N through Z
The Next Century (Halberstam)
Nietzsche: A Very Short Introduction (Tanner)
The Nightmare Years: 1930-1940 (Shirer)
No Rusty Swords: Letters, Lectures, and Notes (Bonhoeffer)
Notebooks (1935-51) (Camus)
The Notebooks of Leonardo da Vinci (MacCurdy, ed.)
Old Possum’s Book of Practical Cats (Eliot)
On the Edge: A History of Poor Black Children and Their American Dreams (Nightingale)
On Looking Into the Abyss (Himmelfarb)
Out of My Later Years (Einstein)
Out of My Life and Thought (Schweitzer)
The Parables of Joshua (Girzone)
Paris 1919: Six Months That Changed the World (MacMillan)
The Passion of the Western Mind (Tarnas)
A Past in Hiding: Memory and Survival in Nazi Germany (Roseman)
Peace Is Possible: The Politics of the Sermon on the Mount (Alt)
The People’s History of the United States: 1492 – Present (Zinn)
Pensees (Pascal)
Physics for the Rest of Us (Jones)
The Plague (Camus)
The Plague: Fiction and Resistance (Kellman)
Philosophical Scientists (Foster)
Plato and a Platypus Walk Into a Bar (Cathcart and Klein)
Plotting Hitler’s Death (Fest)
The Politics of Jesus (Yoder)
Power and Powerlessness (Gaventa)
The Practices of Piety and the Practice of Medicine (Verhey)
Prayers (Quoist)
The Prehistory of The Far Side: A 10th Anniversary Exhibit (Larson)
The Prince (Machiavelli)
The Problem of Evil: An Alternative History of Philosophy (Neiman)
The Problem of Pain (Lewis)
The Prophetic Imagination (Brueggemann)
The Protean Self (Lifton)
The Proud Tower: A Portrait of the World Before the War (1890-1914) (Tuchman)
Rabbi Jesus: An Intimate Biography (Chilton)
Rawls: A Theory of Justice and Its Critics (Kukathas and Pettit)
Reflections on an Affirmative Action Baby (Carter)
Reverence for Life (Schweitzer)
Sara Midda’s South of France: A Sketch Book (Midda)
Schindler’s List (Keneally)
Science and Human Values (Boronowski)
Science and the State in Greece and Rome (Africa)
The Secret Country of C. S. Lewis (Arnott)
Seduced by Hitler (LeBor and Boyes)
The Seekers (Boorstin)
Shakespeare: The Invention of the Human (Bloom)
Shared Values for Troubled Waters (edited by Kidder)
Sharing the Promised Land: A Tale of Israelis and Palestinians (Hiro)
Sheltering the Jews: Stories of Holocaust Rescuers (Paldiel)
A Short History of Myth (Armstrong)
A Short History of the Universe (Hawking)
Signposts in a Strange Land (Percy)
Simone Weil: An Anthology (ed., Miles)
Six Great Ideas (Adler)
The Solace of Fierce Landscapes (Lane)
Sophie’s World: A Novel About the History of Philosophy (Gaarder)
Southern Journey: A Return to the Civil Rights Movement (Dent)
The Spirit Catches You and You Fall Down (Fadiman)
The State Papers of Levi Eshkol (Christman)
Statistics (Koosis)
Statistics in Medicine (Colton)
Statistics Without Tears (Rowntree)
Stephen Hawking: A Life in Science (White and Gribbin)
Stephen Hawking: Quest for a for a Theory of Everything (Ferguson)
The Story of Physics (Motz and Weaver)
‘Subtle is the Lord . . .’: The Science and the Life of Albert Einstein (Pais)
The Sunflower: On the Possibilities and Limits of Forgiveness (Wiesenthal)
Survival in Auschwitz (Levi)
The Survivor: An Anatomy of Life in the Death Camps (des Pres)
The Swing Era: How It Was To Be Young Then (Daniels, ed.)
The Swing Era: Vintage Years of Humor (1937-38) (Daniels, ed.)
Tales of Good and Evil, Help and Harm (Hallie)
A Testament of Devotion (Kelly)
Testimony: The Memoirs of Dmitri Schostakovich (Volkov)
Textual Criticism of the Old Testament: From the Septuagint to Qumran (Klein)
A Theology of Life: Bonhoeffer’s Religionless Christianity (Wustenberg)
Theories of Everything (Barrow)
A Theory of Justice (Rawls)
There Are No Children Here (Kotlowitz)
This I Believe (edited by Morrow)
To Bear Witness: Holocaust Remembrance at Yad Vashem (Gutterman and Shalev, eds.)
The Trial and Death of Jesus (Cohn)
True Patriotism (Bonhoeffer)
Truth Beyond Relativism: Karl Mannheim’s Sociology of Knowledge (Baum)
Tuesdays with Morrie (Albom)
The Two Cultures: And A Second Look (Snow)
Ty Cobb: His Tumultuous Life (Bak)
The Unconscious God (Frankl)
The Universe in a Nutshell (Hawking)
The U.S. Health System: Origins and Functions (Raffel, Raffel, and Barsukiewicz)
V for Vendetta (Moore and Lloyd)
Vietnam: A History (Karnow)
The Ville: Cops and Kids in Urban America (Donaldson)
Voice of Israel (Eban)
Voices from the Future: Our Children Tell Us About Violence in America (edited by Goodwillie)
Walking Between the Times (Sampley)
The Way to Freedom: Letters, Lectures, and Notes (Bonhoeffer)
Ways to the Center (Carmody and Carmody)
The Western Canon: The Books and School of the Ages (Bloom)
Western Painting from Prehistory to Post-Impressionism (eds., Agosta and Smith)
What Is Theology? (Wiles)
What Is This Thing Called Science? (Chalmers)
When Compassion Was a Crime: Germany’s Silent Heroes (1933-45) (Leuner)
Why the Jews? The Reasons for Antisemitism (Prager and Telushkin)
Witches and Jesuits (Wills)
Woman’s Surgeon: J. Marion Sims (Harris)
The Words (Sartre)
The Words We Live By: An Annotated Guide to the Constitution (Monk)
A World Lit Only By Fire: The Medieval Mind and the Renaissance (Manchester)
World of Our Fathers (Howe)
The Youngest Science: Notes of a Medicine Watcher (Thomas)
Sunday, December 30, 2007
Reading for ‘seeing from below’ #4
Reading for ‘seeing from below’ #3
G through M
Galileo’s Daughter (Sobel)
Generations of the Holocaust (Bergmann and Jucovy, eds.)
Genes, Genesis, and God: Values and Their Origins (Rolston)
The Genesis of Ethics (Visotsky)
George Washington’s False Teeth: An Unconventional Guide to the 18th Century (Darnton)
The German Resistance Movement (Wyschograd)
The Germans (Craig)
Get Great Marks for your Essays (Germov)
Get a Grip on Evolution (Burnie)
Get a Grip on Physics (Gribbin)
God and Human Suffering (Hall)
God, Suffering, and Belief (Burkle)
God’s Equation: Einstein, Relativity, and the Expanding Universe (Aczel)
God’s Funeral: A Biography of Faith and Doubt (Wilson)
Good and Evil (Buber)
A Good Life: Newspapering and Other Adventures (Bradlee)
“The Good Old Days”: The Holocaust as Seen by its Perpetrators and Bystanders (Klee et al)
The Gospel According to RFK: Why It Matters Now (MacAfee, ed.)
The Great Composers: The Lives and Music of 50 Great Classical Composers (Nicholas)
Great Photography Workshop (Fortney)
The Great Unraveling: Losing Our Way in the New Century (Krugman)
The Greek Way (Hamilton)
A Grief Observed (Lewis)
The Guns of August (Tuchman)
Guns, Germs, and Steel (Diamond)
Has Modernism Failed? (Gablik)
The Healer’s Power (Brody)
The Healer’s Tale: Transforming Medicine and Culture (Kaufman)
The Hero Within (Pearson)
The Hidden Children: The Secret Survivors of the Holocaust (Marks)
The Hidden Scrolls (Silberman)
The Hidden Wound (Berry)
Historians’ Fallacies (Fischer)
A History of Classical Physics (Bernal)
A History of God (Armstrong)
Hitler’s Thirty Days to Power (Hunter)
Hitler’s Willing Executioners (Goldhagen)
An Honorable Defeat: A History of German Resistance to Hitler, 1933-1945 (Gill)
Hope for the Flowers (Paulus)
How I Believe (Teilhard de Chardin)
How Modern Should Theology Be? (Thielicke)
How to Live Life Well (Carmody and Carmody)
How to Read a Book (Bloom)
How to Read and Why (Bloom)
Human Evolution: A Very Short Introduction (Wood)
I Knew Dietrich Bonhoeffer (Zimmermann and Smith, eds.)
