Ethical Dimensions of Patient Care #8

Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 2)

1. The ‘conscientious objector’ disposition

1.1 Summary: Physicians with this disposition approach the care of their patients with the resolve not to manage a patient’s death by means of euthanasia under any circumstances.

1.2 Metaphor: An individual who appeals for ‘conscientious objector’ status rather than to bear arms must make the case that to take up arms would essentially be to occasion his/her own existential death. Being classified a ‘conscientious objector’ is not popular in a time of national crisis. The government cannot protect the individual from criticism, ridicule, even harm. Physicians who, regarding euthanasia, are analogous to ‘conscientious objectors’ are convinced that performing euthanasia would essentially be to occasion their own existential and professional death. It would not be accurate to use the ‘conscientious objector’ metaphor in reference to all Dutch physicians (from 1968 to the present) who have determined never to perform euthanasia. Other considerations leading to such a resolve have included concerns about public image, economic consequences, or convenience. Some Dutch physicians claim to be categorically opposed to euthanasia in an effort to keep their practice decisions private. However, I do think the majority of Dutch physicians who have determined never to perform euthanasia are analogous to ‘conscientious objectors’.

1.3 Commentary: Each of the Dutch physicians involved in this study -- regardless of his/her disposition about euthanasia -- acknowledges that s/he crosses the threshold from ‘managing life/recovery’ to ‘managing the death/dying process’ with some patients. It is the exception for a Dutch physician not to acknowledge crossing this threshold. Management deliberations and decisions for patients on either side of this threshold are clearly distinguishable. Within the ‘managing the death/dying process’ paradigm, all deliberations and decisions are measured against the goal of avoiding an undignified or humiliating death. ‘Conscientious objector’ physicians in Holland are no exception regarding crossing this threshold in patient care. However, they would limit such patients to terminally ill patients who have somatic illnesses and who are experiencing great pain/suffering from their illnesses. These physicians are prepared to direct management decisions regarding all end-of-life options other than euthanasia toward relieving the patient and toward achieving a ‘good death’. These decisions may knowingly hasten the patient’s death. These physicians are hesitant to say that such decisions are made primarily to hasten the patient’s death. They are very sensitive to the burdens being borne by these patients’ family/friends and are often active in providing hospice care. Political activity for these ‘conscientious objector’ physicians may take three forms. First, they may be active in the Dutch Association of Physicians, a ‘pro-life’ professional organization that formed in 1973 when @1500 KNMG members withdrew after the 30,000 member KNMG took favorable positions regarding abortion and euthanasia. (KNMG is the professional organization in Holland that corresponds to the AMA in the United States.) Second, they may be active in the ‘Pro-Life Platform’. This organization provides leadership for several smaller opposition groups for political activism, public education writings, medical education proposals (e.g., palliative care education for physicians), and professional societies. Third, they may be active in one of three small political parties that represent Christian constituencies in support of a ‘pro-life’ agenda. These parties have held 3-5 seats in the 150-seat Dutch Parliament since the early-1970s. Among the Dutch physicians in this study, two are politically active at the local and national levels. One has initiated an advance directives alternative to the Dutch Voluntary Euthanasia Society’s declaration card. Many physicians who are ‘conscientious objectors’ regarding euthanasia would account for their disposition by reference to their religious (esp., Calvinistic) convictions.

1.4 Distribution: Among the Dutch physicians in this study, 17% (4/24) have identified themselves with the ‘conscientious objector’ disposition. One is a general practitioner and three are long-term care hospital physicians. Prior to the late-1960s, the vast majority of Dutch physicians would have described themselves as categorically opposed to euthanasia. The national discussion of euthanasia was fueled by J.H. van den Berg’s 1969 Medical Power and Medical Ethics. The first signs of consensus in support of euthanasia in Holland were evident by 1973 -- e.g., a series of court cases and favorable position statements from the KNMG. By 1973, perhaps 30% of Dutch physicians would have expressed categorical opposition to euthanasia. By 1984, perhaps 15%. Several national surveys since the late-1980s have found 5-10% of Dutch physicians to be categorically opposed to euthanasia. Most of the Dutch physicians with whom I am acquainted expect this 5-10% to remain constant in the years ahead.

Ethical Dimensions of Patient Care #7

Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 1)

[The first draft of this manuscript was presented in February 1999 to the nursing hospital physicians on staff at Saint Elisabeth Gasthuishof in Leiden, The Netherlands. Variations/revisions of the initial draft have subsequently been presented in numerous academic/professional settings.]

INTRODUCTION

The research upon which this presentation is based began in 1991 as an extension of an ethics project conducted I coordinated with The University of Michigan Department of Obstetrics and Gynecology. We studied end-of-life decision-making from the perspective and experience of 108 gynecologic cancer patients who were receiving care from the department’s gynecologic oncology division. The subject of assisted dying became a central issue in Michigan shortly after the data gathering for this study had been completed. Needing to expand the project to incorporate the subject of assisted dying, I began in Spring 1992 to make what continue to be annual 2-3 week research trips to Holland. The University of Leiden Department for General Practice served as host for the initial visit, has made accessible its faculty as well as its residents, and remains helpful in the coordination of the visits. With each trip, I spend time with a steadily expanding network of Dutch professionals -- including 24 physicians. This research network eventually expanded to include: (1) five general practitioners of varying persuasions regarding euthanasia; (2) a former chair and now emeritus professor with The University of Leiden Department for General Practice who contributed significantly to the formation of a consensus by the early 1980s regarding euthanasia for competent patients experiencing unbearable suffering; (3) a senior neonatologist with the Amsterdam Medical Center who chairs the Dutch Pediatrics Association ethics committee for addressing neonatal decision-making in light of euthanasia guidelines; (4) a senior professor of medical ethics at The University of Leiden who is a past-president of the Voluntary Euthanasia Society; (5) three junior members of the research team at Erasmus University doing follow-up studies to the Remmelink Commission’s 1991 national study of end-of-life decision-making in Holland; (6) a psychiatrist whose assisted-dying case was the first case considered by Holland’s Supreme Court in which the patient’s suffering was not related to a somatic condition.

In this presentation, ‘euthanasia’ refers to action taken by a physician solely or primarily for the purpose of hastening death in response to the persistent request of a competent patient whose suffering is deemed unbearable in spite of all medical interventions. This definition is the definition operative in Holland. In Holland such actions do not include decisions to withhold/withdraw life-sustaining interventions (e.g., ventilator support, surgery, artificial nutrition/hydration, . . .) or decisions regarding the use of medications for the purpose of managing pain symptoms. These limitations on the use of ‘euthanasia’ are consistent with the legal and professional definition used in Holland. In this presentation, ‘euthanasia’ includes ‘assisted suicide’.

I am proposing in this presentation a construct by which to distinguish the range of dispositions toward euthanasia among Dutch physicians. This construct represents an attempt to interpret the views of the network of Dutch physicians whose professional experience it has been my privilege to study longitudinally over the past several years. Four dispositions toward euthanasia among Dutch physicians are differentiated.

“Do I care . . . really?” – Ethics After Being Disillusioned #6

For discussion:

1. Have you experienced this exasperation – “Look where caring got me”? What is the link between caring deeply and becoming jaded/cynical?
   
2. Indications that someone or something is highly valued include (1) the value being clearly explained, (2) the value is consistently assigned, (3) the value seriously influences decisions and actions, (4) the value is encouraged (e.g., incentives), (5) the value is honored. By such criteria, who/what does your residency program value? By such criteria, who/what do you value?
   
3. What relationships do you have and what experiences do you have that refresh and encourage your goal of being a humane physician with a strong social conscience?
   
4. Have you felt disillusioned about medicine and be(com)ing a physician?
   
5. How fluent are you in the language of respect, compassion, and fairness? How often, in your medical practice, do you think/speak in this language? when compared with clinical language? when compared with legal language? when compared with economic language?
   
6. Why stop short of being ‘wedded to medicine’?
   
7. How can difficult patients be sifted out of one’s panel of patients?
   
8. Why would a physician’s spouse and child(ren) think s/he cares more for his/her patients than for them?
   
9. What conclusions about your professional character would result from assessing how you handle your most difficult patients?
   
10. What can be done to make the medical education, training, and practice environments more supportive of physicians resolved to care deeply, to be truly present with patients, to concentrate on the disadvantaged, to be reflective?

“Do I care . . . really?” – Ethics After Being Disillusioned #5

Do physicians attempt to keep alive a humanizing practice of medicine that is neither highly valued nor seriously nourished by the medical education and academic or private practice environments? My experience as an imbedded ethicist inside the medical education and academic or private practice environments has left me with these impressions. A small but nonetheless deeply disturbing number of physicians practice medicine in a fraudulent manner that exploits and assaults patients (i.e., the physician profile in column one). A comparably small number of single-minded physicians are so wedded to medicine that they concentrate all their energy on caring deeply for every patient and challenging prophetically the systemic flaws that oppress patients (i.e., the physician profile in column four). Their single devotion to medicine, sadly, often exacts a damaging price from their personal health, from their support staff, from their spouses, from their children. Most physicians settle somewhere on the spectrum of what is sanctioned as ‘good performance’ in the medical education and academic or private practice environments (i.e., the physician profile in column two). They embrace incentives to practice medicine in a way that actually – if subtlety – discourages being genuinely present, humane, and fair with patients. Many physicians in this number choose so early to plant themselves safely within the medical education and academic or private practice environments’ more fertile regions that they have no qualms hedging respect and compassion for patients. Many other physicians in this number are despondent about the long-since faded intentions they professed so clearly in their personal statements for medical school and residency. Far fewer physicians end each day exhausted but still holding themselves accountable to care deeply for their patients, still finding their character most clearly revealed in how they treated their most difficult patients, still looking to exercise a strong social conscience in their practice of medicine (i.e., the physician profile in column three). They are resilient. But they are at risk – perhaps endangered -- because their professional ethic puts them in the barren soil of the medical education and academic or private practice environments.

