgments, when lawyers and economists remained far from the bedside, when ethics had to do with the sort of person you were, when parents would bring a $125 payment for a delivery done eight years before.

A 1954 ‘After Hours’ column in the American Journal of Obstetrics and Gynecology celebrated the ‘Cinderella Story’ of the specialty. That same year, ACOG’s president proclaimed, “We have come of age”. Yet another inaugural address described the specialty as “a rising sun”. And why not? For every 10,000 live births in 1920, 80 mothers died. For every 10,000 live births in 1950, 7 mothers died. “She is devoted to her obstetrician” was an observation heard often and for very good reasons. But this devotion was also fraught with danger as patient respect could escalate to awe, as patient trust could be blind, as physician confidence could override caution. Still, we would be guilty of the classic historians’ fallacy if we held patients and physicians in or around 1951 accountable for failing to see the harmful consequences that, with hindsight, look so obvious and inevitable.

ethical dimensions of patient care #19

I have had the privilege of collaborating with a surgeon/anthropologist since 1995 when we were among the new faculty members recruited to the Louisiana State University Department of Obstetrics and Gynecology in New Orleans. Since 2002 he has been with the Department of Obstetrics and Gynecology at the Washington University School of Medicine in St. Louis. In addition to his training as a uro-gynecologic surgeon, my friend also received an Oxford D.Phil. in Anthropology. His Oxford thesis reflected the results of a yearlong field study focused on a rural African village. He remains deeply involved in efforts to improve women’s health in Africa (e.g., leading an initiative to make post-delivery fistula repairs available to women who otherwise live humiliated and shunned due to the offensive consequences of unattended uterine damage). He enjoys a secondary faculty appointment in Washington University’s Anthropology Department. He has made noteworthy contributions to the History of Medicine discipline.

My friend and I quickly became close friends in New Orleans, cherishing conversations uncommon in the hallways of academic medicine – i.e., conversations about experiences and subjects where values, ethics, history, anthropology, and spirituality intersect with medical education/practice. He was a regular participant in the ‘Who cares?’ gatherings I coordinated/facilitated with professionally fatigued faculty members. We continue to collaborate on publications for medical journals that draw attention to the ethical complexities faced in medical education and practice. Partnering with him is indeed a special privilege.

My friend’s father was a highly regarded physician during a forty-year career as an obstetrician-gynecologist. Soon after retirement in 1991, the University of Kansas School of Medicine established an annual lecture in his honor. I was invited to present the 1997 lecture, focusing on integrity between patients and physicians. I chose to weave a narrative of the lecture honoree’s professional experience into an analysis of the patient-physician relationship as obstetrics and gynecology evolved into/as a specialty. The core of the lecture follows.

ethical dimensions of patient care #18

[10/1996 journal entry] Two weeks ago, the ‘Who cares?’ meetings began at O’Reilly’s Tavern on Tulane Avenue across from University Hospital. I invited eight of the department’s medical faculty members to participate. We are gradually inviting more faculty members. We meet weekly on Wednesdays after evening board rounds for a 40-minute conversation about times/circumstances we are experiencing that push us to the point of throwing in the proverbial towel. My perception at this point is that the drinks we order (limit of two) are sacramental in a ‘non-religious’ way.

[Note: The ‘community’ I experienced on Wednesday afternoons in that quiet dimly-lit tavern remains my closest realization of the second level of ‘community’ that characterizes my ‘non-religious’ path – i.e., individuals drawn together with no prerequisite other than the common resolve to be ‘with the world face to face’ in a way that initiates respect and conciliation even (especially) when there is no reason to expect reciprocity (the first level of ‘community’ for my ‘non-religious’ path). Disincentives to care deeply are pervasive in the medical education, residency training, and practice environments. Those of us who gathered at O’Reilly’s knew we were at risk not any longer to care. But none of us had previous experience with revealing to colleagues our vulnerabilities, our failures, our isolation, our disillusionment. I was both the prompter and a participant. I proposed that we meet together each week for three months and then decide whether to continue. At the end of three months, I began that week’s discussion by mentioning the time had come to assess the experiment. Their answers could be read from their expressions. Unanimously and urgently, we all agreed we had to continue. Today – ten years later – a variation on the ‘Who cares?’ gathering is still meeting in some New Orleans tavern (or was meeting until Hurricane Katrina hit).]

ethical dimensions of patient care #17

[9/2005 journal entry] The workshop Dr. McRay and I conducted recently in Chicago as part of the program for a meeting of the Society for Teachers of Family Medicine was very well received. The title/focus of the workshop – “Look where caring got me!” We presented a number of the teaching tools/techniques we have developed over many years of working with medical students, with residents, and with young physicians in their first years of practice after residency. We sought a critical review of these tools/techniques from the workshop participants (all fulltime medical school educators). Here are a few highlights from the session.