I Knew Hitler (Ludecke)
I and Thou (Buber)
I Will Bear Witness (1933-41) (Klemperer)
I Will Bear Witness (1942-45) (Klemperer)
The Illustrated Atlas of Jewish Civilization (Bacon and Gilbert, eds.)
Illustrated History of the Third Reich (Hook)
The Illustrated Theory of Everything: The Origin and Fate of the Universe (Hawking)
In the Beginning: A New Interpretation of Genesis (Armstrong)
In Pursuit of Dietrich Bonhoeffer (Kuhns)
In the Shadow of the Reich (Frank)
In the Time of the Americans: The Generation That Changed America’s Role in the World (Fromkin)
The Inextinguishable Symphony: A True Story of Music and Love in Nazi Germany (Goldsmith)
The Inklings (Lewis et al)
Inside Hitler’s Germany: Life Under the Third Reich (Hughes and Mann)
Inside the Third Reich (Speer)
Into Thin Air (Krakauer)
The Invisible Wall: Germans and Jews (Blumenthal)
Ishmael (Quinn)
Israel and the Palestinian Territories (Hellander, Humphreys, and Tilbury)
J.B. (MacLeish)
The Jefferson Bible (with introduction by Percival Everett)
Jesus (Great Lives Observed series, edited by Anderson)
Jesus’ Audience (Derrett)
Jesus the Jew (Vermes)
Jesus and the Forgotten City (Batey)
Jews in Germany: From Roman Times to the Weimar Republic (Gidal)
Judges (Wiesel)
Karl Barth in the Theology of Dietrich Bonhoeffer (Pangritz)
Kingdom Coming: The Rise of Christian Nationalism (Goldberg)
A New Kind of Christian (McLaren)
Language in Thought and Action (Hayakawa)
Late Night Thoughts On Listening to Mahler’s Ninth Symphony (Thomas)
Lee (Freeman)
Legacy of Love: My Education in the Path of Non-violence (Arun Gandhi)
The Legends of Genesis (Gunkel)
Leonardo Da Vinci: Art and Science (Pedretti)
Letters to Freya (1939-45) (Helmuth James von Moltke)
Letters to Leontine Zanta (Teilhard de Chardin)
Letters and Papers from Prison (Bonhoeffer)
Life Together (Bonhoeffer)
Lincoln at Cooper Union: The Speech That Made Abraham Lincoln President (Holzer)
Lincoln at Gettysburg (Willis)
The Lives of a Cell (Thomas)
Lives on the Edge: Single Mothers and Their Children in the Other America (Polakow)
The Living Thoughts of Spinoza (Zweig)
Local People: The Struggle for Civil Rights in Mississippi (Dittmar)
The Lord of the Rings (Tolkien)
Love at the Heart of Things: A Biography of Douglas V. Steere (Hinson)
Love Letters from Cell 92 (Bonhoeffer and van Wedemeyer)
The Making of a Mind: Letters from a Soldier-Priest (1914-19) (Teilhard de Chardin)
The March of Folly (Tuchman)
Martin Buber (Panco)
Martin Buber: An Intimate Portrait (Hodes)
Martin Heidegger: a Political Life (Ott)
Masks of the Universe (Harrison)
Medicine: A History of Healing (Porter, ed.)
Memories of Summer (Kahn)
Messengers of God (Wiesel)
The Message of Job (Atkinson)
The Message of Job (Peterson)
Meeting Jesus Again for the First Time (Borg)
Meetings (Buber)
Mid-century Journey: The Western World Through Its Years of Conflict (Shirer)
Modern Times (Johnson)
The Moral Life of Children (Coles)
Mother Teresa: The Private Writings of the ‘Saint of Calcutta (Kolodiejchuk, ed.)
Mountains Beyond Mountains (Kidder)
The Mythmaker: Paul and the Invention of Christianity (Maccoby)
Reading for ‘seeing from below’ #2
A through F
Abba Eban: An Autobiography (Eban)
The ABCs of Relativity (Russell)
Aequanimitas: With Other Addresses (Osler)
After the Darkness (Wiesel)
Albert Camus: A Biography (Lottman)
Albert Camus: The Invincible Summer (Maquet)
Albert Camus: A Study of His Work (Thody)
Albert Schweitzer: Christian Revolutionary (Seaver)
Albert Speer: His Battle With Truth (Sereny)
All Rivers Run to the Sea: Memoirs (Wiesel)
Amazing Grace: With Evers in Mississippi (Berry)
The Anatomy of Hope (Groopman)
Answer to Job (Jung)
Archeology and the New Testament (McRay)
Archibald MacLeish: An American Life (Donaldson)
Autobiography of a German Pastor (Ehrenberg)
The Autobiography of Martin Luther King, Jr. (King)
Becoming a Doctor (Konner)
Beethoven: The Universal Composer (Morris)
Bergman on Bergman: Interviews (Bjorkman, Manns, and Sima)
Berlin Diaries (1940-1945) (Vassiltchikov)
Bertrand Russell Speaks His Mind (Russell interviewed by Wyatt)
Beyond Good and Evil (Nietzsche)
Black in Selma (Chestnut)
Black and White Photography (Horenstein)
Blood and Iron: From Bismarck to Hitler (Friedrich)
Bonhoeffer (Bethge)
Bonhoeffer: An Illustrated Biography (Bethge)
Bonhoeffer in a World Come of Age (Vorkink, ed.)
The Bonhoeffers: Portrait of a Family (Leibholz-Bonhoeffer)
The Book of J (Bloom and Rosenberg)
The Book of Job (Scheindlin)
The Book of Psalms (Alter)
The Book Nobody Read (Gingerich)
The Boys of Summer (Kahn)
The Brain: A Very Short Introduction (O’Shea)
Breaking the Silence: The Eduard Shulte Story (Lacqueur and Breitmann)
A Brief History of Science (Gribbin, ed.)
The Canaris Conspiracy (Manvell and Fraenkel)
Canaris: Hitler’s Master Spy (Horne)
The Cartoon Guide to Statistics (Gonick and Smith)
The Changing Faces of Jesus (Vermes)
Chess for Beginners (Horowitz)
Chess: 5334 Problems, Combinations, and Games (Polgar)
Children of the Holocaust and World War II: Their Secret Diaries (Holliday)
The Churches and the Third Reich (vol. 1) (Scholder)
The Churches and the Third Reich (vol. 2) (Scholder)
A City Year (Goldsmith)
The Classical Era: From the 1740s to the end of the 18th Century (Zaslaw, ed.) (Man and Music series)
The Cocaine Kids (Williams)
The Coming of the Third Reich (Evans)
The Complete Civil War (Katcher)
The Complete Guide to Digital Photography (Freeman)
The Consolation of Philosophy (Boethius)
A Consuming Fire: Encounters with Eli Wiesel and the Holocaust (Roth)
Contemporary European Ethics (edited by Kockelmans)
The Cost of Discipleship (Bonhoeffer)
Costly Grace (Bethge)
Cotton Patch Parables of Liberation (Jordan and Doulos)
Counterpoint (Piston)
The Creators (Boorstin)
Creation and the Persistence of Evil (Levenson)
Crossings: A White Man’s Journey Into Black America (Harrington)
C. S. Lewis at the Breakfast Table and Other Reminiscences (Como)
The Curse of the Bambino (Shaughnessy)
Dag Hammerskjold: A Spiritual Portrait (Stolpe)
Daring, Trusting Spirit: Bonhoeffer’s Friend Eberhard Bethge (de Gruchy)
The Day the Universe Changed (Burke)
The Death of Common Sense (Howard)
The Death of Ivan Ilyich (Tolstoy)
The Death of Ivan Ilyich: A Reader’s Companion (Jahn)
Degenerate Moderns (Jones)
The Dialogues of Archibald MacLeish and Mark Van Doren (Bush)
Dietrich Bonhoeffer (Bethge, revised edition)
Dietrich Bonhoeffer: A Brief Life (Renate Bethge)
A Discarded Image (Lewis)
The Discoverers (Boorstin)
Disorder and Decline: Crime and the Spiral of Decay in American Neighborhoods (Skogan)
Discovering the Writer Within (Ballenger and Lane)
The Divine Milieu (Teilhard de Chardin)
Doctors: A Biography (Nuland)
Does the Center Hold? (Palmer)
Ecotone: Wayfaring on the Margins (Krall)
Einstein: The Life and Times (Clark)
Encounters (edited by Erikson)
The End of Order: Versailles 1919 (Mee)
The Enlightenment: An Evaluation of Its Assumptions, Attitudes, and Values (Hampson)
Ernie Pyle’s War: America’s Eyewitness To World War II (Tobin)
Essays in Science (Einstein)
The Essays of E. B. White (White)
The Essential Jesus (Crossan)
Ethics (Bonhoeffer)
Ethics After Babel (Stout)
The European Dictatorships 1918-1945 (Lee)
The European Mind 1680-1715 (Havard)
Everyday Science Explained (Suplee)
Evil and the God of Love (Hick)
Evil in Modern Thought (Neiman)
Eyes on the Prize (Williams)
The Ethics of Genetic Engineering (edited by Junker-Kenny and Cahill)
Faith and Meaning in the Southern Uplands (Jones)
The Fall of Berlin (Read and Fisher)
Fiasco: The American Military Adventure in Iraq (Ricks)
Fiction from Tegel Prison (Bonhoeffer)
Final Testimonies (Barth)
The First Dissident: The Book of Job in Today’s Politics (Safire)
The First Man (Camus)
The First Three Minutes: A Modern View of the Origin of the Universe (Weinberg)
The First World War (Gilbert)
The Five Biggest Ideas in Science (Wynn and Wiggins)
Five Days in London (May 1940) (Lukacs)
Five Equations That Changed the World (Guillen)
For the Time Being (Dillard)
Foresight and Understanding (Toulmin)
Friendship and Resistance (Bethge)
From Cradle to Grave: The Human Face of Poverty in America (Freedman)
From Death Camp to Existentialism (Frankl)
From Midwives to Medicine (McGreggor)
From Paracelsus to Newton: Magic and the Making of Modern Science (Webster)
Reading for ‘seeing from below’ #1
Introduction
The reflections about my search ‘for a very healthy center’ I am posting on this website derive from a way to address questions about ‘authority’ – i.e., when, why, how various sources (e.g., a person, an institution, a culture, an idea, a writing, an object, an experience) exercise authority in my life. I find it noteworthy that the word ‘author’ is imbedded in the word ‘authority’. The two words share a common root – i.e., L. augere (to increase, to enlarge). This reminder creates the vivid/challenging image of an authority figure/source ‘writing’/‘editing’ in my life story.