Which of these four physician profiles best represents how you want to be remembered at the end of your career? When those who know you best -- your spouse, your child, your closest colleague, your longtime nurse, your special friend – ask themselves about your practice of medicine, where on this spectrum do their reflections on you as a physician settle?

A few weeks after Dr. Elkins’ untimely death, his wife Carolyn and I sat silently in his office here at Johns Hopkins. The office had not been disturbed since Tom’s death. After several minutes, Carolyn spoke quietly, “It feels like Tom will come rushing through the door any moment. How do we go on? What was it all about?”

I thought back to when Tom and I met in 1980. He had been reassigned to the naval hospital just north of Memphis to complete his commitment to the Navy. I was a novice graduate professor, teaching history and ethics courses. Tom wanted to take a few humanities courses as he transitioned into his career as a teaching physician. He had looked in the yellow pages for a university that offered night courses. I had just begun the first class meeting of my ‘Classics of Spirituality Literature’ course when I saw in my peripheral vision to the left a white blur. It was Tom in his Navy uniform. I soon discovered one of my most searching students, one of my most trusted friends.

Eighteen years later – after countless collaborations – I turned around and Tom was gone. No more rounds. No more clinics. No more surgeries. No more conferences. No more Africa trips. No more pats on the back. No more playful bantering.

Tom left behind a legacy of accomplishments that would be exceptional for a full three-score-and-ten life span. What indeed was it all about? Why did he work day after day to the point of exhaustion? Why did he spend so many hours in the anatomy lab doing research to improve procedures for pelvic surgeries? Why did he patiently educate the uninformed and confront the barriers in order to start model clinics for delivering gynecologic health care to women with mental disabilities? Why did he return again and again to Nigeria and Ghana, knowing yet another bout with malaria could not be avoided?

Sitting quietly in his Hopkins office, I reminded Carolyn that idealistic young men and women begin medical school confident they will be humane physicians. They must immediately adjust to being herded through a grinding eight years. Their every step is evaluated as they master basic medical information, become efficient in examining patients, and learn to do procedures. They absorb standards for identifying ‘good performance’ that have little to do with valuing patients as individuals. They finish residency still feeling the effects of chronic fatigue, but anxious to focus on their patients. Instead, they struggle for several years to find their own practice styles among new colleagues and under the oppressive fiscal scrutiny of their practice administrators. They receive few, if any, incentives to give of themselves . . . to care deeply . . . to be truly present with their patients . . . to concentrate on the disadvantaged . . . to be reflective. By their early 30s, they have acquired a trade. They have job security. But the dreams with which they began have all but faded away. They are practicing a kind of medicine they had not intended.

“Carolyn,” I said, “It was about reaching out to those young men and women. Some viewed Tom as an anachronism, a Don Quixote. I will remember Tom as a visionary within the medical education and academic practice environments, defending the idea(l) of being a humane physician who is truly present with patients and who exercises a resolute social conscience in the practice of medicine. He cared . . . really.”

If your eyes have been opened – as had Tom’s -- to what masquerades as professional integrity. If you have experienced – as had Tom -- compassion fatigue, caring fatigue. If you have found yourself – as did Tom -- wondering, “Do I care . . . really?” Then for you, ethics has essentially to do with two tasks – (1) finding firm moral ground on which to stand as a physician and (2) accepting the responsibility to invest in the nurturing relationships/experiences that enable you day after day to return refreshed and encouraged to your profession, not just to your work.

“Do I care . . . really?” – Ethics After Being Disillusioned #4

Steve is a young physician in a very busy practice owned and managed by a for-profit organization. He is now four years past residency. Steve and I became friends when he was a third-year medical student. Three years ago, Steve and I began meeting at 6:00 AM on alternating Wednesdays to discuss his struggle to maintain his resolve to be humane toward patients and to exercise a strong social conscience in his practice of medicine.


Steve begins most days poised to be empathetic (i.e., the physician profile in column three). He is prepared to give disproportionate attention to his more vulnerable patients. He is ready to open himself to his patients’ suffering to the point of risking burnout. He intends to be meaningfully present with his patients. He grips firmly his integrity. He gauges his capacity to tolerate the moral dissonance he experiences from value clashes with some of his patients. He seeks to grow professionally for patient benefit as much as for personal security. He feels a nagging tension between his lifestyle interests – simple for a physician -- and his accountability to/for his patients.

Steve would violate his integrity if he refused to look beyond each patient’s presenting problem. He has seen far too much. However, he accepts that he is not yet one of those rare physicians who seem capable of saying “yes” to every deeply pained patient and enter yet another broken story (i.e., the physician profile in Column four). Fatigue, accountability to his other patients, administrative obligations, family responsibilities, reimbursement pressures, personal interests apart from medicine, and a host of other considerations force him to say “no” as often as “yes” and thereby to limit many patients’ access to his time, his energy, his heart. Instead, Steve triages his patients carefully to sift out the encounters in which he will enter more deeply into the patient’s story, in which he will make and impose on others the sacrifices to be fully ‘I and thou’ with the patient.

Even on his most exhausting days, Steve remains angered that malevolent physicians (i.e., the physician profile in column one) continue to escape detection – e.g., the resident who alters a chart to disguise an error, the primary care physician who ‘sees’ as many as seventy patients a day, the obstetrician who fraudulently convinces healthy women they need high-risk management and procedures to protect against premature labor/delivery, the researcher who fabricates data, . . . . Such physicians are criminals who assault patients. Medicine for them is a scam. They exploit patient suffering and desecrate the social fabric. For them, self-interest is everything. They are harmfully present with patients. They reduce patients solely to means for self-serving ends. Professional advancements provide cover for their hidden purposes. They have no conscience. They experience no moral dissonance. They have no professional integrity.

Especially on his most exhausting days, Steve might glance enviously toward the many flourishing physicians for whom the medical environment is most fertile (i.e., the physician profile in column two). For these physicians, a patient encounter is a sale; the patient, a consumer. These physicians are entrepreneurs who capitalize on the medical environment. Lifestyle incentives motivate them. They subtly sift out difficult patients from their panel of patients. They stay sufficiently detached from patient suffering to avoid any risk of being burned out. They have learned to make patients think they are present and care. They turn professional advancements into marketing tools. They lead unreflective lives. They have an easy conscience. But Steve is not seriously tempted to join their number.

However, Steve is troubled by how often he ends the day thinking of the next patient as one more demand; thinking of himself as a mechanic (i.e., this diagram’s bracketed tension). He ends many days numb toward patients and tired of confronting the medical delivery system. He feels acutely the loss of important family experiences as he does his job. He often sees little evidence that he is making a difference in the lives of vulnerable patients. He finds himself apathetic to patient suffering as the day’s paperwork drains him. He feels ambivalent toward patients for whom he has a dimming vision. He senses that his struggle to stay current with advancements in his specialty is posing subtle risks to patients. He is haunted by the look in his child’s eyes, a look that asks, “Dad, do you care more for your patients than you do for me?” He can sound defensive. He can look disheartened.

“Do I care . . . really?” – Ethics After Being Disillusioned #3

‘Encounter’ is one of those everyday words in medicine. To encounter (Latin, in + contra) is to come upon another face to face, often unexpectedly. To encounter is to meet another suddenly, often violently. Each day is a series of encounters – turning hallway corners, crossing lanes, reaching for an object, getting in line, looking up from a table, chasing a prize, competing for a position, . . . . Encounters make concrete and visible the set of values, the sense of purpose, out of which we each decide what ought to be done.

Medical school is no exception. Residency is no exception. Academic medicine is no exception. Private practice is no exception.

The most efficient schema I have found in the history of ideas for framing what is at stake in every encounter is the ‘I-It’ and ‘I-Thou’ schema put forward by the highly regarded philosopher, Martin Buber (1878-1965). Born in Vienna and raised by his grandparents, Buber studied philosophy and the history of art at the Universities of Vienna, Berlin, Leipzig, and Zurich. Buber’s classic I and Thou was published in 1923, the year he accepted the chair of Jewish History of Religion and Ethics at Frankfurt University. Buber lost that post soon after Hitler came to power in 1933. By 1938 he had been completely silenced by the Nazis and had reluctantly immigrated to Jerusalem where he accepted the position of Professor of Social Philosophy at Hebrew University. He worked tirelessly to life’s end for a peaceful solution to Jewish-Palestinian relations. Reduced to a pregnant couplet, Buber’s core proposition was:

“I-thou” can only be uttered with the whole of our being;
“I-it” can never be uttered with the whole of our being.

How might Buber’s proposition be transposed for reflection on being a physician? I think it would be:

“I-thou” is only defining for physicians who are centered by a grand humanizing idea;
“I-it” is never defining for physicians who are centered by a grand humanizing idea.

To treat someone as a ‘thou’ is to be artistic, subjective, freeing, reciprocal, gentle, engaged, holistic, attentive, patient, modest, trusting, graceful, reconciling, humanizing. In short, to be treated as a ‘thou’ is to be respected. To treat someone as an ‘it’ is to be scientific, objective, detached. Or to treat someone as an ‘it’ is to be rough, indifferent, curt, suspicious, selfish, alienating, dehumanizing.

Therein lies the complexity of patient encounters, the complexity of the artful practice of modern medicine. The values and decisions represented by ‘it’ behavior and ‘thou’ behavior can overlap. To be treated by a physician as an ‘it’ is not necessarily damaging. To illustrate: excellent medical care is scientific, evidence-based. The physician objectifies the patient with statistical associations or by concentrating on damaged/diseased body parts. Differential diagnoses reflect plausible cause and effect explanations. The physician necessarily focuses on the patient’s immediate problem more than on the patient’s larger story. The physician must be sufficiently detached to achieve aequanimitas or balance. (A similar analysis can be made with the patient as ‘I’ and the physician as either ‘it’ or ‘thou’.)