The workshop participants seemed intrigued by our use of the ‘personal statement’ with residents near the end of their grueling training experience. A ‘personal statement’ is part of the application fourth-year medical students submit to the residency programs where they hope to interview. These ‘personal statements’ are routinely replete with expressions of caring, passion, anticipation, confidence. Here are some examples we lifted last fall from the personal statements of some senior family medicine residents with whom we spent three hours in an afternoon didactic session --

Medicine is the most humanistic of the scholarly professions.

I yearn for an approach to health care that heals all aspects of a human
being.

What I love about medicine is serving the great variety of needs for all of my patients. The breadth of practice can be so exhilarating!

A family physician has the responsibility to stay on top of the latest developments in many fields.

Family practice is the backbone of medicine. It takes a special breed to be a family
physician.

I am well rounded, love to develop relationships with people, can be flexible from moment to moment.

I am confident about my career choice and my ability to perform. I feel just as committed to my choice of specialties now as at the time of my application.

I am always willing to teach or lead where needed.

My education from medical school is incomplete. I received little or no foundational philosophy on which to base my understanding of health. Is health merely a disease-free state? Why is community health education for the most part disease prevention?

It is important to be able to communicate with people in their own language. . . . [These experiences] have helped me learn to appreciate a variety of cultures and adapt to different situations quickly. This aspect of personal interaction is the aspect of medicine I enjoy the most.

I love medicine. . . . In the practice of medicine, I can become the type of person I desire to be.

I have immensely enjoyed participating in the care of ill individuals.

During the residency portion of my training, my goal is to seek out experiences that will further my development into a compassionate, flexible, and competent practitioner of primary medicine.

One of our teaching methods is to put such expressions one by one before graduating residents. They do not know we have had access (anonymously) to their ‘personal statements’. Interestingly, they rarely recognize their words/thoughts. The selections from their ‘personal statements’ suggest very clear, trusting, expectant, energetic interpretations of “Look where caring got me!” Their reactions three years later to the selections from their ‘personal statements’ suggest very frustrated, betrayed, wounded, trapped, despondent, fatigued interpretations of “Look where caring got me!” One resident in the group last fall wrote the following in her very thoughtful and carefully crafted ‘personal statement’ –

I am passionate about socio-economic issues that contribute to suffering. . . . Inspired by Albert Schweitzer and 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.

When she saw these statements on the screen three years later, she became emotional as she confessed –

I think I said something like that in my personal statement. . . . Now where am I? I dream of taking care of rich patients, educated patients, compliant patients, healthy patients. What has happened?

The ensuing discussion we have with such residents probes the exposed distance between where they were at the end of medical school and where they find themselves at the end of residency, with particular attention to phrases such as “What I yearn for is . . .” or “What I love about medicine is . . .” or “ . . . can be so exhilarating” or “I am confident about . . .” or “ . . . is the aspect of medicine I enjoy the most” or “I am passionate about . . .”.

The workshop participants also mirrored the responses of residents when we ask them to identify the word we were defining with – “relieved from a deception” . . . “relieved from a misapprehension of the true state of affairs” . . . “relieved from a faulty perception of an external object” . . . “relieved from a figment of the imagination”. The guesses are always the same – “education” . . . “illumination” . . . “informed” . . . . The word being defined – disillusioned. No one has yet guessed correctly. We begin by constructing the value/progress inherent in being disillusioned. Then we turn to the crucial task of regrouping on the other side of being disillusioned, since one’s vision and motivation are so often tied to that which has been shown/experienced to be illusion.

The conference program committee chair has encouraged us to submit a workshop proposal for next year’s meeting. The title/focus will be – “I have learned how mean and selfish I can be” (a painful admission made by a dismayed and burdened intern near the end of his first year of residency during a didactic afternoon Dr. McRay and I spent last Spring with a group of first-year family medicine residents).

ethical dimensions of patient care #16

[1994 journal entry] The problem of denying finitude is found on the opposing sides of the physician-assisted dying debate. To seek control of the dying process can be a denial of finitude. To oppose control of the dying process can be a denial of finitude expressed in terms of casting the reality of finitude into the context of the infinite.

