Down the Trump Rabbit Hole - 2 July 2020

[Sent 2 July 2020 to my wife and our daughters re Independence Day 2020]

Hi. I trust you are all well. I saw this man in a recent news clip. He is protesting against COVID-19 public health restrictions.

I keep thinking about this ‘Selfish and Proud!’ man – the sporty t-shirt, the wraparound sunglasses, the backward cap, the graying hair, the tan, the fine watch, the wedding ring, the cutely drawn exclamation point. He is affluent (in the etymological sense of ‘to flow to/ward’). He is not deprived or lacking. What is he like as a parent? a brother? a spouse? a neighbor? a teacher? a co-worker? a passenger in an adjacent seat on a long flight? a driver approaching an intersection? a customer in a checkout line? a partner on a risky assignment? Would he present himself as ‘Selfish and Proud!’ on a school or job application? For whom/what does he vote?

‘Selfish and Proud!’ – this interpretation of independence is the reason I will not celebrate on Saturday the ‘Fourth’. I will instead pause to search deeply and honestly for evidence of this revolting/embarrassing image of America in my attitudes, decisions, and actions with the resolve to renew my efforts to be otherwise. Am I engrossed in myself? Do I care only for myself? Am I satisfied with caring primarily for myself? Do I notice/regard others only to exploit them for my gain? Am I drawn to ‘enlightened self-interest’ reasoning? Was Hobbes right about us all?

The Trump administration – with federal government complicity – every day tramples any restraint against normalizing and championing a ‘Selfish and Proud!’ America. Two days ago, the Health and Human Services Secretary Azar cheered the Trump administration for outbidding and outmaneuvering all other countries to grab/corner the entire world supply of the COVID-19 medication remdesivir “to ensure that any American patient who needs remdesivir can get it”. How many heard this announcement as yet another example of a ‘Selfish and Proud!’ America?

The 30-40% of voting-age US citizens who are unwavering Trump supporters celebrate a ‘Selfish and Proud!’ America. They are complicit in and accountable for Trump’s ruinous opposition to integrity, decency, modesty, respect, empathy, peacemaking, standing with those at risk, sacrifice, caution, prioritizing an international social contract, unfettered education, . . . – all defining traits for a way of being that in my judgment remains worth living for, sacrificing for, and if necessary dying for. May we use Independence Day 2020 to reset/refresh these core values.

Doug/Dad

DOWN THE TRUMP RABBIT HOLE – 11 June 2020

Good afternoon. I trust you all continue to be safe and well. We are being careful when out on our several walks each day. We have not yet returned to a restaurant. I had my second on-campus meeting yesterday – i.e., the ‘values clarification re abortion’ session an Ob/Gyn faculty member and I have facilitated for the past decade with each year’s incoming Ob/Gyn interns. Otherwise, my medical/surgical ethics work remains virtual. I thought you would be interested in the e-mail response I sent last week to one of our department’s trauma surgeons with whom I am collaborating on several surgical ethics projects. She is in her late-30s and very thoughtful (her undergraduate program centered on a ‘great books’ curriculum). She called to discuss a manuscript we are revising for publication. Near the end of the conversation, she shifted the focus to her having read earlier in the week Elie Wiesel’s Night for the first time. She was gripped by Wiesel’s jarring narration of his teenager experience surviving Auschwitz and Buchenwald concentration camps, but confused by the quite religious image of Wiesel she brought to reading Night based on her superficial awareness of him while she had been in medical school at Dartmouth and later in a public health master’s program at Harvard. We only had a very few minutes to discuss her questions. I sent her the e-mail message below the following morning. Doug/Dad

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Good morning. I appreciate very much your introducing into our phone conversation last night your response to reading Elie Wiesel’s Night this week. I apologize for slipping so quickly into my ‘professor’ archives! I have now refreshed/organized my recollections and want to share some highlights re Wiesel, Night, and my personal journey.