However, at some point, ‘I-it’ encounters and ‘I-thou’ encounters become mutually exclusive. At that threshold, only by keeping the ‘aim eye’ fixed on patients as individuals worthy of respect, compassion, and fairness can a physician avoid the indifference that degrades patient encounters into self-serving alienation . . . the indifference that leaves patients bruised, manipulated, exploited, dehumanized.

Every story of being disillusioned I have heard over the past 20+ years has had variables specific to the medical student, the resident, the academic physician, the practicing physician. Common to each story has been the fact that the three required languages in medical education and medical practice – i.e., clinical, legal, and economic – all default to ‘I-it’ encounters that diminish patients as individuals.


As this diagram’s shading from lush green to barren yellowish-brown suggests, the environments for medical education and academic or private practice are most fertile for ‘I-it’ encounters. Listen to echoes from rounds, dictations, call room conversations, doctor’s lounge conversations, grand rounds, morbidity-mortality conferences, evaluation sessions, faculty meetings, medical staff meetings, discussions about ranking residency candidates, depositions, productivity reviews, . . . .

An ethic firmly rooted in an ‘I-thou’ approach to patient encounters entails a fourth language -- the language of respect, compassion, and fairness – a fourth language that is fundamentally distinguishable from clinical language, from legal language, from economic language. Fluency in the language of respect, compassion, and fairness is not required to successfully complete medical school, to pass post-graduate boards, to be rewarded by practice management, to secure hospital privileges, to pass recertification examinations, to be promoted, to be elected to national positions of leadership, to be on the hospital ethics committee, . . . . Fluency in the language of respect, compassion, and fairness is, however, essential for sustaining the experience of being a humane physician who cares deeply about patients – especially the most difficult patients -- and who brings a resolute social conscience to the practice of medicine.

“Do I care . . . really?” – Ethics After Being Disillusioned #2

To be disillusioned is to be moved closer to reality. To be disillusioned is also to suffer a devastating blow to motivation, purpose, courage, resiliency, inspiration. Young people in our society continue to be drawn to medicine by the vision of caring deeply for patients, the vision of making a difference in patients’ lives. At various points across the continuum of medical education, they realize the vision that drew them to medicine is, far more often than not, an illusion. For many, the humanistic language they used just a few years before in their personal statements for medical school feels hollow, embarrassingly naive, when recast in their personal statements for residency.

Anxious medical students cope with their disillusionment behind an unstated code of silence. Weary residents wrestle with decisions to place higher priority on much-needed sleep than on actions and experiences that would benefit patients. Insecure young physicians stumble through their first few years after residency without mentors to hold them accountable as they sort out their professional values and priorities.

A junior pre-med student, during a visit with the community health center where I work, disclosed -- “I have shadowed a number of physicians – private and academic – this past year and did not find one physician I would like to be around.”

A frustrated medical student, near the end of his first year, disclosed – “We had the ‘keep your balance, don’t lose your relationships’ orientation talk from the dean on Day One. And an ethicist reminded us the same day to ‘nurture your interior life’. Day Two blew by all that. After the first round of tests, reality set in. Getting decent grades means 80-100 hours of study every week. What’s left for relationships? or for my ‘interior life’? The grades for my first set of tests reassured me. I can do this. But at what price? I guess the dean and the ethicist will recycle their platitudes to the next class of new students. Where is the dean? Where are the ethicists? Obviously not near enough to us to speak with understanding and integrity. I feel betrayed.”

A confused third-year medical student – considered by the faculty to be one of the top students in her class – admitted soon after her first clinical rotation – “I am excited about finally being in the clinical setting. I want to help patients. I want to contribute to the team. I understand I need to make my upper level look good. And yes, I want to impress the residents and attendings. But now I feel very uncertain. Residents and attendings broke bluntly into my case presentations. It’s demeaning to be told -- ‘We don’t have time for a 3rd-year medical student history and physical’-- and then to be ignored. The one thing I thought I knew how to do was a ‘history and physical’. I am afraid of failing, of appearing weak.”

A shaken student near the end of his third year, in response to questions about the way he selects rotations and thinks about possible residency programs, realized – “It’s all about balancing residency program status with personal convenience. I am in the rural-track program of my medical school because I began with the intent to practice in an underserved area. But my fellow rural-track students and I hardly ever talk about that goal when we discuss rotations and the residency programs we are considering.”

A tearful fourth-year medical student, during her interview for a residency program, revealed – “I majored in English Literature. But when I sat down to write my personal statement for the residency application, I discovered I had lost the skills to think in narrative style or to write an essay.”

A second-year Ob/Gyn resident, during a lunch conversation, admitted -- “By the third year of medical school, I realized that being a physician is not what I had envisioned. Being with patients and making a difference in their lives 90% of the time would be great. Even 70%. But 40%? or less? I feel stuck. What else can I do? It is hard to quit after having invested so many years. I am not in medicine for the money. There are much faster and easier ways to that goal. My college friends are making shit buckets full of money while I am sacrificing my 20s and amassing an enormous debt. I am frightened by the ways I have changed. Fatigue has darkened my mood and shaken my plans. My family/friends do not understand how tired I am. Will these changes reverse after residency?”

A young physician, three years out from residency, explained -- “The audience in residency is your attending physician. You tend to adopt his/her approach. If you take your own approach, you risk getting into trouble. So you put personal responsibility on a back burner. Your career rides on the attending’s interpretation and your upper level’s interpretation of your performance. Residents – especially interns – implement the decisions of those above them. They must move quickly. They know their medical analyses will be quizzed. They have little time to think about anything else. Every year that such reflection is suppressed, the harder it is to recover. Many residents take the position – ‘When I get out, I won’t do it that way’. The danger in taking a ‘later’ attitude is that you tend to become what you do. Many days slip quickly into a downward spiral. You fall behind due to patient volume and the inability to anticipate or control the complexity presented by patients. ‘Getting the work done’ takes over. Addressing the ‘chief complaint’ without falling further behind severely restricts attention to deeper issues in the patient’s story. This cycle eats away at the joy of what you are doing.”

A physician in his late 30s, a couple of years past his decision to leave the practice of medicine, remembered --
“I made undergraduate course selections for requirements other than pre-med courses based on whether a course or instructor would make it easier to get into medical school. The humanities were downplayed/downgraded at my undergraduate school. Pre-med students were perceived and thought of themselves as the toughest among all the students in science programs. The sneering about the humanities was severe. I did not realize then that to let the mental habits characteristic of the humanities atrophy is to let a crucial part of the self die. Yet students, residents, academic physicians, and practicing physicians who place value on these traits run the serious risk of being perceived as not being fully committed to medicine. Medical school and then residency are meat grinders that spit you out on the other side. You are pushed through. There is little or no opportunity to pause and assess. There is hardly any occasion to ask, ‘Why am I doing this? Is this what I want to do? Is this what I ought to do?’ It is ironic that during the years when you need to be most reflective, you do not have the tools, the time, or the energy.”

A 43-year-old physician, with fourteen years experience as lead physician for a non-profit community health center in a poverty-burdened Appalachia un(der)service area, concluded --
“Medical school and residency are not educating experiences. You are not taught how to think. You do not engage ideas. You memorize information and learn to make differential diagnoses. There is little historical perspective. Medicine is not integrated into larger and related spheres of thought. Becoming a physician is analogous to a trade school experience. Little attention is given to what it means to be a ‘professional’.”

A physician in her late-40s, after reviewing the manuscript for this presentation, reflected – “I remember quite clearly my first day in medical school. The dean did not mince his words. ‘Medicine must be your husband, your wife, your children, your family, your life. If you can’t make this commitment, get out now.’ I fought to keep hold of the grand ideas that brought me into medicine. I fought against the dean’s angle on medicine. And twenty-five years later, I am disillusioned about my profession, burned out, cynical. The medical school, residency, and practice settings have worn me down.”

Such grim dispositions are too widespread to be ignored in discussions of ‘ethics’, ‘the art of medicine’, ‘professional competency’, ‘integrity’.

“Do I care . . . really?” – Ethics After Being Disillusioned #1

Grand Rounds
Johns Hopkins University School of Medicine
Department of Obstetrics and Gynecology
19 February 2004

A few months ago, our youngest daughter – thirteen years old – asked, “Dad, how should I answer when my friends ask me, ‘Morgan, what does your dad do?’” I could have recounted for her a dinner conversation in New Orleans with a thoracic surgeon friend from Northwestern. I described for him my various roles inside the medical education and practice environments. I detailed my role at that time as coordinator for a large inner-city Ob/Gyn residency program with responsibilities to keep the rotation schedule untangled, construct the didactic sessions, interview prospective residents, moderate the resident evaluation committee, attend morbidity/mortality conferences, visit the anatomy lab, pore over resident statistics, co-chair the research committee, wrestle with the national accrediting organization. At one point, my friend interjected, “Doug, you are like an anthropologist who is studying a previously unknown population. He (or she) pitches camp on the edge of the village. The villagers gradually come to trust the anthropologist who finally moves into the village.” Instead, I suggested to my daughter, “Just tell them your dad is an irrigation ditch.” By the end of the conversation, she seemed to understand the metaphor. For the past twenty-plus years, I have been privileged to work closely with medical students, residents, academic physicians, and practicing physicians who remain resolved to be humane toward their patients and to exercise a strong social conscience in the practice of medicine.