[Note: In 1987 my collaborative work with my close friend and the first physician with whom I had a collaborative relationship -- Tom Elkins, MD -- shifted to the University of Michigan when he became the gynecology division chief for the medical school’s Ob/Gyn Department. One of the several research projects we conducted studied the end-of-life hopes and preferences of 108 gynecologic cancer patients receiving care from the division’s oncology service. Dr. Kevorkian’s assisted-dying cases took the national headlines soon after we had completed the data gathering re the 108 gynecologic cancer patients. A junior faculty member in the Michigan Ob/Gyn Department from Holland, where euthanasia had been openly discussed since the early 1970s, arranged introductions for me at Amsterdam Medical Center and at Leiden University. In 1992 I began making annual research trips to Holland to track the end-of-life care being delivered by a cross-section of Dutch physicians who represent the full spectrum of judgment in Holland re euthanasia.

In 1994 the Michigan legislature formed a commission to address possible ways to respond to Dr. Kevorkian and the subject of physician-assisted dying. I was asked me to submit a statement to the commission based on my study of the Dutch experience. I closed my statement as follows with some observations that develop in more detail the thoughts in this 1994 journal entry.]

The main character in Albert Camus’ novel The Plague is an exemplary physician, Dr. Rieux. While faithful to the task of fighting against the plague, Dr. Rieux recognized that the people of Oran only experienced their communal ideals (e.g., mutual respect, compassion, integration, justice) in their response to the suffering indiscriminately imposed by the plague. When the plague eventually receded, Dr. Rieux could not celebrate with the survivors in Oran because he knew they would soon slip back into a shallow and socially irresponsible pursuit of personal pleasure and gain.

The Paradox: To fight against disease, injury, and death is to fight against the very experiences that force us to engage the most fundamental truth about our humanity – i.e., our finitude.

Until a very few decades ago, human beings could do little more than appeal to divine providence or attempt to manipulate fate when threatened by disease, injury, or death. Modern medicine has fueled a shift away from that resignation for Western societies. Is it possible that patients expect the curative/corrective interventions of medical professionals to rescue them from having to face their finitude? If so, physician-assisted death could be for them the final denial of finitude, particularly if requested as a preemptive action rather than as a last resort in the struggle with human frailty.

Seeing ‘Jesus’ From Below #12

[4/1997 journal entry] ‘Religion’ today corresponds to the synagogues, the temple, the clergy, the Sanhedrin ‘Jesus’ faced.

Seeing ‘Jesus’ From Below #11

[4/1997 journal entry] Is the word ‘Christian’ so restricted to or nuanced by the ‘religious’ sphere that I am not a ‘Christian’ (though I am definitely a student of ‘Jesus’)? Being the sort of person who can be genuinely with another person is my center for being in this world and the basis for my being a student of ‘Jesus’. I do not accept the traditional Christian mandates re exclusivity and evangelism.

Seeing ‘Jesus’ From Below #10

[11/1996 journal entry] As the ‘religious’ paradigm failed for me, I found all that remained was my resolve to ‘hold to my integrity’ (the reason the story/play Job rings true to me). My concepts/images of ‘Jesus’ died too (as I had seen/considered him within the ‘religious’ sphere). I eventually came to a point where I saw ‘Jesus’ -- apart from the assumptions/interpretations of him within the ‘religious’ sphere -- as having maintained his integrity. Thereby, I found what I consider a ‘non-religious’ way to respect (i.e., to look back at, to look again at) him that in turn has become my experience/idea of discipleship.

[Note: I remain cautious re see(k)ing a historical ‘Jesus’ in the four Gospels. As ‘a historian first, theologian second’, I approach these texts with the same historiographical caution/rigor I bring to any other text. Attempting to be ‘with the world face to face’ and to ‘see from below’, I carefully critique ‘Jesus’ as I do any other potential thinker/teacher. This journal entry indicates I had concluded that ‘religion’ is the reverse on both counts. With theological assumptions constraining/discrediting historical inquiry, much more in the ‘religious’ sphere can be taken as historically credible in the four Gospels than I take to be historically credible. And the longing in the ‘religious’ sphere to be ‘face to face with Christ my savior’ (to quote a beloved hymn from my childhood) precedes/trumps/filters how the ‘world’ is seen/experienced.]

Seeing ‘Jesus’ From Below #9

[9/1996 journal entry] For me, being ‘non-religious’ means that the story/play Job and the essay Ecclesiastes are my only ways in/out of Jewish Scripture or Christian scripture, my only ways to/from ‘Jesus’. I see myself first in relation to the questions raised by Job and Ecclesiastes; then second and indirectly, in relation to ‘Jesus’. I do not think of myself any longer as representing Christian ‘religion’ or any particular denomination.