• I was raised (b. 1951) in a small West KY town where a narrow view of ‘the world’ was uncritically taken for granted. I never saw/read a newspaper with a national or international scope. My family – immediate and extended – was comfortable in fundamentalist/cultist Christianity. My public school education was politically cautious but rather solid re valuing education, creating for me an alternative to the fear/hostility toward critical thinking in my home and religious community. I was something of a sponge re school (especially math and history). But my primary aim/ambition focused on becoming a professional baseball player, which seemed a distinct possibility until a serious neck injury during a high school football game in my junior year. I graduated from high school with no clear direction, having only thought about the regional Murray State University because its Class B minor league level baseball program could have been a step toward a major league career. My parents sent me to a West TN junior college aligned with my family’s religious and social worldview. I explored the possibility of following the example of my three uncles who were West KY pastors. After these two years, I married my first wife (d. 1987) – also from a small West KY town -- whom I had known/admired since high school and who was something of a piano prodigy. We returned to West KY. I entered the regional university (studying history, sociology, literature/oral interpretation). She had her first MS symptoms. Resolving to be a ‘historian first’, my graduate studies (which fortuitously became something of a consortium involving St. Meinrad Monastery/Seminary, Southern Seminary, and Oxford University) centered on the history of ideas – political, scientific, philosophical, theological – that have been seminal/pivotal ideas in shaping western civilization. My wife’s courageous fight against unremitting MS was the existential crucible within which I tested these seminal/pivotal ideas. ‘Melting’ and ‘crumbling’ are the most descriptive analogies re the failure of the ideas I inherited and brought into this experience.
  
  
• It was in this context that I first engaged Night, as an assigned reading in a mid-1970s graduate seminar. I knew little about Wiesel at that time beyond this raw/unsentimental chronicle of horror. He was not yet recognized as a Holocaust survivor icon/legend in the US and Nobel Peace Prize recipient. After a decade of undergraduate and graduate studies, Night was among the few writings that remained on my ‘history of ideas’ list of credible modern sources (along with such sources as Camus’ The Plague, Frankl’s Man’s Search for Meaning, Simone Weil’s essays/articles, Dietrich Bonhoeffer’s Letters and Papers from Prison, . . .). I recall being disappointed to discover that Wiesel’s writings subsequent to Night did not build on Night or go in the direction I anticipated. I retained Night but not Wiesel. Some fifteen years ago, I discovered my most valued Holocaust survivor voice -- Primo Levi, his life and his novels. And I have spent considerable time with as many published or oral records of Holocaust survivor recollections as well as with biographies and memoirs of a wide/diverse range of individuals in Europe who came of age between WWI and WWII.
  
  
• Wiesel returned to my attention after my first trip with Dr. McRay to Israel/Palestine in 2004, when our global health education project was only an idea. I vividly remember being embarrassingly ignorant of the Middle East backstory and shocked by the ‘abused become abusers’ political/military actions of the State of Israel toward the Palestinians in/for which the US was complicit. As Dr. McRay and I developed/implemented our global health elective year after year, I found Wiesel either to be silent or to be an ‘Israel right or wrong but, right or wrong, Israel’ defender. In his later years, I was disappointed to see him align with Christian fundamentalist Zionist-supporting tele-evangelists such as John Hagee, support Israel prime minister Netanyahu, even have a private lunch with presidential candidate Trump. My bottom line assessment -- Wiesel was raised in, groped in the dark for, struggled against, reconciled with, and became co-dependent on his very Orthodox Jewish origins.
  
  
• Shortly after moving in 2007 to St. Louis, I learned of Hedy Epstein (1924-2016). Hedy’s home was Freiburg. She was rescued from the Nazis by ‘Kindertransport’. Almost all of her family perished in Auschwitz. She immigrated to the US in 1948. She lived in St. Louis for most of her adult years. I often went to hear Hedy speak. For several years, I stood each Tuesday Noon-1:00pm on Delmar Blvd at the west end of The Loop with Hedy and the ‘Women In Black’ chapter members in silent protest against Palestinian oppression. I had the privilege of speaking with her over coffee several times at the nearby Panera Bread cafe before or after the silent protests. I learned about her sustained activist efforts – local, national, international. I sought her guidance for what Dr. McRay and I were doing in the West Bank and in Gaza. Hedy was the Holocaust witness/activist I failed to find in Wiesel.