Four physicians have created ways for me to be imbedded in the medical education and practice settings since the early 1980s – (1) Tom Elkins, an internationally respected pelvic-floor surgeon who died of heart failure August 1998 at age 48 just as he was establishing himself here at Johns Hopkins as director of this department’s gynecologic specialties; (2) Sheldon Korones, founder in 1968 and still director of the University of Tennessee Memphis Neonatal Intensive Care Unit who has welcomed me to spend hundreds of hours with him in and out the unit gaining insight into the complexities associated with intensive care for critically-ill newborns; (3) Emmalee Bandstra, a neonatologist at the University of Miami who invited me to work with her and her staff for four years as she led two federally funded intervention projects in the 1990s that targeted cocaine-abusing women who were delivering -- prematurely – cocaine-exposed babies; (4) David McRay, a family physician who has spent the years since he completed residency in 1989 leading the efforts of a non-profit community health center in the Appalachia Mountains of East Tennessee to make primary medical care – including surgical obstetrics – accessible to uninsured patients (and where I have worked as a member of the executive leadership team for the past seven years).

Any insight in my comments today I owe to the resolve of these four physicians (and a circle of like-minded colleagues) to keep alive the vision of genuinely caring for patients to the point of the fatigue and the edge of cynicism implicit in the question – “Do I care . . . really?”

Seeing 'Jesus' from Below #3

I do not hear ‘Jesus’ saying he likes everything about his adversaries. He has in mind good deeds, rather than fond feelings. I do not see ‘Jesus’ overlooking evil with a smile or folding his hands in passive resignation. Moral farsightedness, not cowardice, under gird his alternative to violent retaliation. I do not think ‘Jesus’ contradicts his insistence that justice is the measuring rod of human behavior. Victims of oppression, senseless injury, or exploitation have no cause to doubt his alignment or advocacy. Whip in hand, he drives away from the temple in Jerusalem those who have turned the house of prayer into a den of robbers.

I do see ‘Jesus’ charting a radical approach to a very healthy center – Be so centered on championing mercy, peace, and justice for others that you do not feel an insulting slap . . . that you are not deterred by the theft of your own property . . . that you overlook being forced to go an extra mile . . . that you do not keep a ledger of what you give . . . that you can risk being impoverished. He leaves no room for a spirit of retaliation or for seeking revenge. He instead insists on a much stronger self-image. He expects the tactic of restraint to take the victory out of violence. He stands against injustice without blurring the distinction between exploitation and the exploiter. He appeals to conscience in the midst of power politics. He is convinced an evil deed does not fully express who an offender is. He refuses to walk down the path of destructive self-promotion -- religious or secular.

Could the ‘Jesus’ I saw/see be the friend ‘the scrapheap Job’ expects, the friend who can remain meaningfully near as Job confesses he has forsaken “fear of the Almighty”? This ‘Jesus’ – I think so. Is his integrity suspect as is Job’s integrity? This ‘Jesus’ – I think not. Does he live for others out of the sheer goodness of heart? This ‘Jesus’ – I think so. Does he remain consistent with his values and vision to life’s end when his is an ignoble end? This ‘Jesus’ – I think so.

Could the ‘Jesus’ I saw/see fit as easily into our time as into his own? This ‘Jesus’ – I think not. Would he recoil from the diversities – e.g., ethnicities, gender, ages, religious traditions, academic interests, professional experiences, preferences in the arts, favorite authors, refreshing hobbies, defining moments, . . . -- among us today? This ‘Jesus’ -- I think not. Would he take an unassuming place among those who conspire to keep alive the vision of living humanely and with a resolute social conscience? This ‘Jesus’ – I think so.

Seeing 'Jesus' from Below #2

The ‘Jesus’ I saw/see is a carpenter’s son from the Galilean village of Nazareth. He has few possessions. The cries of the oppressed echo in his mind. He can name neglected beggars who grasp for a few coins at the village gate. He touches the diseased and maimed. He surrenders much-needed money to exploiting tax collectors. He listens carefully as friends feverishly lash out with revolutionary invectives against Rome’s occupation army. He knows widows who have been manipulated out of their meager means by self-righteous religious leaders. He has neighbors whose hearts can no longer be stirred . . . and others who can be taken in by any charlatan offering hope of deliverance and restoration of the old days of national glory.

The ‘Jesus’ I saw/see travels at about age thirty to the Jordan River where his cousin is baptizing those who respond to a call for repentance. After baptism and much heart-searching time alone in the desert, he begins to attract attention as he makes his way back through Bethany and Cana to Capernaum. Once home again in Nazareth, he announces his intentions to a Sabbath audience by reading from the prophet Isaiah:

The spirit of the Lord is upon me, because he has anointed me to preach good news to the poor. He has sent me to proclaim freedom for the prisoners and recovery of sight for the blind, to release the oppressed, to proclaim the year of the Lord’s favor.

A riot breaks out in the synagogue in response to this bold claim. Neighbors he has known for years drive him out of the city. Narrowly escaping, he leaves for Capernaum.

Talk spreads rapidly from village to village. The crowds this ‘Jesus’ attracts swell with the curious and the serious from regions far and near -- in today’s terms, grisly miners . . . polished executives . . . political refugees . . . tinseled TV evangelists . . . homeless children . . . divinity school professors . . . maimed war veterans . . . streetwalkers . . . public defenders . . . AIDS victims . . . . Some seek personal relief. Some are drawn by his words. Some are ready for him to declare a holy war against Rome. Some begin plotting his death because he flaunts religious tradition, tells stories that honor the socially marginal, and questions the integrity of religious officials.

To keep his spiritual balance, the ‘Jesus’ I saw/see frequently seeks the isolation and quietness of high places. After one such all-night retreat, he comes down to a great multitude that has gathered to hear and receive. When he sits down on a level place, his special students identify themselves by moving close to him. Within hearing distance of many in the multitude, he begins to explain the implications of his way of living and thinking:

If you take the narrow and precarious path -- you will know poverty first hand . . . you will be mournfully touched by the human condition . . . you will be gentle . . . you will be driven by a passion for justice . . . you will be forgiving . . . you will be single-minded . . . you will be peacemakers . . . you will be like salt, or a city built on a hill, or a torch for light in your communities. Many will laugh at you, ridicule you, even abuse you just as previous generations did to those who stood up for mercy and justice. But you will be consumed by a vision of being together, the standards for which are not satisfied when the secrets of the heart contradict observable behavior.

Then – after transposing this extraordinary vision for living into case study applications about murderous thoughts, sexual infidelity, and dishonesty – the ‘Jesus’ I saw/see pushes to the breaking point:

Some teachers argue -- “Eye for an eye and tooth for a tooth”. My view – do not resist an evil person. If someone strikes you on the right cheek, offer the other also. If someone wants to sue you and take your tunic, give your cloak as well. If a Roman soldier forces you to carry his baggage for one mile, do so for two miles. Give to the one who asks you and do not turn away from the one who wants to borrow from you. Expect nothing in return. Some teachers argue -- “Love your neighbor and hate your enemy”. My view – love your enemies . . . pray for those who persecute you . . . and do good for them. . . . It is hardly enough to flock together like birds of a feather. The question that matters is -- who are you when you are with people who are not like you or who do not like you? . . . It is far more healing and, perhaps to your surprise, more blessed to be a giving sort of person rather than a taking sort of person.

The scene does not end there. The ‘Jesus’ I saw/see goes on to make unsettling comments about the need to break free from linking self-image to material possessions, from self-aggrandizing shows of piety, from hypocritically judging others. But I see the focus in such a scene shifting to his students. Perhaps a few slip back into the crowd. Why?

To stay near meant admitting and uprooting any complicity with those who rewarded aggression, manipulation, intimidation, coercion. No simple task. Subtle attitudes as well as every action had to be scrutinized.

Seeing 'Jesus' from Below #1

Who is ‘Jesus’ and what place – if any -- does ‘Jesus’ have in these reflections on my search for a very healthy center? (The single quotes are my way of indicating attention to the variety of images/interpretations that have evolved from the historical figure ‘Jesus’ since the beginnings of Christianity.) I have no better place to begin an explanation than a 1986 conversation with my special friend Sheldon Korones, MD. It was a few days before Passover. I was sitting with Shelly at his kitchen table engaged in yet another of our weekly meetings to reconstruct the experiences that led to his leaving private practice in 1968 to care for critically-ill inner-city newborns. Though Shelly is Jewish by birth and I Christian by birth, we have discovered during two decades of conversations that – as he once put it – “we drink the same wine from different goblets”.

That evening in 1986, Shelly recalled fondly his Lower East Side childhood experiences at Passover in the Yiddish home of his Russian grandparents. Before moving on to another subject, we detoured into a discussion of ‘Jesus’. One exchange from that conversation still echoes clearly for me. Shelly reflected, “Doug, it’s a shame what we did to one of our boys.” To which I responded, “And it’s a shame what Christianity has done with him, too.” I had ruinous anti-Semitism in mind and more.

My earliest ideas about ‘Jesus’ formed as I grew up deep inside a small West Kentucky town/culture in which it was taken for granted that the Bible -- literally read -- meshes into a unified and authoritative way of thinking about ‘God’, nature, and life. Those ideas began to melt away when, as a historian-in-training, I sought to know who this Jewish figure from the days of Augustus Caesar was, the ‘Jesus’ before the theological portrayals of him generated by the religion that evolved in his name. And as a storyteller straining to ‘see from below’, I had to decide if the image of ‘Jesus’ still possible after historical examination merits attention as someone capable of having a respectful and gentle presence with victims of innocent suffering, clearly distinct from the bruising presence so characteristic of the religion that claims to represent him.