I think in terms of a spectrum with ‘authoritarian’ repression of an individual’s responsibility/liberty to write his/her life story at one end and ‘authorities’ that nurture/encourage such responsibility/liberty at the other end. I keep this range of experiences with ‘authorities’ in mind as I ponder the timeline from infancy to adulthood -- e.g., inheriting ‘authorities’ at birth, childhood criteria for assessing ‘authorities’, adolescent reaction to ‘authority’, the need thoughtfully to determine who/what is permitted (to remain) inside one’s story ‘with pen in hand’, . . . . As an educator, I am especially mindful of the transitions from elementary student to graduate student – e.g., the variations in testing/grading, the differences between a report and an essay, the maturation in footnoting, the evolution in the student-teacher relationship.
Exploring the association of ‘author/ing’ and ‘authority’ led me to begin keeping a log of the books/authors I have chosen to read since my decision two decades ago to leave my ‘home’ in academia and in the ‘religious’ sphere in order to be imbedded in the medical education/practice sphere as I search for a ‘very healthy center’. I find a person’s elective reading – i.e., reading not assigned or required – to be very revealing. The list below documents the books/authors I have chosen to read thus far during my search since the late-1980s for a way to experience/encourage spirituality and ethics that sees ‘from below’, is ‘non-religious’, and is authentically ‘with the world face to face’. The list – which I have kept alphabetically by title rather than chronologically -- includes some sources initially read prior to and then read again after the late-1980s. Otherwise, writers/ings studied thoroughly/carefully prior to the late-1980s during my graduate education and during my years as a history/theology professor – are not included. Some of the listed works have been read several times.
The reflections about my search ‘for a very healthy center’ I am posting on this website derive from a way to address questions about ‘authority’ – i.e., when, why, how various sources (e.g., a person, an institution, a culture, an idea, a writing, an object, an experience) exercise authority in my life. I find it noteworthy that the word ‘author’ is imbedded in the word ‘authority’. The two words share a common root – i.e., L. augere (to increase, to enlarge). This reminder creates the vivid/challenging image of an authority figure/source ‘writing’/‘editing’ in my life story.
I think in terms of a spectrum with ‘authoritarian’ repression of an individual’s responsibility/liberty to write his/her life story at one end and ‘authorities’ that nurture/encourage such responsibility/liberty at the other end. I keep this range of experiences with ‘authorities’ in mind as I ponder the timeline from infancy to adulthood -- e.g., inheriting ‘authorities’ at birth, childhood criteria for assessing ‘authorities’, adolescent reaction to ‘authority’, the need thoughtfully to determine who/what is permitted (to remain) inside one’s story ‘with pen in hand’, . . . . As an educator, I am especially mindful of the transitions from elementary student to graduate student – e.g., the variations in testing/grading, the differences between a report and an essay, the maturation in footnoting, the evolution in the student-teacher relationship.
Exploring the association of ‘author/ing’ and ‘authority’ led me to begin keeping a log of the books/authors I have chosen to read since my decision two decades ago to leave my ‘home’ in academia and in the ‘religious’ sphere in order to be imbedded in the medical education/practice sphere as I search for a ‘very healthy center’. I find a person’s elective reading – i.e., reading not assigned or required – to be very revealing. The list below documents the books/authors I have chosen to read thus far during my search since the late-1980s for a way to experience/encourage spirituality and ethics that sees ‘from below’, is ‘non-religious’, and is authentically ‘with the world face to face’. The list – which I have kept alphabetically by title rather than chronologically -- includes some sources initially read prior to and then read again after the late-1980s. Otherwise, writers/ings studied thoroughly/carefully prior to the late-1980s during my graduate education and during my years as a history/theology professor – are not included. Some of the listed works have been read several times.
The Scrapheap Job -- #9
[Since writing this essay in 1995, I have come to see/interpret Job as unprepared throughout the story to argue that ‘righteousness is to be pursued because it is right’. Instead, his complaints reveal he has not yet turned loose the expectation that his righteousness would be blessed. I do see him at a decision point whether or not to embark on the radical (i.e., into the roots) rethinking and reconstructing re spirituality, ethics, theology prerequisite to his being able to make the argument. The epilogue does not encourage imagining his doing so.]
A Parable: Before the introduction of double/thermal-paned windows, homeowners could use storm windows for protection from the chilling effects of winter. Late one fall, new homeowners decide to put storm windows on their home’s fourteen windows before winter arrives. They check at every hardware store in their small town, but can find only eleven storm windows in stock. They purchase the eleven. Once home, they have to decide which windows have to be covered and which will be left to leak the cold winter air. Their one child -- a four-year-old daughter -- suffers with asthma.
I grew up with protected windows -- literally and metaphorically speaking. None of my close friends or neighbors had too few resources to be insulated from life-threatening chill. I would have told the parable’s couple they could still find the remaining three storm windows. I did not yet know their crisis, their fear.
Education -- especially in the history of ideas -- raised new questions for me. Experience with tragedy -- especially chronic, humiliating disease -- reduced my answers. Life became a series of decisions about which windows to cover and which windows to leave exposed. In time, the ‘scrapheap Job’ and Ecclesiastes’ Koheleth became the canonical voices with whom I sit as I reconsider Jesus of Nazareth. I imagine all three meeting beyond the reach and control of organized religion. I imagine listening closely to their exchanges because I see all three as knowing the force of being face to face with the full range of life experiences.
One way to experience Job is to assess the story’s ‘storm window’ options. The narrative by itself – i.e., the abbreviated form in which the story circulated initially and which is most familiar in religious circles down to today -- seems to fit the ‘God is just and the righteous are blessed’ theological paradigm. However, that paradigm breaks down when pressed hard by day-to-day realities. ‘God’ seems too human -- e.g., proud, petty, discriminating, exasperated, indulgent. The fairy-tale ending – i.e., the climax to the abbreviated form of the story -- cannot completely erase memories of the devastation borne by the animals, the hired help, the children, their mother, and the ‘scrapheap Job’.
And so the characters in the simple narrative were at some point developed. As the dialogues unfold, it becomes apparent that Job and his special friends -- Eliphaz, Bildad, and Zophar -- do not see the hand of the Accuser in human affairs. Their working hypothesis is that ‘God’ -- who has immediate and intentional control of the natural order -- dispenses blessing to the righteous and curses the unrighteous. The ‘scrapheap Job’ claims to have had his doubts even before the tragedies that befell him and his family. Travelers’ testimony and his own observations had left him uncomfortable with traditional wisdom. As his devastation drags on for months, the ‘scrapheap Job’ maintains his integrity against charges that he had collapsed into unrighteousness, leaving him at times to picture ‘God’ as a ruthless enemy and at other times to picture ‘God’ as distracted for some reason from his situation.