Do with these reflections whatever seems best for you. I am certainly available to discuss any of these matters with you at your request.

Doug

DOWN THE TRUMP RABBIT HOLE – 31 May 2020

Hi. I started to use ‘Good afternoon’, but today across the US we did not awake to a ‘good’ day. The protests in St. Louis linked to George Floyd’s murder are significant and sustained. Mom and I are looking for ways to be aligned with the unfolding protest – so raw, pained, exasperated, exhausted -- to this brutal and senseless death . . . and the day after day/year after year dehumanizing encounters that have led to this tipping point. The reckless vandalizing on the periphery must not distract us from concentrating on what in essence is deeply rooted systemic injustice. Is our society near enough to the November elections for this eruption to sweep Trump and his congressional enablers out of office? Biden’s VP selection will be pivotal.

From the May 5 leaks about the February 23 lynching of Ahmaud Arbery through last Monday’s dismaying murder of George Floyd – this month in search for footing I have frequently (re)turned to a three-hour continuing education workshop three years ago for 20-25 experienced/‘in the field’ social workers our university’s social work program asked me to facilitate. The assigned subject – ‘pursuing justice’. We began with a reality check posed by the Organization for Economic Cooperation and Development criteria for assessing the OECD member nations --

The workshop participants were quick to share stories illustrating the OECD message that pursuing justice in the US is precarious and discouraging. We used a set of probing questions re ‘pursuing’ and re ‘justice’ for the workshop’s three parts – thirty minutes alone with the questions, an hour disclosing/listening in small groups, and an hour for full group strategic planning. We paused to feel the full force of the term/image ‘pursue’ before we claimed to be among those who are pursuing justice. We then dared to ask ourselves – e.g., What does it mean to ‘pursue’ justice? What indicators clarify where we are on a spectrum with ‘fleeing justice’ at one end and with ‘pursuing justice’ at the other end? What alternatives lie between ‘fleeing’ and ‘pursuing’? How defensive are we about our own affluence/privilege? Can we keep our jobs even if our effort falls short of pursuing justice? What barriers do we face when we pursue justice? How do we work with colleagues who are not pursuing justice? What competes with justice for our attention? Do we think about quitting? How do we recover from fatigue and disappointment? How do we define success? What urgency about justice would our personal statement project if we were applying for a new position?

According to the feedback, most of us departed agreeing that to be of any use we must stay near, be attentive, and expect opportunities to find us. I wonder what we would say to each other if we huddled again tomorrow.

Doug/Dad

DOWN THE TRUMP RABBIT HOLE – 14 April 2020

Hi. I thought you would be interested in the communication (inserted below) I sent earlier today to the 170+ surgeons (most are faculty members in Departments of Surgery across the country, with a few either surgery residents or non-academic surgeons) who comprise the surgical ethics working group my friend/colleague Dr. Kodner (WashU emeritus colorectal surgery professor) and I have nurtured over the past decade. This communication is #31 in the ‘Surgical Ethics Education Resources’ series I began sending the working group in May 2018. Be safe! And much love! Doug/Dad

[Sent – 14 April 2020 to the 170+ surgeons et al of our Surgical Ethics (Education) Consortium]

Good morning. For ‘Surgical Ethics Education Resources #31’, I am sharing with you an attempt during the COVID-19 pandemic to raise awareness of and to press for insight into the disproportionate risk, suffering, and death faced by vulnerable ethnic populations among our patients. Here in St. Louis, patients residing in predominantly African American sections of the city are tracking toward the worst scenario public health models while the city overall is tracking toward the best scenario public health models as the peak for a COVID-19 surge reaches St. Louis. Not surprisingly, the overall impression absorbs (conceals?) the experience of vulnerable sub-sets of the city’s population. One of our BJC network of hospitals is located in the hardest hit section of the city. For the past decade, I have led the hospital’s ethics consult team and am now assisting the hospital’s recently constituted COVID-19 triage team. Last week I sent to these front-line medical staff and nursing staff leaders (as well as to the hospital’s full ethics committee) links to four recent newspaper articles in the St. Louis American. For more than a century, the St. Louis American has reported local, state, and national news through an African American lens. Issues are published weekly, available throughout the city, and free. I have inserted below the links to these four St. Louis American articles as examples of a way to alert, to remind, and to encourage caregivers to be mindful of those easily overlooked and poorly understood as they make/implement excruciating decisions about (re)distributing severely limited resources. I hope you have a few minutes to take a look. What patient groups in your communities are experiencing disproportionate risk, suffering, and death during the COVID-19 pandemic? I suspect your communities have resources such as the St. Louis American that draw attention to these patient groups (essentially call for ‘respect’, meaning to be seen). How can you use these resources to advocate for those patients too/so easily missed on the margins/periphery of who is included in ‘the public’, ‘the community’, in ‘we/us’? Doug