By the 1986 conversation with Shelly, I had been carried far away from the religious language about ‘Jesus’ familiar to me from my youth, carried away by educational experiences – esp., learning to work with Latin, Greek, and Hebrew sources from antiquity; studying carefully the history of ideas that have shaped western societies; and becoming familiar with the underpinnings of today’s scientifically ordered milieu – and carried away by exposure to the unspeakably harsh realities of human suffering. My eyes had been opened to the complexities of interpreting ancient texts. I had realized that living in sheep-like naiveté makes one easy prey for life’s wolves. I was engaging the implications of admitting that speaking of ‘God’ as creator . . . as lord . . . as king . . . as father . . . as up there . . . as listening . . . as anticipating . . . as acting . . . as controlling . . . and the like collapses into idolatrous language when spoken as children speak of Santa Claus (i.e., without reservation/caution re the anthropo-, socio-, and cosmomorphic nature of such ‘God’ language). I was coming to grips with the fact that my way of seeing life experiences is irreversibly scientific. I had resolved to speak consistently whether among academic historians, theologians, and philosophers or in the medical education sphere or with parents of mentally and/or physically disabled children or before graduate students in seminars about human suffering, or . . . . And I was prepared to reject any ideas that would draw me back or away from the resolve to become the sort of person who strives to be truly present -- without regard for spiritual or theological cost -- with individuals who are experiencing the worst of life.

I had already looked for ‘Jesus’ through this multi-layered grid for many years prior to the 1986 conversation with Shelly. I have continued this critical inquiry to the present. Here is the ‘Jesus’ I saw then and still see. In spite of the many ways ‘Jesus’ was representative of his time (and, therefore, distant from today’s modern/scientific time), I benefit from pondering his decisions. I listen to his stories. I resonate with his vision for life. I commemorate his execution.

The Scrapheap Job - #4

Some exposures to pain and misery slip past us too quickly for the focus to be sharp. Other exposures linger too long to be avoided. Many -- who can do so -- look for ways not to pause, not to see, not to listen, not to decide. But the guard is down -- however briefly -- when the victim of tragic innocent suffering is a spouse, a child, a parent, a colleague, a friend. If our mind’s eye has time to adjust, we begin to notice all the other sufferers near the one we know.

It happened to me just that way. I had been in the shacks in which some of my high school teammates lived. I had a classmate whose mangled body had to be pulled from a wrecked car. I had seen my disabled cousin mocked. I had played and worked with orphans. I had visited nursing homes. I had officiated at the graveside of a stillborn baby, . . . . But none of these experiences swept me out from behind the protective wall that kept me from being shaken. My place was not yet with them, not until multiple sclerosis carried my wife out among them. Then I learned that to see/respect her was to see/respect all the other sufferers she symbolized – e.g., the two-year-old toddler brutally murdered by neighborhood boys, the dying cancer patient whose skin tears away from her shriveled frame as nurses turn her, the disfigured war veteran who will never leave his veterans’ hospital ward, the fatigued parents of a severely disabled child who never have a night out, the terribly abused kids at the K-Bar-B Youth Ranch too traumatized to be placed in foster homes, . . . .

Job’s way of thinking about ‘God’ and life – the conventional wisdom upon which his integrity had been based -- failed him . . . set him up . . . left him to protest being treated like a worthless outcast. Had he not seen enough to keep him from thinking his noble behavior would somehow insulate him and his family from devastating tragedy? Had he not learned from the campfire reports of caravan merchants that calamity indeed occurs to the honorable as often as to the scoundrel? With his own miseries added to the accumulated weight of those reports, the way of thinking about ‘God’ and life most familiar to Job finally crumbled and with it the motivation for using his strength – however diminished on the ‘scrap heap’ -- to befriend the unfortunate.

The approach to spirituality, ethics, theology described in this website’s entries is rooted in my ongoing search for another way to think about ‘God’ and life, a way to be with seriously wounded individuals without harming them or attacking them in self-defense, a way dependent on no motive more than – to use the accuser’s phrase – the sheer goodness of heart. I always have my heavily marked text of the ‘scrapheap’ Job’s story with me whenever I attend a ‘religious’ gathering.

The Scrapheap Job - #3

I might have walked away from this drama after my 1974 graduation except for a neurologist’s single sentence just a few months before – “Your wife has multiple sclerosis.”

Mayo Clinic. 1973. She was twenty-one; I, a year older. We had been married less than two years. We had associated the tingling, the numbness, the double vision, and the loss of balance to the stress of maintaining a perfect academic record while wearing herself out as an accomplished pianist and vocalist. Instead, she was on a slowly debilitating path that – in spite of a valiant fight -- ended fourteen years later with her paralyzed, withered, dead tissue around pressure points, disoriented, stripped of dignity. She died at home early one Monday morning in September 1987, her body having drowned in its own fluids.

Job’s wife haunted me from the start. She withdrew from her spouse in disgust. Would I? I read somewhere that most divorce spouses with multiple sclerosis. Would I? I had vowed to remain present “in sickness or in health”. Would I? Or would I plead ignorance and excuse myself? Or would I learn to appear present with her, but in my mind stay safely distant from her?

Just as constant water pressure against a small crack will cause a huge dam eventually to collapse, so it was with my attempt to be for my wife the missing character in the story of Job – i.e., the sort of person who can be present, without regard for spiritual or theological cost, with individuals who are experiencing the worst in life. All the motivations I brought to the task – e.g., “be like God” . . . “imitate Jesus” . . . “stick to the Golden Rule” . . . “mimic the Good Samaritan” . . . “keep that Boy Scout character” . . . “meet the expectations of family and friends” . . . – eventually gave way. But the resolve to be truly present with her and other innocent sufferers she symbolized did not give way. Why? I think it was because the day-to-day realities kept demanding a verdict from me – “Will I or will I not remain present with her past the point of existential, spiritual, and theological risk?”

I had little time to consider tragic human suffering from an abstract or theoretical perspective. As with Job’s closest friends, my wife’s illness made my own vulnerability to random illness/injury unmistakably clear. To withdraw to a safe distance from her – as the three friends did from the ‘scrap heap’ Job -- would have been to opt for a way of being that imposed rigid limits on every other human relationship. If I could not be unconditionally present with someone I had invited in marriage to trust me to be with her “for better or worse”, then I would not be so present with anyone else. My scores were not always high. But this was the test to which I held myself accountable.

Since her death, my attention has centered on the question raised about Job’s integrity. Job’s behavior had certainly been exemplary. He had gently held feeble hands. He had steadied the weak and fatigued. He had contended in the public square against purveyors of injustice. He had encouraged the dying. He had been eyes to the blind and feet to the lame. He had championed abused foreigners. He had collared street thieves. He had made sure poor families were not left to shiver in the cold; no stranger, left at night on the streets.

But did Job live this way unconditionally? for nothing? for no reason other than the inherent rightness of it? No. Would he be chivalrous to life’s end if his was an ignoble end? No. His gestures toward the weak and the exploited had been calculated. He had done good deeds for others. But he had not genuinely been with them. The drama offers no indications to the contrary. Instead, you hear Job pine –

“Where’s the strength to keep my hopes up? . . . What future do I have to keep me going. . . Isn’t it time to call it quits on my life? . . . My spirit is broken, my days used up, my grave dug and waiting? . . . . My life’s about over. All my plans are smashed, all my hopes are snuffed out. . . . Oh, how I long for the good old days, . . . those golden years when God’s friendship graced my home, . . . when everything was going my way. . . . When I sat with my friends in the public square, I was honored by everyone in town. When I spoke, everyone listened; they hung on my every word. . . . After I spoke, they’d be quiet, taking it all in. . . . I thought, ‘I’ll die peacefully in my own bed, grateful for a long and full life, a life deep-rooted and well-watered, a life limber and dew-fresh, my soul suffused with glory and my body robust until the day I die.’ . . . Now my life drains out. . . . What did I do to deserve this? . . . Haven’t I wept for those who live a hard life, been heartsick over the lot of the poor? But where did it get me? . . . If I’ve ever used my strength and influence to take advantage of the unfortunate, go ahead, break both my arms, cut off all my fingers! The fear of God has kept me from these things.”

The Scrapheap Job - #2

Job’s three closest friends – Eliphaz, Bildad, and Zophar -- come on stage with the intent to comfort him. Still at some distance, they draw back in horror, unable to recognize him. Sobered, they draw near and sit together with him in silence for several days. A trusting Job -- believing that “when desperate people give up on God Almighty, at least their friends should stick with them” -- ventures to utter in their presence what he has been thinking night and day –

“Obliterate the day I was born. . . . Why didn’t I die at birth, my first breath out of the womb my last? . . . What’s the point of life when it doesn’t make sense, when God blocks all the roads to meaning? . . . The worst of my fears has come true. What I’ve dreaded most has happened.”

The visibly unnerved three friends are hesitant in their initial reactions. But once released, Job’s brutally honest thoughts surge –

“The arrows of God Almighty are in me – poison arrows – and I’m poisoned all through! . . . I’m given a life that meanders and goes nowhere – months of aimlessness, nights of misery! . . . I can only conclude that God destroys the good right along with the bad. . . . I try to make the best of it, try to brave it out, but you’re too much for me, relentless, like a lion on the prowl. . . . Why treat me like I’m your enemy? Why kick me around like an old tin can? Why beat a dead horse? . . . Your anger tears at me, your teeth rip me to shreds, your eyes burn holes in me – God, my enemy! . . . ”

The friends tighten their interpretations of Job’s plight into defensive counter arguments. They remain loyal to the brighter side of conventional wisdom’s coin. Job, however, cannot escape the darker side. The friends, still convinced that ‘God’ consistently rewards the upright and punishes the wicked, deduce that Job has committed some grievous offense. Their counsel –

“Think. Has a truly innocent person ever ended up on the scrap heap? . . . Does God mess up? Does God Almighty ever get things backward? Do you think it’s because he cares about your purity that he’s disciplining you, putting you on the spot? Hardly. It’s because you’re a first-class moral failure. . . . If I were in your shoes, I’d go straight to God, I’d throw myself on the mercy of God. . . . Give in to God. Come to terms with him and everything will turn out just fine. . . . Even though you’re not much right now, you’ll end up better than ever”.