Elihu attempts to explain human suffering as a prospective warning from ‘God’. Then the whirlwind section challenges the anthropocentric perspective otherwise assumed in the story – e.g., it is tough even for ‘God’ to maintain order in the cosmos . . . in some quarters chaos reigns . . . still order in the natural realm argues for order in the moral realm.
Most of my considerations -- except for human will, the earth’s evolutionary age, randomness, and scientific causality -- get attention in the story of Job. I find the ‘scrapheap Job’ believable and compelling. Even after Copernicus, anthropocentrism is hard to shake. Prolonged suffering intensifies this struggle against taking ourselves too seriously. Human suffering is, for me, an uncovered window during cold winter months. Every attempt to explain why so many suffer so much requires sacrifices that are too costly to make, that severely damage one’s integrity. This judgment does not make integrity easier to maintain. It does sharpen the focus on the sufferer in the midst of the suffering.
The Scrapheap Job -- #8
[Is God GOD? is a book title that was published in the midst of a broad theological discussion in the 1950s/1960s known as the ‘God’ is dead debate. Most seem to have easily dismissed this debate (e.g., the “God’s not dead, I talked to him last night” bumper sticker). But beneath this obviously sensational phrase remains a very serious and spiritually practical question about the relationship between ‘God’ language and the reality to which that language points. Also, since writing this essay, I have moved to the end of the spectrum in the third paragraph re no contact between God and ‘God’.]
Is ‘God’ God?
Does this sound like a trick question? That is, if you view it as a question at all . . . and many would not. For me, the validity of the question depends on who asks it. Some ask “Is ‘God’ God?” in search of a philosophical novelty or an academic publication or even something that can be marketed. Frankly, for them I have little interest and no time. Others ask “Is ‘God’ God?” out of deep wounds they have experienced or observed. They ask cautiously, yet earnestly. The ‘scrapheap Job’ is among them. I am too.
The force of the question stems from the subtle distinction signaled by the single quotation marks. ‘God’ points to the language we use to picture a reality that transcends the reach of our words -- i.e., God. In other words, God exceeds every meaning for ‘God’. Job’s story probes several variations on the meaning of ‘God’. Have you noticed variations expressed by Job first before and then after his shattering experiences? by Job’s wife? by Job’s friends? by the story’s narrator?
At one end of the spectrum, some are convinced that God and ‘God’ have no contact. At the opposite end of the spectrum, some are convinced that the reality and the language for the reality (usually their particular meaning of the words) exactly correspond. The former see idolatry in every appeal to ‘God’. The latter cannot see their idolatry.
I remember a few Sunday School teachers in my childhood who introduced the word ‘anthropomorphism’ to us. The meaning of the word ‘God’ always embodies something human, whether or not it discloses something about a transcending reality. Nicholai Berdyaev -- a 20th-century Russian theologian -- stretched this assessment of ‘God’ language to include ‘sociomorphism’ and ‘cosmomorphism’. The point -- God does not have eyes or hands (anthropomorphisms). God is not a mother, a father, a shepherd, a king, or a friend (sociomorphisms). God is not ‘up there’ or ‘out there’ (cosmomorphisms). These descriptions are metaphors or analogies.
Is ‘God’ God?
Does this sound like a trick question? That is, if you view it as a question at all . . . and many would not. For me, the validity of the question depends on who asks it. Some ask “Is ‘God’ God?” in search of a philosophical novelty or an academic publication or even something that can be marketed. Frankly, for them I have little interest and no time. Others ask “Is ‘God’ God?” out of deep wounds they have experienced or observed. They ask cautiously, yet earnestly. The ‘scrapheap Job’ is among them. I am too.
The force of the question stems from the subtle distinction signaled by the single quotation marks. ‘God’ points to the language we use to picture a reality that transcends the reach of our words -- i.e., God. In other words, God exceeds every meaning for ‘God’. Job’s story probes several variations on the meaning of ‘God’. Have you noticed variations expressed by Job first before and then after his shattering experiences? by Job’s wife? by Job’s friends? by the story’s narrator?
At one end of the spectrum, some are convinced that God and ‘God’ have no contact. At the opposite end of the spectrum, some are convinced that the reality and the language for the reality (usually their particular meaning of the words) exactly correspond. The former see idolatry in every appeal to ‘God’. The latter cannot see their idolatry.
I remember a few Sunday School teachers in my childhood who introduced the word ‘anthropomorphism’ to us. The meaning of the word ‘God’ always embodies something human, whether or not it discloses something about a transcending reality. Nicholai Berdyaev -- a 20th-century Russian theologian -- stretched this assessment of ‘God’ language to include ‘sociomorphism’ and ‘cosmomorphism’. The point -- God does not have eyes or hands (anthropomorphisms). God is not a mother, a father, a shepherd, a king, or a friend (sociomorphisms). God is not ‘up there’ or ‘out there’ (cosmomorphisms). These descriptions are metaphors or analogies.
You may be wondering, “Could a pair of single quotation marks possibly matter?” The ‘scrapheap Job’ and many who have been deeply wounded by life experiences cherish what makes those marks so significant. For them, the difference is the freedom to remain conscious of God even as previously trusted meanings of ‘God’ die and new possibilities are tested.
The Scrapheap Job -- #7
“My integrity is at stake.”
Isn’t it always? ‘At stake’, I mean. Perhaps integrity is most visible (and least noticed) in the mundane and usually forgotten details of living in which we react out of instincts rather than out of reflection. Then something happens that suddenly or eventually puts our integrity ‘at stake’. The force of such defining experiences -- like a hurricane’s winds and waves -- can sweep/tear away what is extraneous to who we are.
Defining experiences can be painful, surprising, frightening, devastating, exhilarating. Some slip past too quickly for our focus to be sharp. Others can hardly be avoided. Most of us look for ways not to pause, not to see, not to listen, not to decide. Instead, one paradigm after another lures us or holds us by the promise to explain or at least to help us forget. But our guard is down -- however briefly -- when the victim is a spouse, a child, a parent, a colleague, a friend. As our mind’s eye adjusts, we begin to notice ‘the others’.
It happened to me just that way. I had been in the shacks in which some of my high school teammates lived. I had classmates whose bodies had to be pulled from wrecked cars. I had seen the disabled mocked. I had played and worked with orphans. I had visited the aging in nursing homes. I had officiated at the graveside of a stillborn baby. . . . But none of these experiences swept me away from the protective barriers standing between them and me. My place was not yet among them.
What question centers Job’s story? I think it is ‘integrity’. The stage is set around questions about Job’s integrity. The narrator sketches Job’s values, his manner of being, his standing. Then the curtain is drawn to reveal a stunning scene of celestial celebration as messenger after messenger praises ‘God’ and his handiwork. Then out from the crowd meanders the Accuser. He too has glanced around the heavens and the earth. He has a wager, not an affirmation. At issue -- Job’s integrity. He grants Job’s behavior. He raises doubt about Job’s intentions, Job’s ‘core’. The Accuser predicts Job can be made to curse ‘God’.
Leaving undecided the question of whose ‘hand’ – ‘God’ or the Accuser -- to blame for devastating Job and so many around him, the narrator quickly and dramatically replaces the initial image of Job with a horrible image -- financial ruin, sons and daughters dead, painful sores. ‘God’ calls attention to Job’s integrity (2:5). Job’s wife understands -- ‘Are you still holding on to your integrity’ (2:9). Job tries in vain to get through to his closest friends -- ‘Relent, do not be unjust; reconsider, for my integrity is at stake’ (6:27); ‘ . . . till I die, I will not deny my integrity’ (27:5).
Integrity has to do with character, soundness, reliability; with what makes something or someone whole, complete. ‘Integer’ and ‘integrate’ share etymological roots with ‘integrity’. Could Job keep a grip on his integrity without having a way to see ‘God’ as an ally? The story says no. Severely stricken, Job searches intensely through alternative meanings for the term ‘God’. Would Job still possess his integrity if he yielded to the pressure around him to deny his moral consistency? The story again says no.
As Job’s struggle unfolds, others are drawn into the crucible. What of his wife’s integrity? His family’s integrity? His friends’ integrity? His religious and social communities’ integrity? What of the integrity of ‘God’? What of your integrity? And mine?
The Scrapheap Job -- #6
‘After this, . . .’ (3:1)
After what? And how long after? Is this fast-paced narrative moving to closure? That is the way the story of Job seems so often to have been told and retold --
‘After this, Job opened his mouth and cursed the day of his birth’ (3:1).