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http://www.stlamerican.com/news/local_news/black-st-louis-left-behind-in-covid-19-testing-supplies/article_c70a05f4-7451-11ea-8571-832f999891aa.html

http://www.stlamerican.com/news/columnists/guest_columnists/why-north-st-louis-city-needs-a-covid-19-testing-site-now/article_59851be4-7029-11ea-8a47-33453dfbc765.html

http://www.stlamerican.com/news/local_news/covid-19-and-structural-racism/article_65fb3012-79c4-11ea-8cf9-e336755de3ea.html

http://www.stlamerican.com/news/columnists/guest_columnists/now-is-the-time-to-prioritize-older-adults-before-it-s-too-late/article_23c02c8a-72b1-11ea-bb49-8b8e17551334.html

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DOWN THE TRUMP RABBIT HOLE – 29 January 2020

Earlier this week, the 75th anniversary of the 27 January 1945 liberation of Auschwitz was widely recognized. I was reminded of two timely articles re the classic Atlas of Topographical and Applied Human Anatomy that was created by a Viennese anatomy professor (Eduard Pernkopf) and his team during the Nazi years who drew the remarkably detailed illustrations from dissections of victims executed by the Nazis. One article is a personal essay by Susan Mackinnon, MD, published last week in the British Medical Journal. Dr. Mackinnon -- a senior plastic surgery faculty member in our department -- was the lead surgeon in the surgical case that anchors the second article. This second article – published in the journal Surgery last year -- is a comprehensive analysis of the sensitive, complicated, and controversial issues associated with using the Pernkopf atlas in training and in practice. Dr. Mackinnon is the lead author of this second article, with several of us in our department as co-authors. I appreciate the opportunity to have contributed to and to be associated with these two articles. I am inseparably/deeply disturbed by the ironic Nazi echoes/similarities in the dismissive attitudes, ghettoizing policies, and brutalizing tactics by which the government of Israel has for decades -- with the unwavering permission, shielding, and funding of the US government – victimized the Palestinians. I found yesterday’s Trump/Netanyahu announcement especially sickening. Doug/Dad

DOWN THE TRUMP RABBIT HOLE – 20 January 2020

As Martin Luther King, Jr. Day 2020 dawns, I continue to ponder a statement in a brief PBS commentary on today’s commemoration I heard Saturday – i.e., “Dr. King changed the heart and soul of America”. I am saddened/disturbed to disagree. ‘Confronted’, yes. ‘Challenged’, yes. ‘Called for a verdict’, yes. But ‘changed’, no . . . not enough . . . not yet. A decade ago with the energy/anticipation associated with Obama’s 2008 election still invigorating, my reaction to such a celebrating/promising assessment of the struggle King led for expansive civil/human rights would surely have been more affirming. However, the day-after-day-after-day revelations over the past five years re ‘the heart and soul of America’ – e.g., the capacity to fear, to seethe, to bruise/maim/kill recklessly, to disregard the vulnerable, to tolerate poverty, to trivialize truth/facts, to hoard privileges, to idolize capitalism, to demand exceptional treatment in the international community, to . . . – are cause for pause. This darkness in ‘the heart and soul of America’ remains deeply rooted, appears widespread, and now represents (defines?) ‘America’ nationally and internationally. At least for now. The 2020 election in November will reveal for how long. Is there in ‘the heart and soul of America’ the capacity to pivot decisively toward modesty, empathy, sacrifice, welcome, peace, mercy, fairness, integrity, respect, . . . ? toward the image of ‘America’ championed by King and those courageously standing/working in his shadow? I remain hopeful. But we must remain firmly grounded in our core values regardless of the answer/results. Doug/Dad