Job -- certain that he is innocent of any mistakes proportional to such severe discipline -- cannot avoid the terrifying thought that ‘God’ is free to take sadistic delight in torturing people for no reason. Job defends himself against his friends’ charges –

“One look at a hard scene and you shrink in fear. . . . Time after time you jump all over me. Do you have no conscience, abusing me like this? . . . You pretend to tell me what’s wrong with my life, but treat my words of anguish as so much hot air. Look me in the eyes. Do you think I’d lie to your face? Think carefully – my integrity is on the line! . . . If you’re thinking, ‘How can we get through to him? get him to see that his trouble is all his own fault?’ Forget it. Start worrying about yourselves. . . . I refuse to say one word that isn’t true. I refuse to confess to any charge that’s false. I’ll not deny my integrity even if it costs me my life.”

When the exchanges between the ‘scrap heap’ Job and his three close friends play out to a stalemate, a young student impatient with the three friends’ defense of conventional wisdom speaks briefly from the periphery about apparent tragedies refining character. Then, contrary to what Job expects when face to face, ‘God’ dramatically storms on stage to muscle Job to his knees. But before the friends sigh with relief after hearing an intimidated Job mutter to ‘God’ “I’m convinced. You can do anything and everything”, ‘God’ surprisingly validates Job – “I’m fed up. You (the friends) haven’t spoken of me what is right – not the way my friend Job has.” And what had Job spoken? ‘God’ is selfish . . . ‘God’ is distracted . . . ‘God’ is negligent . . . ‘God’ is confused . . . ‘God’ is erratic . . . ‘God’ is psychotic . . . ‘God’ is guilty . . . ‘God’ is lawless . . . ‘God’ is sadistic . . . ‘God’ is ruthless . . . – all true?

And so, the narrator leaves the audience at a critical fork in the road. Will it be the familiar “all’s well that ends well” epilogue? If so, the ‘God’ language of conventional wisdom is left intact. And the ways conventional wisdom had left Job to see ‘God’ from the ‘scrap heap’ are rejected as not just false but heretical. Or will it be the uncharted search for a way of thinking about ‘God’ and life that is radically (i.e., to the root) different from the conventional wisdom within which Job’s charges against ‘God’ cannot be escaped without attacking Job’s integrity?

The Scrapheap Job - #1

I remember clearly my first serious work with the story of Job. It was Spring 1974 . . . my final undergraduate semester . . . a 400-level course in oral interpretation . . . an entire course devoted to preparing and delivering a single oral presentation. Though in her last year before retirement, Professor Crider – ‘Miss Ruby’ to her colleagues and to the inner circle among her students – was still listening, still imagining. I could tell by the verve of her staccato approval -- “Yes. Yes. Something from the story of Job.” -- and by the delight in her eyes that this slight yet vibrant teacher sensed the challenge before me.

So I plunged into the old Jewish drama of Job’s story. I wrestled with questions about the story’s textual integrity. I identified core questions. I became intimately familiar with the characters. I traced the plots. I probed the metaphors. I marveled at the satire. I experimented with ways to convey angst. I faced the demand for verdicts. I found myself interpreted by the story with liberating clarity.

For more than three decades now, this ancient drama – which holds a perplexing place in the canon of Judaism’s sacred writings -- has never released its grip on me. The academic hurdle back in 1974 enlarged into a journey inward that continues unabated (including preparing twice-monthly tutorial presentations 2000-2007 for a Wisdom Literature and Hebrew language specialist). Simply put, the story of ‘the scrapheap Job’ became essential to the fabric of my thought about spirituality, ethics, theology.

Many are familiar with the short version of the story. Celestial messengers appear before ‘God’ to report in turn on the state of creation. (Italics indicate quotes from the text, using Peterson’s translation in The Message; single quotation marks for ‘God’ serve as a reminder to distinguish the word from the subject/reality.) ‘God’ singles out a coy accuser among the stream of heralds – “What have you been up to? . . . Have you noticed my friend Job?” ‘God’ points proudly to Job’s values, his behavior, his religion – “There’s no one quite like him!” The unconvinced accuser questions Job’s motives and the insight of ‘God’ by pointing instead to the thick hedge of aristocratic and affluent privileges enjoyed by Job and his family – “So do you think Job does all that out of the sheer goodness of his heart?” The accuser proposes a wager that this supposed champion of chivalry can be made to turn against ‘God’. A hush sweeps over the heavenly celebration. The stakes are high. ‘God’ accepts the wager. The accuser, with the permission of ‘God’, cuts down Job’s protective hedge with swift strokes – cattle and camels stolen . . . sheep trapped and consumed by a fire . . . hired hands killed . . . sons and daughters crushed to death under a collapsed house. Job grieves deeply and visibly. But not once did he blame God. ‘God’ expects the brazen accuser to fold in defeat – “. . . (Job) still has a firm grip on his integrity. You tried to trick me into destroying him, but it didn’t work”. Instead, the undeterred accuser argues that Job’s integrity remains in doubt as long as he has his health – “But what do you think would happen if you reached down and took away his health?” Again with the permission of ‘God’, the accuser breaks Job’s health by covering his body with painful sores and decaying tissue. Sleepless, smelling foul, ostracized, mocked, covered with maggots and scabs, . . . – Job withers away as month after month passes. His wife breaks – “Curse God and be done with it!” Still Job does not blaspheme in what he says. Finally, ‘God’ claims victory. Though never informed of the wager, Job soon appears far more blessed than before all the trouble God had brought him. His sores disappear. His vigor returns. His fortune is restored many times over. New sons and daughters are born. He regains his coveted position of honor in his family and community.

Perhaps there is a touch of history imbedded in this story’s seductive promise of rewarded endurance. Perhaps an actual Job lived in Uz. But what grips me are the spiraling cycles of raw monologues and bitter dialogues that break apart the short version of the story into a disturbing prologue and a fairy tale epilogue. The searing poetry of the monologues and dialogues transforms a simple story into a commanding drama. I have found that far fewer have seriously watched and listened to this longer version of the story. I know I had not prior to 1974.

About Me

In 2006 Barnes-Jewish Hospital in St. Louis created a new position -- 'hospital ethicist'. I began developing this position February 2007. The primary purpose for the position is to make possible an expansion of the hospital's ethics program from being reactive and fragmentary to being proactive and comprehensive as a resource within the hospital. The journey that has taken me to this experience has been quite circuitous. The common threads -- the search for ‘a very healthy center’ . . . the attempt to ‘see from below’ . . . the resolve to be ‘with the world face to face’.

I am 56 years old. My wife and I have three daughters.

I was raised in a small Western Kentucky town in a lower-middle class, community-service oriented, religiously conservative family of which I was the first to graduate from college. I focused seriously on becoming a professional baseball player until my numerous football-related injuries undermined my ability to train. Having been scouted by the Cardinals and the Reds allows me still to enjoy thinking about this childhood dream/fantasy!

My undergraduate studies began with a regional junior college and continued with a regional state university where I concentrated on history, communications, and sociology. After completing a seminary program in religious studies, my doctoral studies tracked the history of some of the more central ideas -- theological, philosophical, political, and scientific -- that have shaped modern western societies. I concentrated on the time periods around the 4th-century fall of Rome, the 12th-century rise of universities, the 18th-century shift toward a scientifically-oriented society, and the World War II era. I continue to find through this discipline of study advantageous resources for understanding the ways we assign meaning in our lives, especially when faced with acute or chronic conditions that threaten our sense of security and hope. I have had occasion to test many of these ideas in such settings as: (1) a spouse at my first wife’s side during her fourteen-year battle with multiple sclerosis (d. 1987); (2) a graduate professor with seminars for such subjects as human suffering, ethics, history of religious thought, classics in spirituality literature, philosophy of religion (1979-91); (3) a researcher into end-of-life decision-making (including physician-assisted dying issues), involving clinical research projects and annual research trips to Holland (1992-2004) to better understand the Dutch experience with euthanasia; (4) a social historian, writing life-narratives for/about 125 cocaine-abusing women living in poverty-burdened sections of Miami who had delivered cocaine-exposed babies.

My first opportunities to collaborate with medical faculty on projects pertaining to the integration of ethics with medical education and residency training came about in the early 1980s at the University of Tennessee Memphis School of Medicine with a young physician who had recently joined the Ob/Gyn Department after completing his commitment to the Navy, and with a pioneering pediatrician who founded in 1968 and continued to direct until 2004 the UT Memphis Neonatal Intensive Care Unit. Since then it has been my privilege to have formal affiliations with the University of Michigan, Michigan State University, the University of Miami, Louisiana State University, and East Tennessee State University. Since 1991 I have had an adjunct appointment with Michigan State’s Center for Ethics and Humanities in the Life Sciences.

Since 1992 I have had three ‘on the field’ or ‘inside’ experiences within the health care sphere (these very educational experiences have overlapped each other somewhat):

1. For four years, I worked closely with a neonatologist with the University of Miami who was the principal investigator for two projects involving in combination 300+ cocaine-abusing mothers who had delivered cocaine-exposed babies. These women and their children lived in two of the most poverty-stricken and violent sections of Miami. My responsibilities included guiding the evaluation process, (re)interpreting the vision and hypotheses, refreshing the overly-stressed social workers on the staff, and framing policy issues as well as writing the mothers’ life-narratives.
   
   
2. For five years, I worked within an Ob/Gyn Department with responsibilities for ethics education, residency coordination, and faculty development -- e.g., (1) coordinating the department’s three-site residency program, (2) implementing changes designed to bring the residency program into compliance with accreditation guidelines, (3) designing an ethics and jurisprudence curriculum, (4) facilitating research projects -- including but not limited to ethics projects -- within the department.
   