In a single sentence, the narrator tears apart a neatly packaged story on the verge of a happily-ever-after ending. In a single sentence, he shakes the reader’s confidence. Is the Accuser right after all? Is Job charging ‘God’ with wrongdoing? Has ‘God’ utterly ruined him? In a single sentence, Job becomes at the same time much more familiar and yet deeply disturbing.
Do not be surprised if you hesitate to cross this jarring transition. A remarkable number in religious circles have never read closely what follows ‘after this, . . .’ (3:1). Is the narrator merely pointing to a much longer and complicated route to the story’s eventual ending? Or is the narrator -- by disclosing the raw truth about Job’s struggle -- boldly challenging accepted ways of associating ‘God’ with human experience? We face a choice. Will we treat the abbreviated story -- from prologue to wager to tragedies to epilogue -- as complete, leaving the extended interlude (chs. 3:1-42:9) either to be forced into theological conformity or to be ignored? Or will we regard what comes ‘after this, . . .’ (3:1) as the story’s core, even if the views advanced in the abbreviated version of Job’s story collapse – for us as well as for the ‘scrapheap Job’ -- as a house of cards?
After what? And how long after? Is this fast-paced narrative moving to closure? That is the way the story of Job seems so often to have been told and retold --
Messengers appear before ‘God’ to report in turn on the marvels of the creation. ‘God’ notices and challenges the Accuser among them – ‘Have you looked closely at my servant Job?’ ‘God’ points confidently to Job’s values, his behavior, his religion. The Accuser questions Job’s motivation and the insight of ‘God’ when he points to the thick hedge of blessing around Job and his family -- ‘Does Job fear God for nothing?’ (1:9). Unknown to Job, a wager is set. The stakes are high. The Accuser, with the approval of ‘God’, cuts down Job’s hedge in swift strokes. Job grieves deeply and visibly, but ‘did not charge God with wrongdoing’ (1:22). ‘God’ mistakenly expects the Accuser to fold in defeat -- ‘ . . . (Job) still maintains his integrity, though you incited me against him to ruin him without any reason’ (2:3). Instead, the Accuser argues that Job’s integrity remains in doubt as long as he has his health – ‘Strike his flesh and bones’ and see the truth. The Accuser, again with the approval of ‘God’, covers Job with painful sores. Sleepless, in agony, smelling foul -- Job withers away. His wife breaks – ‘Curse God and die!’ (2:9). Still Job does not ‘sin’ in what he says. Three close friends rush to him, only to hesitate from a distance when they can barely recognize him. Grief overtakes them. They sit in the silence with him for seven days and nights.What could be ‘after this’? Job has weathered two tests of character. The Accuser’s suspicion -- that Job’s ultimate intent is prosperity -- is surely false. The link between uprightness and blessing -- i.e., a matter of gift rather than payment -- has been clarified. All that remains is for Job to be restored. Job’s story is comforting, even edifying, to many when the story they hear closes with ‘After this, . . . the Lord made him prosperous again and gave him twice as much as he had before’ (42:10). This way of telling Job’s story seems in line with the narratives about Noah and Daniel (Ezekiel 14). It seems to fit the reason James pointed his readers to ‘Job’s perseverance and . . . what the Lord finally brought about’ (5:11).
‘After this, Job opened his mouth and cursed the day of his birth’ (3:1).
In a single sentence, the narrator tears apart a neatly packaged story on the verge of a happily-ever-after ending. In a single sentence, he shakes the reader’s confidence. Is the Accuser right after all? Is Job charging ‘God’ with wrongdoing? Has ‘God’ utterly ruined him? In a single sentence, Job becomes at the same time much more familiar and yet deeply disturbing.
Do not be surprised if you hesitate to cross this jarring transition. A remarkable number in religious circles have never read closely what follows ‘after this, . . .’ (3:1). Is the narrator merely pointing to a much longer and complicated route to the story’s eventual ending? Or is the narrator -- by disclosing the raw truth about Job’s struggle -- boldly challenging accepted ways of associating ‘God’ with human experience? We face a choice. Will we treat the abbreviated story -- from prologue to wager to tragedies to epilogue -- as complete, leaving the extended interlude (chs. 3:1-42:9) either to be forced into theological conformity or to be ignored? Or will we regard what comes ‘after this, . . .’ (3:1) as the story’s core, even if the views advanced in the abbreviated version of Job’s story collapse – for us as well as for the ‘scrapheap Job’ -- as a house of cards?
The Scrapheap Job -- #5
[For the first few months after moving to New Orleans (January 1995), my family and I participated as guests with a Disciples of Christ congregation. That fall the pastor – with whom I met often for coffee and conversation – asked me to facilitate a discussion group re the story of Job. I entitled the discussions ‘Out of the Silence’. These next five ‘scrapheap Job’ postings – each prepared for the discussion series -- illustrate how my understanding of the ‘scrapheap Job’ had matured by 1995. This first posting opens with a sentence from a letter my doctoral supervisor and close friend – Glenn Hinson, PhD/DPhil -- sent me shortly after the discussion group began to meet.]
Job had three dear friends. They had prayed together, planned together, laughed together, worried together, taken public stands together. He was confident they would come -- to console, to encourage, to affirm, to show pity, to remember. And they did.
How many ‘dear friends’ do you have? How many count you ‘a dear friend’? No conditions. No small-print loopholes even if they or you are driven to curse the day of birth, to despair, to ‘forsake the fear of the Almighty’. They or you are ready to die -- physically, socially, spiritually -- together. The intensity and the vulnerability keep the number to a few. A single ‘dear friend’ makes you rich.
There are a few individuals in my life who would come to me or to whom I would go simply and solely because of intimate friendship. For instance, my doctoral mentor -- Glenn. And Shelly -- a Jewish neonatologist from New York City who has given his professional life to critically-ill inner-city newborns. And Tom -- a Schweitzer-like obstetrician-gynecologist from Texas. And Erin, Kimberly, Morgan – my three daughters. And Barbara -- my most intimate friend. And then there are others with whom shared experiences may in time take us to the rare treasure of being ‘dear friends’.
And yet I trust my ‘dear friends’. I believe they would risk themselves for me and I for them. Why?
“I am proud to claim you as one of my students and a dearThis sentence in a letter I received recently forced me to pause, to remember. Nearly twenty years ago, the person who sent the letter began to guide my doctoral study of the theological, philosophical, scientific, and political ideas that have shaped western civilization. Why did I seek to study with him? Yes, I had noticed the Oxford ‘DPhil’ beside his name. Yes, I had heard he knew well such notables as Thomas Merton and Douglas Steere. From my first conversation with this Quaker-leaning contemplative, I wanted to be his student. He walked humbly. He spoke with gratitude. He had reason not to take health for granted. He seemed genuine. I hoped he would find reason to be proud to claim me as one of his students. But ‘a dear friend’? I had not anticipated this gift, this responsibility.
friend.”
Job had three dear friends. They had prayed together, planned together, laughed together, worried together, taken public stands together. He was confident they would come -- to console, to encourage, to affirm, to show pity, to remember. And they did.
How many ‘dear friends’ do you have? How many count you ‘a dear friend’? No conditions. No small-print loopholes even if they or you are driven to curse the day of birth, to despair, to ‘forsake the fear of the Almighty’. They or you are ready to die -- physically, socially, spiritually -- together. The intensity and the vulnerability keep the number to a few. A single ‘dear friend’ makes you rich.
There are a few individuals in my life who would come to me or to whom I would go simply and solely because of intimate friendship. For instance, my doctoral mentor -- Glenn. And Shelly -- a Jewish neonatologist from New York City who has given his professional life to critically-ill inner-city newborns. And Tom -- a Schweitzer-like obstetrician-gynecologist from Texas. And Erin, Kimberly, Morgan – my three daughters. And Barbara -- my most intimate friend. And then there are others with whom shared experiences may in time take us to the rare treasure of being ‘dear friends’.
‘You see something dreadful and are afraid . . . ‘You treat the words of a despairing man as wind’ . . . ‘Relent, do not be unjust’ . . . ‘You smear me with lies; you are worthless physicians’ . . . ‘Your maxims are proverbs of ashes’ . . . ‘Miserable comforters are you all’ . . . ‘Surely mockers surround me; my eyes must dwell on their hostility’ . . . ‘How long will you torment me and crush me with words?’ . . . ‘Shamelessly you attack me’ . . . ‘All my intimate friends detest me’ . . . ‘You say -- Where now is the great man’s house, the tents where wicked men lived?’ . . . ‘So how can you console me with your nonsense?’ . . . ‘How you have helped the powerless! How you have saved the arm that is feeble!’These are hard, pained words from Job to his three close friends. Eliphaz, Bildad, and Zophar respond in kind. Their good intentions fail. The word ‘friend’ – in the special or ‘dear’ sense -- withers away.