Surgical Ethics Education Resources #34

[Sent 22 June 2020 to the Surgical Ethics Education working group]

Greetings from St. Louis and WashU.  For ‘Surgical Ethics Education Resources #34’, I am sharing with you (inserted below and also attached) a way to frame surgical ethics with ‘trust’ as the linchpin (i.e., the peg or pin that holds a wheel on an axle, that keeps a wheel from slipping off an axle).  This explanation is the third of seven brief ‘Ethics 101’ promptings I prepared for our surgery clerkship students.   We circulate a prompting every couple of weeks during their 12-week surgery clerkship.  I welcome your feedback about this way to position ‘trust’ in framing the ethical dimension of surgical care.  Doug
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What do we invite patients and their families to trust about us?

Douglas Brown, PhD

Trust is counter-intuitive . . . involves risk . . . is necessary to work . . . requires courage . . . .

‘Fiduciary’ in ancient Roman law denoted the transfer of a right from one person to another person with the recipient’s obligation to return the right either at some future time or on the fulfillment of some condition.  The fiduciary held this right as a trustee with the responsibility to exercise the right on another person’s behalf.  In modern surgery, ‘fiduciary obligation’ refers to the trust patients place in their surgeons to act in their best interests.  The surgeon receives the patient’s trust because the surgeon possesses the special authoritative knowledge and technical skills to which the patient seeks access.  Such knowledge and skills prompt the patient to seek out the surgeon in the first place.  The vulnerability acknowledged by the trusting patient creates a fiduciary obligation for the surgeon who accepts responsibility for the patient’s care.

A relationship this special must be rigorously safeguarded.  Surgeons who prioritize their fiduciary obligation to patients seriously consider conflicts of interest.  Surgeons are among a large and diverse work force that brings to the hospital numerous potentially conflicting priorities.  Many surgeons are engaged in clinical research and in training/education healthcare learners, both being responsibilities that use patients as means to accomplish interests other than the patients’ best interests.  And surgeons have to navigate the availability of commercially-driven surgical innovations that far too often result in eventual injury to surgical patients and even skew professional organization’s technical bulletin guidelines.

Accordingly, the ethical dimensions of patient care can be effectively framed by asking -- “What are we inviting patients and families to trust about their caregivers?”

Each response to this centering question puts into clinically familiar language one of the four basic intentions that are foundational to surgical ethics -- i.e., to avoid adding to the patient’s pain/suffering (non-maleficence), to make a desired difference in the patient’s well-being (beneficence), to align management plans with the patient’s values and goals (self-determination), and to be fair in the use of limited resources (justice).  When surgeons are able to follow through on these four intentions in an integrated way, the ethical dimension of their patients’ care is sound, balanced, in harmony and the surgeons experience what brought them into a surgical career.  For cases in which the ethical dimension of care is shaken or broken, the centering question – “What do we invite patients and families to trust?” -- can be an effective starting point for determining which one or combination of the four intentions has failed to such a degree that respect has given way to loss of confidence, suspicion, adversarial defensiveness.

The trust upon which safe and beneficial care depends is a partnership/collaboration between surgical teams and patients (with their families and friends).  In order for surgeons to follow through on what they invite patients and families to trust, surgeons need their cooperation, their participation, their assistance.  Thus the companion question – “What do surgeons need/expect from patients and families in order to follow through on what they invite patients and families to trust?”  

As surgeons work to avoid harm, they need patients and families to provide complete and reliable information.  As surgeons seek to deliver desired beneficial outcomes, they need patients and families to make a determined effort to adhere to the management plan.  As surgeons establish goals of care that align with patients’ values and preferences, they need patients and families to realize there are limits to what can be achieved.  As surgeons strive to be fair in the utilization of limited resources, they need patients and families to consider the interests of other patients and families.  These clarifications highlight the accountability patients and families bear for following through on the four basic intentions that are foundational to surgical ethics.