   
3. For the ten years previous to coming to Barnes-Jewish Hospital, I was a member of the executive leadership team for an East Tennessee non-profit community health center that exists to deliver comprehensive primary care (including all the obstetrics in the area) to the disadvantaged and un(der)served families in three rural poverty-burdened Appalachia Mountain counties.

Photography -

Photography has been for many years my most important spiritual exercise. I enjoy photography because the experience can quicken the ability to see, refresh sensitivities, raise awareness. The years my family and I lived in Vermont deepened my appreciation for the natural, the simple, the true. I like to think some of my images evoke this appreciation. The years we lived in New Orleans taught me the worth of lagniappe, the unanticipated ‘little extra’ that makes an already satisfying experience special. I like to think some of my images give this gratuity.

About Me

Here is a summary of seven opportunities I have been privileged to experience over the past 25+ years within the medical education/practice sphere. I continue to draw deeply from these ‘on the field’ ways to participate in the promotion of respectful, humane, and socially sensitive patient care as I seek a very healthy center by/through which to ‘see from below’.

1. Residency Education/Training

Tom Elkins, MD, (1949-98) recruited fourteen fulltime medical faculty members to join him in rebuilding the LSU Obstetrics and Gynecology Department’s residency program and establishing its social conscience. I was brought on board first as an adjunct faculty member (1992-94) and then as a fulltime faculty member (1994-97) with the following responsibilities as the department’s residency program coordinator and as an imbedded ethics educator.

Ethics education. I was brought on board with the specific assignment to create an ethics program that would clarify and enhance his vision for the department. With the assistance of numerous medical faculty members and residents in the department, we created and field-tested a survey instrument that was administered at the beginning, the mid-point, and the end of the four-year residency program. The data gathered using the survey instrument assisted in resident evaluations as well as provided discussion points for didactic sessions. We integrated a series of ethics seminars into each year’s teaching schedule. We concentrated on the professional maturation of the younger medical faculty members since they spent more time than others with the residents in patient encounters.

Resident rotations. My responsibilities included (but were not limited to) (1) reviewing/revising the four-year rotation templates to the three teaching sites to insure uniformity, (2) assigning residents (with the necessary written and oral communications) to the appropriate rotations, (3) arranging for transitions at each three-month rotation shift for 2nd and 3rd year residents (with orientation meetings for all incoming residents), (4) updating the weekly schedule (clinic assignments, conference times, operating assignments, labor/delivery coverage), (5) monitoring/revising intern rotations to meet the RRC primary care requirement, (6) updating the clinic staff re the residents assigned to New Orleans, (7) gathering/reviewing evaluations of off-service and elective rotations, (8) adjusting all schedules when rotation assignments were changed, (9) writing communications to chairpersons/program directors of departments with which our residents had off-service rotations.

Clinics. My responsibilities included (but were not limited to) (1) meeting at least every other week with the supervising medical faculty, the chief residents, and the clinic’s head nurse to trouble-shoot clinic needs, (2) maintaining (with regular revisions) the schedule of faculty assignments to clinic coverage, (3) preparing reports on faculty attendance assigned to the clinics in order to comply with the required 1:4 faculty-resident ratio, (4) answering staff and resident inquiries about faculty coverage assignments, (5) arranging for replacements when emergencies or oversights kept assigned faculty members from being in clinic, (6) creating/circulating continuity-of-care clinic dates for each resident projected over six month periods, (7) keeping updated lists of the residents’ panel of continuity-of-care clinic patients, (8) preparing communications for and conducting meetings with residents to insure their understanding of the continuity-of-care clinic format and process, (9) supervising the clinic worker who had as part of her work responding to the on-site needs of the continuity-of-care clinics.

New interns. My responsibilities included (but were not limited to) (1) contacting faculty members and residents about their availability to interview applicants, (2) forming interview teams for each interviewing session, (3) making sure preparations had been made for each interviewing session (e.g., rooms, food, handouts, folders for interviewers, hospital/clinic tours), (4) preparing schedules for each interviewing session, (5) writing letters to applicants, (6) conducting each interviewing session, (7) participating in the interviewing of applicants, (8) updating the handout circulated to applicants, (9) organizing the three-day orientation schedule for incoming interns (including at least two hours of my own meetings with the new interns), (10) preparing explanatory handouts for incoming interns, (11) arranging for mentors for incoming interns.

Statistics. My responsibilities included (but were not limited to) (1) (re)educating residents on the proper interpretation of statistical categories and on the importance of accurate/complete documentation, (2) revising the obstetrics and gynecology statistics forms used in all teaching sites, (3) making sure adequate supplies of these statistics forms were available in all teaching sites, (4) making sure primary care cards were being filled out, collected, and tabulated for all residents, (5) supervising the collection and computer-entry of all obstetrics and gynecology statistics forms, (6) updating tabulations quarterly on each resident’s obstetrics and gynecology procedure statistics, (7) circulating updated tabulations to each class of residents for their review and correction, (8) arranging for the updating of the computer software designed for data entry of obstetrics and gynecology statistics information, (9) making sure the obstetrics and gynecology statistics reports for the monthly department conferences were prepared, copied, and circulated, (10) preparing statistics reports on each resident for program director and Education Committee review.

Resident evaluation. My responsibilities included (but were not limited to) (1) scheduling and conducting the monthly meeting of the Resident Evaluation Committee, (2) preparing a detailed summary of each meeting for the program director (including extensive commentary on residents about whom the committee had significant concern), (3) reviewing this summary with the program director and devising remedial plans for the residents so identified by the committee, (4) participating in the remedial plans for some residents and insuring that all remedial plans were completed, (5) supervising the transfer of student evaluation scores into resident evaluation folders, (6) reviewing at least twice yearly each resident’s evaluation material and meeting with residents whose evaluations were of concern, (7) observing residents in clinic, on labor/delivery, in the operating room, (8) visiting residents in Baton Rouge and Lafayette, (9) collecting evaluations on residents assigned to Baton Rouge and Lafayette, (10) preparing various analyses of CREOG scores for assessment of strengths/weaknesses in fund-of-knowledge among the total residents, among residents by level, and for each individual resident.

Faculty evaluation. My responsibilities included (but were not limited to) (1) revising evaluation forms, (2) scheduling regular resident evaluations of each medical faculty member, (3) supervising the transfer of resident and student evaluation scores into faculty evaluation folders, (4) reviewing at least twice yearly with the chairperson and program director each faculty member’s evaluations, (5) forming and implementing recommendations for remediation as indicated by the evaluations, (6) implementing strategies for faculty enrichment (e.g., teaching methods, professionalism, ethics/humanities).

Didactics. My responsibilities included (but were not limited to) (1) meeting with members of the Education Committee in order to schedule the Monday afternoon teaching conferences for the academic year, (2) scheduling Grand Rounds for the academic year, (3) making sure preparation was complete (including assigned faculty to conduct the conferences) for the monthly obstetrics and gynecology statistics and morbidity/mortality conferences, (4) making sure preparation was complete for the monthly gynecologic pathology conference, (5) juggling the weekly schedule of presentations as/when unexpected conflicts kept speakers from fulfilling their assignments, (6) keeping attendance records for residents and faculty, (7) evaluating conference presentations, (8) monitoring the quality of instruction -- faculty to resident and resident to student -- in the work settings at all three teaching sites, (9) upgrading the library resources available to residents, (10) arranging for the selection of residents to attend various professional meetings, (11) scheduling special didactic series (e.g., fetal monitoring sessions for the interns and 2nd year residents).

Department research. My responsibilities included (but were not limited to) (1) arranging for meetings of the Research Committee, (2) participating in the Research Committee’s meetings and related activities, (3) keeping each resident on the established time line -- from internship to Resident Research Day presentation -- for the program’s research requirement (e.g., regular meetings with the Research Committee, 3rd year resident presentations in the Monday afternoon conference schedule, 4th year resident presentations at Grand Rounds).

2. Miami Intervention Project re Cocaine-abusing Mothers

I worked closely with Emmalee Bandstra, MD, a neonatologist with the University of Miami, during the first five-year funding cycle when she was the principal investigator for two projects involving in combination 300+ cocaine-abusing mothers who had delivered cocaine-exposed babies. Those women and their children lived in Overtown and Liberty City, two of the most poverty-stricken and violent sections of Miami. My responsibilities included (1993-97) guiding the evaluation process, (re)interpreting the vision and hypotheses, refreshing the overly stressed staff, framing ethical issues, and writing the mothers’ life-narratives. The target population –

Individual Factors. These women and their children were at serious risk to undervalue education, to see women treated as inferior to men, to absorb the language and assumptions of racial prejudice, to underutilize primary health care services, to lack proper nourishment, to thirst for genuine attention, to cease to dream. Childlike resiliency, concreteness, and a sense of humor insulated them somewhat from the full impact of their circumstances.

Family Factors. These women and their children were at serious risk to bear parenting responsibilities for younger siblings, to suffer physical and/or psychological abuse, to witness/experience domestic violence, to not know one or both parents, to lack family support for educational achievement, to never have celebrated a birthday, to feel betrayed, to regard adolescent pregnancy as normal. The incidence of adolescent pregnancy could, ironically, be reinforced by family members (whose behavior toward the pregnant girl often became dramatically more gentle and affirming) and by the expanded availability of societal resources. Many of these women desperately wanted to retain parental responsibility for their children. Few, if any, wanted their children to experience their way of life. Extended family members (esp., grandmothers) often shielded their children from at least the most severe disadvantages and conveyed to them that they were loved and wanted.

Education Factors. These women and their children were at serious risk to have attended school irregularly, to have been taught by demoralized teachers, to have attended improperly equipped schools, to have formed poor study habits, to have had discipline problems, to have lost their intellectual curiosity.