And yet I trust my ‘dear friends’. I believe they would risk themselves for me and I for them. Why?
Friday, December 28, 2007
Image #7
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Image #6
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Thursday, December 27, 2007
Image #5
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Image #4
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Image #3
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Image #2
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Image #1
Franklin, TN, . . . 2004 . . . neighbor's backyard . . . subjects quietly observed a few hours the previous day . . . light and wind promising . . . a full morning taught by the subjects -- responsible, alert, mindful, grace, playful, artistic, . . .
Thursday, December 20, 2007
Leaven #22
“Who is missing?”
An empty chair at the table often calls attention to a late arrival or a ‘no show’. An empty chair at the table can be in the way or serve as a temporary shelf or be used by others gathered nearby or simply be a blank space.
An empty chair at the table can also function as a symbol waiting to bring to the table a reality otherwise overlooked or absent.
Many years ago, I began quietly testing the symbolic meaning/force of the empty chair often found at the tables –- tables for private or family gatherings as well as tables for professional gatherings -– at which I sit in conversation with others. How? By imagining who could be sitting in the empty chair. I then try to listen and speak at the table with them in mind.
Considered this way, an empty chair at the table brings to mind the many individuals -– some living, some deceased –- who have healed and enriched my life with their encouragement, their patience, their honesty, their counsel, their trust, their example. A spouse . . . a parent . . . a sibling . . . a grandparent . . . a teacher . . . a coach . . . a friend . . . a colleague . . . a caregiver . . . .
If we were to experiment a bit with speaking together as if one of the individuals who have given us so much and whose respect we cherish were sitting in the empty chair at the table, how would our table discourse be altered?
Considered this way, an empty chair at the table also brings to mind the many individuals – some near, many more at a distance -- whose life stories I know to be far more fragile than my own, whose life stories too often unfold only on the margins of my vision/attention. The barred . . . the badly treated . . . the disfigured . . . the powerless . . . the scoffed . . . the lonely . . . the forgotten . . . the ignored . . . the disgraced . . . .
If we were to experiment a bit with speaking together as if an individual for whom life is far more difficult than our own and toward whom we so easily show disrespect were sitting with us, how would our table discourse be altered?
Is it too much to suggest we try testing this empty chair symbolism at the tables where we sit together at work Рat a cafeteria table? . . . at a conference table? . . . at a medical staff lounge table? . . . at a table for rounds? . . . at a break-room table? . . . at a caf̩/restaurant table? . . . ?
Think about it. Perhaps talk to a coworker.
An empty chair at the table often calls attention to a late arrival or a ‘no show’. An empty chair at the table can be in the way or serve as a temporary shelf or be used by others gathered nearby or simply be a blank space.
An empty chair at the table can also function as a symbol waiting to bring to the table a reality otherwise overlooked or absent.
Many years ago, I began quietly testing the symbolic meaning/force of the empty chair often found at the tables –- tables for private or family gatherings as well as tables for professional gatherings -– at which I sit in conversation with others. How? By imagining who could be sitting in the empty chair. I then try to listen and speak at the table with them in mind.
Considered this way, an empty chair at the table brings to mind the many individuals -– some living, some deceased –- who have healed and enriched my life with their encouragement, their patience, their honesty, their counsel, their trust, their example. A spouse . . . a parent . . . a sibling . . . a grandparent . . . a teacher . . . a coach . . . a friend . . . a colleague . . . a caregiver . . . .
If we were to experiment a bit with speaking together as if one of the individuals who have given us so much and whose respect we cherish were sitting in the empty chair at the table, how would our table discourse be altered?
Considered this way, an empty chair at the table also brings to mind the many individuals – some near, many more at a distance -- whose life stories I know to be far more fragile than my own, whose life stories too often unfold only on the margins of my vision/attention. The barred . . . the badly treated . . . the disfigured . . . the powerless . . . the scoffed . . . the lonely . . . the forgotten . . . the ignored . . . the disgraced . . . .
If we were to experiment a bit with speaking together as if an individual for whom life is far more difficult than our own and toward whom we so easily show disrespect were sitting with us, how would our table discourse be altered?
Is it too much to suggest we try testing this empty chair symbolism at the tables where we sit together at work Рat a cafeteria table? . . . at a conference table? . . . at a medical staff lounge table? . . . at a table for rounds? . . . at a break-room table? . . . at a caf̩/restaurant table? . . . ?
Think about it. Perhaps talk to a coworker.
Wednesday, December 19, 2007
Fragments #9 - Assessing Patients’ Spiritual Needs
(Part 5)
5. ‘Respect’ as the anchor for responding to patients’ spiritual needs:
5.1 ‘Respect’ is foundational to effective assessment of patients’ spiritual needs. The root meaning of respect – i.e., ‘to look back or to look at again and again’ -- is very vivid. There is very little benefit from attempting to assess a patient’s spiritual centeredness or spiritual distress if the professionals responsible for the patient’s care do not genuinely respect the patient.
5.2 It should not be taken for granted that health care professionals possess the skill/art of truly respecting their patients. I suspect that many caregivers have been born into and/or raised in fairly conservative religious and social settings. I was. In the religious and social setting into which I was born and in which I was raised, I remember being taught to doubt the motives and to avoid taking seriously the ideas of all others who differed from ‘us’. In time I came to see this instruction as instruction in disrespecting others. Variations on instruction in disrespecting others are implicit, if not explicit, to some degree in virtually all organized constituencies or spheres in our society (including the medical sphere).
5.3 ‘Respect’ does not mean ‘cater to’. It does mean ‘take very seriously’. This clarification calls attention to the rather complicated process by which the attending physician and medical team work with the patient and family/friends in decision-making.
5.4 The following sets of questions illustrate the skill/art physicians and other health care professionals need in order to be fully informed about and respectful of hospitalized patients who are experiencing spiritual distress:
Where do you call ‘home’? Are there individuals to whom you feel especially close? Are you a member of any groups or organizations that have significantly influenced your beliefs and values, your hopes and dreams?
5.1 ‘Respect’ is foundational to effective assessment of patients’ spiritual needs. The root meaning of respect – i.e., ‘to look back or to look at again and again’ -- is very vivid. There is very little benefit from attempting to assess a patient’s spiritual centeredness or spiritual distress if the professionals responsible for the patient’s care do not genuinely respect the patient.
5.2 It should not be taken for granted that health care professionals possess the skill/art of truly respecting their patients. I suspect that many caregivers have been born into and/or raised in fairly conservative religious and social settings. I was. In the religious and social setting into which I was born and in which I was raised, I remember being taught to doubt the motives and to avoid taking seriously the ideas of all others who differed from ‘us’. In time I came to see this instruction as instruction in disrespecting others. Variations on instruction in disrespecting others are implicit, if not explicit, to some degree in virtually all organized constituencies or spheres in our society (including the medical sphere).
5.3 ‘Respect’ does not mean ‘cater to’. It does mean ‘take very seriously’. This clarification calls attention to the rather complicated process by which the attending physician and medical team work with the patient and family/friends in decision-making.
5.4 The following sets of questions illustrate the skill/art physicians and other health care professionals need in order to be fully informed about and respectful of hospitalized patients who are experiencing spiritual distress:
Where do you call ‘home’? Are there individuals to whom you feel especially close? Are you a member of any groups or organizations that have significantly influenced your beliefs and values, your hopes and dreams?
- Has a particular religion influenced what you believe and value? (If so) what would you want us to know about your religious experience that would help us take better care of you? (If not) what would you want us to know about the source of your beliefs and values that would help us take better care of you?
- What gives your life meaning and purpose? What effect do your beliefs and values have on how you view being sick? (or injured?) What effect is your illness (or injury) having on your attitude toward life? Do you have any special memories -- including painful ones -- that you think we should know about as we care for you?
- Do you have family members or friends who are especially supportive at this time? Do they live near enough to be present while you are in the hospital? Would you like for us to meet them?
- Are you concerned that being in the hospital will interfere with your ability to participate in any activities that are especially important to your spiritual well being? How can we help you continue these practices while you are in our care?
- Do you feel encouraged? discouraged? Do you have specific hopes and goals that we should know about as we care for you? Would you want us to look for any special literature or other resources that might be encouraging to you while you are in the hospital?
- Do you have any questions or concerns that may be keeping you from having confidence in those of us who are caring for you in the hospital? If so, please share them with one of us. Having your trust is critical to our efforts to care for you.