Seeing ‘Jesus’ From Below #8

[8/1996 journal entry] The ‘non-religious’ understanding of ‘Jesus’ I am seeking develops (i.e., unfurls) around a Matt. 25:31-46 type interpretation of integrity. In this way, being ‘non-religious’ might be thought of as ‘unconscious Christianity’ (Bonhoeffer’s phrase in his prison correspondence). Approaches to ethics and spirituality that are detached from ‘the least of these’ are not ‘of Jesus’ (at least as he would be interpreted ‘non-religiously’).

[2005 Note: One of the serendipities of our December 2004 move to Memphis is my opportunity again to spend time with Dr. Korones. Shelly is now 81 years old. I round with him during the months when he is the attending physician for the Newborn Center (neonatal intensive care unit) he founded in 1968 (before there was a neonatology specialty) and still directed until this past July. We also meet once or twice a week to continue working together on his autobiography. We are presently revising/expanding the manuscript we completed shortly before my family and I moved in 1992 from Memphis to Vermont. We were recently discussing the following paragraphs from the manuscript’s first chapter --

What would my grandfather think of his grandson’s life? I have often pondered this question. I know I would have to give account for my neglect of the ritual Papa regarded as mandatory for a religious Jew. Perhaps, if I had been shown a closer link between ceremony and principle, I would have remained lashed to the all-encompassing ritual. Instead, I rebelled against the imposed rigidities when I left home. I concluded then and still think that religion has done far more harm than good to human beings.

Twenty years passed before I, with more circumspection, questioned myself – “What drives me to do what I do? Why do I walk the floor over a sick patient? Why have I stocked a private closet with vaporizers for parents facing emergencies with their children?” With this self-examination, I had begun the journey back into the religious and cultural milieu out of which the way I live life was born via Reformed Judaism.

In spite of the virtual absence of my grandfather’s ritual, I still consider myself to be a very Jewish man. I like to think that Papa, after carefully surveying the results of my decision to wager my medical career on caring for sick babies ignored or discriminated against by society, would say to me – “Gut getton, Kindele” (Yiddish for “Well done, Child”).

When Shelly commented that no religious tenet accounts for how he lives life, I told him what is for me the most revolutionary/riveting story attributed to ‘Jesus’. He listened attentively as I told him about

. . . the king who said to those on his right hand, ‘Come, you that are blessed by my father, inherit the kingdom prepared for you from the foundation of the world. For I was hungry and you gave me food; I was thirsty and your gave me something to drink; I was a stranger and you welcomed me; I was naked and you gave me clothing; I was sick and you took care of me; I was in prison and you visited me.’ Then the righteous will answer him, ‘Lord, when was it that we saw you hungry . . . or thirsty . . . or a stranger . . . or naked . . . or sick . . . or in prison . . . ? And the king will answer them, ‘Truly I tell you, just as you did it to one of the least of these who are members of my family, you did it to me.’

At that point, Shelly beamed with delight and said, “That’s it. That’s exactly where I am. Their actions had nothing to do with being religious, with obeying the king, with trying to be righteous. They simply/truly cared.” I responded, “That’s exactly where I am too.” We shook hands firmly in friendship, in fellowship.

Seeing ‘Jesus’ From Below #7

[July 2005 journal entry] This past Sunday morning, I completed a seven-week ‘Bible Reading 101’ series of discussions (each 35-40 minutes in length) for a small gathering in Memphis. Each discussion probed the striking disclosure in the Synoptic Gospels that the individuals who had the greatest difficulty using ‘language of caring’ attributed to ‘Jesus’ were the individuals most fluent in the ‘language of religion’. I laced each discussion with narratives about life experiences, leading the participants to see the contrast between these two ‘languages’. We began by identifying languages in Bible times, illustrating translation efforts/challenges ancient and modern, and tracing canon decisions. We then worked with the ideas of starting with ‘the Exodus’ or with the Davidic monarchy, distinguishing ‘the gospel of Jesus’ from ‘the gospel about Jesus’, and facing the chasm separating us from antiquity’s pre-modern/pre-scientific thought. The last discussion in the series pressed the proposition that the Bible, if it is to be significant for conversations using the ‘language of caring’, must be read as a critique on political, economic, and religious power.

Seeing ‘Jesus’ From Below #6

[1994 journal entry] I have recently been working with the imagery of huddling behind the line of scrimmage re ‘community’. How many churches fit this imagery? I have known very few. What needs to be pursued/recovered (i.e., the huddle) is a gripping and inspiring vision (e.g., Matthew 5:38-48) re being and being together ‘with the world’ (i.e., the line of scrimmage).

Seeing ‘Jesus’ From Below #5

[1994 journal entry] “Can any thing good come out of Nazareth?” or Cuba? or Harlem? or an Indian reservation? or Iraq? or Palestinian territory? or ‘an Appalachian holler’? or . . . .