Peer Factors. These women and their children were at serious risk to form relationships based on ‘macho’, to link self-image to strength, to resort quickly to violence when in conflicts, to be taunted toward destructive misbehavior, to be suspicious of others, to find street-gangs attractive. Community-based athletic programs, religious organizations, substance-abuse support groups (e.g., TRUST Groups), and community-based social organizations (e.g., Big Brother/Sister, YMCA/YWCA, Boys/Girls Club) made constructive peer relationships at least a possibility.

Neighborhood Factors. These women and their children were at serious risk to lack a sense of pride in their community, to live in deteriorated housing, to change residence frequently, to regard violence as normal, to have a street name, to ‘work’ on a lower rung of the drug-world ladder, to have a family member and/or neighbor who had died a violent death or who had AIDS, to regard the police as the enemy. Their neighborhoods did vary in the degree of risk they posed. Even in the most hostile neighborhoods, local groups -- some formally established, others ‘street-organized’ -- could be found working to insure a measure of safety and encouragement for these women and their children.

Society/Media Factors. These women and their children were at serious risk to have no sense of membership in the larger society, to have never visited other parts of the city, to have learned by watching closely the adults around them how to ‘work the system’, to have a surreal worldview shaped by television, to be influenced by militant music, to place no value on newspapers or news magazines. Harsh predispositions against them, widespread in the larger society, made interactions across social lines predictably adversarial. Sustained efforts to introduce resources and options (e.g., businesses, vocational institutes, and community colleges) could be found attempting to create fresh start opportunities.

Shortly after the proposal was funded, two medical school collaborators abruptly abandoned Dr. Bandstra’s leadership team, pulling critical legs out from under the project. Then Hurricane Andrew slammed through Miami, leaving the city in utter chaos. Six months later, signs of recovery in the city were still scant. With the cocaine-abusing mothers scattered by the storm and difficult to locate, Dr. Bandstra’s turf battles with other researchers intensified. And her case management staff had completely turned over.

My first task was to help Dr. Bandstra and her staff regroup. We went back to basics. Could they answer the five questions of a mission statement – i.e., Who/what are we? What do we do? For whom? To what end? By what values? – with wording that had centripetal force? Only then could we determine what (if any) goals were still feasible.

We proposed to rebuild the intervention project around writing life narratives with/about the mothers. Each mother’s story was badly broken. But it was her story. And we were convinced there was more to each mother than her cocaine-addiction. Each narrative developed around the same set of questions. Who is this mother? What does she value? How does she make sense of her experiences? In what social context does she live? How does she view parenting? What aspirations does she have for herself? for her child/ren? How does she define key words (e.g., hope, joy, success, power, freedom, fear)? How does she view her involvement with drugs (e.g., a fact, a recreation, a coping mechanism, a threat to well-being)? Does she want to be drug-free? Does she want her child/ren to be drug-free? What barriers does she face? Why does she try or not try to benefit from available resources? Why do her attempts succeed or fail? How does she define success or failure?

3. Neonatal Intensive Care

Sheldon Korones, MD, a pioneer in the formation of the neonatal subspecialty, is founder and 1968-2005 director of the University of Tennessee Memphis neonatal ICU. He was my closest friend during the last two and most difficult years of my first wife’s fight against multiple sclerosis (d. 1987). Our collaborative relationship began during a 1985-86 sabbatical I spent with Dr. Korones and his NICU staff. The many hours in the unit allowed me to learn much from and about the nurses as well as from Dr. Korones and his physician colleagues. Dr. Korones and I have worked together on various ethical issues peculiar to neonatal medicine. However, our primary work together continues to be writing his professional biography. We have given particular attention to his experience beginning with his Yiddish grandfather’s immigration in 1901 from Czarist Russia to New York’s Lower East Side and ending with his 1967 decision to leave a lucrative private pediatric practice in Memphis in order to devote his career to the socially disadvantaged babies in inner-city Memphis dying two-to-three times the rate of socially advantaged babies in the Memphis suburbs (a decision he traces to his childhood impressions from his grandfather’s stories of Czarist oppression against the Jews). The research related to this project deepened my appreciation for Jewish history/culture and continues to anchor my search for an approach to ethics and spirituality that recognizes/supports every professional’s integrity.

4. Primary Care for Rural and Uninsured Families

David McRay, MD, leads three community health clinics located in counties along the eastern Kentucky-Tennessee state line. These clinics exist to extend health care -- without regard to ability to pay -- to families whose geographic and cultural isolation leaves them far removed from standard medical care. In both part-time (1994-97) and full-time (1997-2007) affiliations with Dr. McRay and the health center he leads, my responsibilities have centered on refining the organization’s vision and hypotheses, prompting the physicians’ professional motivations, framing the ethical issues they face, coordinating resident and student rotations, extending the health center’s involvement with public health issues, and writing narratives about the clinics’ patients.

I had first visited this East Tennessee/Kentucky Appalachia health center a few months before our move from Vermont to New Orleans. I had been invited to return every six weeks or so to spend long weekends with the medical staff members and their families as they attempted to embrace the experience of living among and practicing with disproportionate attention to poor/uninsured Appalachia families. They recognized the need for a simple yet potent statement of mission that would center/steer the health center’s direction, decisions, actions by answering five questions – (1) What are we? (2) What do we do? (3) For whom do we do what we do? (4) To what end do we do what we do? (5) By what values do we do what we do? After reviewing stacks of health center material and interviewing numerous representatives, I deduced a first draft. On each of my visits over the next eighteen months, I listened carefully as the participants in the process of crafting a statement with ‘pause effect’ pressed every word in the latest draft. Between visits I would circulate yet another revised draft. Here is the adopted mission statement --

Dayspring Family Health Center is a not-for-profit community health center founded on the conviction that everyone should have access to affordable quality healthcare. We are committed to providing our patients comprehensive medical care in a fair and gentle manner. A healthy community is one in which all of its members begin life with hope, experience life with joy, and end life with dignity. We are convinced that many health problems have community causes and community solutions. Therefore, our ultimate purpose is to promote the full health – physical, spiritual, mental, and economic – of the communities we serve.

5. Field Research re Dutch End-of-life Care (Including Euthanasia)

I made annual research trips to Holland 1992-2004 to track the professional experience of a cross-section of Dutch physicians with end-of-life care (including euthanasia). This research began in 1991 as an extension of an ethics project I had facilitated for the University of Michigan Department of Obstetrics and Gynecology (where I had been an adjunct researcher since 1985). My responsibility with the department was to facilitate research/writing projects with various medical faculty members in the department who were interested in addressing the clinical and surgical situations they were facing from an ethics/values perspective. I continued to work with the department through 1997. The anchoring project studied end-of-life decision-making from the perspective and experience of 108 gynecologic cancer patients who were receiving care from the department’s gynecologic oncology division. The subject of assisted suicide became a central issue in Michigan shortly after the data gathering for this study had been completed. Needing to expand the project to incorporate this subject, I began in 1992 to make what became annual research trips to Holland. The University of Leiden Department for General Practice served as host for the initial visit, made its faculty as well as residents accessible to me, and remained helpful for many years in the coordination of research efforts. A steadily expanding network of Dutch professionals -- including twenty-four physicians -- formed. This research network included (1) five general practitioners of varying persuasions regarding euthanasia; (2) a former chair of and now emeritus professor with the University of Leiden Department for General Practice who contributed significantly to the formation of a consensus by the early 1980s regarding euthanasia for competent patients experiencing unbearable suffering; (3) a senior neonatologist with the Amsterdam Medical Center who chaired the Dutch Pediatrics Association ethics committee for addressing neonatal decision-making in light of euthanasia guidelines; (4) a senior professor of medical ethics at the University of Leiden who was a past-president of the Voluntary Euthanasia Society and now serves in the Dutch Parliament; (5) three junior members of the research team at Erasmus University doing follow-up studies to the Remmelink Commission’s 1991 national study of end-of-life decision-making in Holland; (6) a psychiatrist whose assisted-dying case was the first such case considered by Holland’s Supreme Court.

6. Social Justice and Health Care Policy/Delivery in Israel and the Occupied Palestinian Territories (OPT)

David McRay, MD, (introduced above) and I began making annual trips to Israel and the OPT in 2004 for four purposes – (1) to establish professional ties with physicians and support staff members in both settings who are resolved to address health care disparities with a keen sense of social justice, (2) to examine the medical education and post-graduate training methods in both settings for reinforcing the social conscience of health care professionals, (3) to identify onsite ways for us to encourage/assist the educators, policymakers, and clinicians in the OPT, (4) to explore the possibility of creating educational rotations in both settings for medical students and residents in the United States who are interested in international medical relief efforts.

7. Barnes-Jewish Hospital Ethicist

In September 2006 Barnes-Jewish Hospital (the teaching hospital for Washington University School of Medicine) created a fulltime ethicist position. As an imbedded ethics educator in this position, I (1) round on services throughout the hospital, (2) attend (often on the agenda for 10-15 minute ethics education ‘pauses’) faculty or staff meetings, (3) provide resources/guidance for resident ethics education, (4) participate with the hospital’s Cultural Diversity and Inclusiveness initiative, (5) serve on the IRB, (6) participate in ethics training for the hospital’s nursing staff. In each setting, I draw attention to and strengthen the understanding of “the ethical dimensions of care” (found on the BJH Basics poster hanging throughout the hospital).

My aim is to maximize the fluency of the hospital’s ethics committee members with the language and literature of medical ethics (with particular attention to the promotion of a respectful, gentle, fair, and socially responsible delivery of healthcare services) and to facilitate with/through them a proactive and comprehensive ethics program (1) that raises awareness and a sense of accountability re ‘the ethical dimensions of care’ throughout the hospital, (2) that qualitatively alters decisions and actions throughout the hospital, (3) that provides an effective educational environment re medical ethics for caregivers (in training), and (4) that positions the hospital as a leading voice in regional and national deliberations re ethics and medicine.