5.5 Adding the responsibility of assessing patients’ spiritual needs increases the likelihood that caregivers will often be in a position to share their beliefs and values with patients. Healthcare professionals who interpret the responsibility to assess and respond to their patients’ spiritual needs as liberty to look for opportunities to evangelize or proselytize patients risk failing to respect or to be truly present with their patients. Their beliefs and values may lead them to prejudge the spiritual needs of patients whose beliefs and values differ from their own. Their attention span may narrow. Their diagnosis and/or management can be adversely influenced. Also, considerable diversity regarding spirituality and religion is usually found among the numerous professionals involved in a patient’s care. Liberty to evangelize or proselytize patients would not be restricted to the attending physician. Instead, all the professionals involved in a patient’s care -- including consultants, residents, medical students, nurses, social services personnel, et al -- could assume the same liberty, thus potentially putting patients in confusing as well as pressured situations. In order to guard against disrespecting patients and weakening their trust, caregivers should limit the way they share their beliefs and values with patients to discussions (1) they would summarize in the patient’s chart and (2) the medical team would consider part of the patient’s care.
CONCLUSION
I realize I have asked you to ‘think above the bar’, above the effort needed to achieve the minimum necessary to satisfy Joint Commission regulations. If there is a ‘take home’ from this pause in your busy and exhausting day, perhaps it will be that you will leave with an additional angle by which (1) to ponder the art of practicing medicine and (2) to measure your agreement that medicine ought not only be the most scientific of the humanities, but also the most humane of the sciences.
Fragments #8 - Assessing Patients’ Spiritual Needs
(Part 4)
4. Defining/distinguishing ‘spirituality’ and ‘religion’:
4.1 I suggest that you begin with this premise – i.e., all individuals are more than the insights made possible through various empirical analyses. In the health care sphere, this premise implies that patients are more than potential or actual illnesses and accidents; professionals, more than highly skilled scientists/technicians. To consider this ‘more’, a vocabulary and a manner of discourse -- in addition to scientific language -- are required. I have found that most (perhaps all) individuals have, with varying levels of sophistication, such vocabulary and manner of discourse. Such vocabulary and manner of discourse disclose, in the most elemental and inclusive way, each individual’s spirituality. An individual’s spirituality shapes and sustains his/her integrity (i.e., wholeness, oneness, character).
4.2 The definition of ‘spirituality’ that has worked well over the years for me in opening discussions of this subject with health care professionals is: ‘Spirituality’ has to do with the sort of person a patient is, with the basis upon which her life has integrity and balance. A patient reveals her spiritual identity when she shares her core beliefs and life values and when she explains how she sustains these beliefs and values. Feelings of fear, loneliness, and guilt as well as happiness, contentment, and wonder are windows into a patient’s spirituality.
4.3 You may be among those who question the absence of the word ‘God’ or a reference to a divine transcendence in this definition of spirituality. This definition represents an attempt to define spirituality so as to minimize the risk of eliminating individuals as ‘spiritual’ by definition. I am hesitant to make either a reference to a divine transcendence or a claim of experience of/with a divine transcendence prerequisite to being considered ‘spiritual’. Instead, the transcendence that, in my judgment, is prerequisite to a fully inclusive approach to spirituality is the human spirit (i.e., the ‘more’ about human beings for which empirical analysis/explanation alone does not account). I am proposing (1) that this transcendent realm is present in/with all patients and (2) that this transcendent realm is very relevant to the empirically-driven health care professionals who are expected to assess their patients’ spirituality. With this transcendence – i.e., the human spirit -- in common, patients experience and express their spirituality in ways special/peculiar to each one (including but not limited to those who interpret their spirituality in terms of experience of/with a divine transcendence).
4.4 The definition of ‘religion’ that has worked well over the years for me in opening discussions such as this one is: ‘Religion’ has to do with the way many patients experience and express their spirituality. They center their lives on worshipful devotion to ‘God’ as a mystery that transcends human beings and the world. They are encouraged in their communities of faith to live this way through the study of sacred writings, the affirmation of core beliefs and life values, the sharing of inspirational stories, and the celebration of special rituals.
4.5 You may be among those who express concern that this definition of religion is decidedly institutional in wording. There are certainly less institutional ways to define/nuance ‘religion’. However, in order to meet the Joint Commission regulations for assessing patients’ spiritual needs and in light of the likely assumptions many caregivers hold re ‘religion’, it seems to me that an institutional definition of religion accomplishes the primary objective of distinguishing religion as a subset of the larger phenomenon of spirituality.
4.6 I suspect that a significant number of physicians and their support staff as well as most of their patients are more familiar with the following association of ‘being spiritual’ and ‘being religious’:
4.1 I suggest that you begin with this premise – i.e., all individuals are more than the insights made possible through various empirical analyses. In the health care sphere, this premise implies that patients are more than potential or actual illnesses and accidents; professionals, more than highly skilled scientists/technicians. To consider this ‘more’, a vocabulary and a manner of discourse -- in addition to scientific language -- are required. I have found that most (perhaps all) individuals have, with varying levels of sophistication, such vocabulary and manner of discourse. Such vocabulary and manner of discourse disclose, in the most elemental and inclusive way, each individual’s spirituality. An individual’s spirituality shapes and sustains his/her integrity (i.e., wholeness, oneness, character).
4.2 The definition of ‘spirituality’ that has worked well over the years for me in opening discussions of this subject with health care professionals is: ‘Spirituality’ has to do with the sort of person a patient is, with the basis upon which her life has integrity and balance. A patient reveals her spiritual identity when she shares her core beliefs and life values and when she explains how she sustains these beliefs and values. Feelings of fear, loneliness, and guilt as well as happiness, contentment, and wonder are windows into a patient’s spirituality.
4.3 You may be among those who question the absence of the word ‘God’ or a reference to a divine transcendence in this definition of spirituality. This definition represents an attempt to define spirituality so as to minimize the risk of eliminating individuals as ‘spiritual’ by definition. I am hesitant to make either a reference to a divine transcendence or a claim of experience of/with a divine transcendence prerequisite to being considered ‘spiritual’. Instead, the transcendence that, in my judgment, is prerequisite to a fully inclusive approach to spirituality is the human spirit (i.e., the ‘more’ about human beings for which empirical analysis/explanation alone does not account). I am proposing (1) that this transcendent realm is present in/with all patients and (2) that this transcendent realm is very relevant to the empirically-driven health care professionals who are expected to assess their patients’ spirituality. With this transcendence – i.e., the human spirit -- in common, patients experience and express their spirituality in ways special/peculiar to each one (including but not limited to those who interpret their spirituality in terms of experience of/with a divine transcendence).
4.4 The definition of ‘religion’ that has worked well over the years for me in opening discussions such as this one is: ‘Religion’ has to do with the way many patients experience and express their spirituality. They center their lives on worshipful devotion to ‘God’ as a mystery that transcends human beings and the world. They are encouraged in their communities of faith to live this way through the study of sacred writings, the affirmation of core beliefs and life values, the sharing of inspirational stories, and the celebration of special rituals.
4.5 You may be among those who express concern that this definition of religion is decidedly institutional in wording. There are certainly less institutional ways to define/nuance ‘religion’. However, in order to meet the Joint Commission regulations for assessing patients’ spiritual needs and in light of the likely assumptions many caregivers hold re ‘religion’, it seems to me that an institutional definition of religion accomplishes the primary objective of distinguishing religion as a subset of the larger phenomenon of spirituality.
4.6 I suspect that a significant number of physicians and their support staff as well as most of their patients are more familiar with the following association of ‘being spiritual’ and ‘being religious’:
‘Religious’ (in/through a particular religion or even a subdivision of that religion)rather than:
‘Spiritual’ (a favorable assessment according to that religion’s criteria)
‘Not spiritual’ (an unfavorable assessment according to that religion’s criteria)
‘Spiritual’4.7 The definition of and approach to spirituality followed by a hospital, in a clinic, and by a medical team need to be inclusive of all the patients for whom care is being delivered. Not all patients are religious. Not all patients are affiliated with a particular religion. Not all patients are members of any one sub-division of one particular religion. And crucial non-religious aspects of every patient’s spirituality are missed when spirituality is reduced to religion. Concerning these missed windows into a patient’s spirituality, here are some examples:
‘Religious’ (in experience and expression)
‘Non-religious’ (in experience and expression)
a morning/evening walk
participation in community/civic organizations
a refreshing hobby (e.g., photography or gardening or hiking or . . .)
participation in volunteer community service activities
reminders of life-changing experiences
travel opportunities
inspiring music
the company of a pet
a thought-provoking book
a favorite art gallery or museum
social pleasures (e.g., a glass of wine or a pleasant dinner or a theater outing or a sports event or . . .)
a special friend
Fragments #7 - Assessing Patients’ Spiritual Needs
(part 3)
3. Understanding a patient’s spiritual distress:
3.1 The root meaning for ‘distress’ has to do with pressure, strain, . . . . To be distressed, therefore, is to be strained, tense, troubled, oppressed, threatened. ‘Spiritual distress’ has to do with the loss of peace, joy, hope, and resolve individuals experience (to varying degrees) when faced with unsettling life circumstances that threaten to overwhelm their core beliefs and values.
3.2 Responses to respiratory distress may range from ‘observe closely’ to ‘intensive intervention’. You are trained to think in terms of the least invasive/intrusive means (i.e., ‘do no harm’) to resolve a patient’s condition. Your response to an asthmatic patient who is wheezing should be less intensive than your response to an asthmatic patient who is listless. The intervention should match the level of concern/danger. You should have an analogous framework by which to assess a patient’s spiritual needs. Think in terms of a diagram with two paradigms – i.e., ‘spiritually centered’ and ‘spiritually distressed’ – separated by a threshold. Variations of the ‘spiritually centered’ paradigm range from ‘thriving’ to ‘holding’ as you move nearer to the threshold. Variations of the ‘spiritually distressed’ paradigm range from ‘troubled’ to ‘despairing’ as you move away from the threshold. Caregivers cross the threshold when the paradigm or framework that most fully accounts for their observations about a patient shifts from ‘spiritually centered’ to ‘spiritually distressed’.
3.3 Patients who are spiritually centered are capable of participating meaningfully in the decisions about their care and can be counted on to be diligent in fulfilling their responsibilities. Some of these patients may appear to be undisturbed by their condition. They come across as attentive, hopeful, and self-confident. They ask insightful questions, make accurate comments about their condition, and have a sense of humor. Other of these patients may be struggling to maintain their balance and focus. They show signs of being fearful, upset, disoriented, and impatient. As these dispositions strengthen, they are moving toward and may eventually cross the threshold into the ‘spiritually distressed’ paradigm.
3.4 Patients who are spiritually distressed complicate the decision-making process and the management of their care. Some of these patients are troubled for inward as well as circumstantial reasons. They are losing confidence, motivation, hope. They may appear despondent or panicky. They may deny the reality of their situation. Other of these patients are despairing. They are immobilized, depressed, apathetic, fatalistic. Their spiritual distress may surpass in urgency their injury or disease. Professionals with special training for such situations (e.g., social workers, psychologists, chaplains, ethicists, . . .) may need to be grafted into the medical team for these patients.
3.1 The root meaning for ‘distress’ has to do with pressure, strain, . . . . To be distressed, therefore, is to be strained, tense, troubled, oppressed, threatened. ‘Spiritual distress’ has to do with the loss of peace, joy, hope, and resolve individuals experience (to varying degrees) when faced with unsettling life circumstances that threaten to overwhelm their core beliefs and values.
3.2 Responses to respiratory distress may range from ‘observe closely’ to ‘intensive intervention’. You are trained to think in terms of the least invasive/intrusive means (i.e., ‘do no harm’) to resolve a patient’s condition. Your response to an asthmatic patient who is wheezing should be less intensive than your response to an asthmatic patient who is listless. The intervention should match the level of concern/danger. You should have an analogous framework by which to assess a patient’s spiritual needs. Think in terms of a diagram with two paradigms – i.e., ‘spiritually centered’ and ‘spiritually distressed’ – separated by a threshold. Variations of the ‘spiritually centered’ paradigm range from ‘thriving’ to ‘holding’ as you move nearer to the threshold. Variations of the ‘spiritually distressed’ paradigm range from ‘troubled’ to ‘despairing’ as you move away from the threshold. Caregivers cross the threshold when the paradigm or framework that most fully accounts for their observations about a patient shifts from ‘spiritually centered’ to ‘spiritually distressed’.
3.3 Patients who are spiritually centered are capable of participating meaningfully in the decisions about their care and can be counted on to be diligent in fulfilling their responsibilities. Some of these patients may appear to be undisturbed by their condition. They come across as attentive, hopeful, and self-confident. They ask insightful questions, make accurate comments about their condition, and have a sense of humor. Other of these patients may be struggling to maintain their balance and focus. They show signs of being fearful, upset, disoriented, and impatient. As these dispositions strengthen, they are moving toward and may eventually cross the threshold into the ‘spiritually distressed’ paradigm.
3.4 Patients who are spiritually distressed complicate the decision-making process and the management of their care. Some of these patients are troubled for inward as well as circumstantial reasons. They are losing confidence, motivation, hope. They may appear despondent or panicky. They may deny the reality of their situation. Other of these patients are despairing. They are immobilized, depressed, apathetic, fatalistic. Their spiritual distress may surpass in urgency their injury or disease. Professionals with special training for such situations (e.g., social workers, psychologists, chaplains, ethicists, . . .) may need to be grafted into the medical team for these patients.
Fragments #6 - Assessing Patients’ Spiritual Needs
(Part 2)
2. Objectives for considering a patient’s spiritual needs:
2.1 Given the immediate attention in health care settings to patients’ physical needs (in the context of psycho-social circumstances), the objectives for integrating attention to spiritual needs into patient care need to be precise and appropriately circumscribed. Hospitals and clinics do not have purposes parallel to spiritual retreat centers, synagogues, churches, mosques, . . . . What would be objectives for attending to a patient’s spiritual needs that are consistent with the purposes of health care settings? Possible answers might be (1) to insure effective communication, (2) to show respect for and understanding of patient preferences regarding their medical care, (3) to maximize the health benefits associated with patients having the heart of a fighter, (4) to search for factors contributing to a patient’s failing health.
2.2 Meeting a patients’ spiritual needs, then, has to do with minimizing the spiritual disturbance she is experiencing due to being in a hospital and/or due to injury/illness in order to maximize the benefits from her spiritual resources (1) for making decisions about her care and (2) for realizing her fullest measure of healing. To make the objectives for assessing a patient’s spiritual needs concrete, think in terms of assessing a patient’s centeredness – her balance and her focus. It is crucial that the patient has (or recovers) sufficient balance and focus to communicate well (which requires listening carefully, thinking courageously, and speaking clearly) and to participate appropriately in decisions about her care.
2.3 Assisting patients in the recovery of balance and focus is, in my judgment, the goal/consequence that makes giving attention to spirituality pertinent to caring for patients. (Fear of) serious illness or injury can challenge/threaten a patient’s balance and focus, thus raising crucial questions about the credibility of the spiritual foundation upon which she has built her life. A hospital is a particularly difficult setting in which to face this possibility. Sheer pain may eclipse a patient’s use of her spiritual resources. By being in a clinic exam room or in a hospital, she is distant from (or even cut off from) the activities and experiences essential to her spirituality. Then again, a patient’s spirituality may be contributing to her loss of balance and focus.
2.4 Loss of balance and focus may be a deeply significant process by which a patient’s spirituality is tested and eventually strengthened. My experience has led me to conclude that few individuals, before being confronted with (the possibility of) significant injury or disease, have ever taken seriously the existential hypothesis that facing one’s finitude is prerequisite to authentic living. Whatever the fraction who have, it is far too low for you to assume that a patient will retain her balance and focus when faced with (the real possibility of) life-threatening injury or disease. You thus may face a dilemma -- (1) on the one hand, you need your patient to be balanced and focused in order for management decisions to flow, (2) while on the other hand, you may have to give some of your patients time/opportunity to experience the spiritually refining/restructuring that may be necessary for them to again be centered.
2.1 Given the immediate attention in health care settings to patients’ physical needs (in the context of psycho-social circumstances), the objectives for integrating attention to spiritual needs into patient care need to be precise and appropriately circumscribed. Hospitals and clinics do not have purposes parallel to spiritual retreat centers, synagogues, churches, mosques, . . . . What would be objectives for attending to a patient’s spiritual needs that are consistent with the purposes of health care settings? Possible answers might be (1) to insure effective communication, (2) to show respect for and understanding of patient preferences regarding their medical care, (3) to maximize the health benefits associated with patients having the heart of a fighter, (4) to search for factors contributing to a patient’s failing health.
2.2 Meeting a patients’ spiritual needs, then, has to do with minimizing the spiritual disturbance she is experiencing due to being in a hospital and/or due to injury/illness in order to maximize the benefits from her spiritual resources (1) for making decisions about her care and (2) for realizing her fullest measure of healing. To make the objectives for assessing a patient’s spiritual needs concrete, think in terms of assessing a patient’s centeredness – her balance and her focus. It is crucial that the patient has (or recovers) sufficient balance and focus to communicate well (which requires listening carefully, thinking courageously, and speaking clearly) and to participate appropriately in decisions about her care.
2.3 Assisting patients in the recovery of balance and focus is, in my judgment, the goal/consequence that makes giving attention to spirituality pertinent to caring for patients. (Fear of) serious illness or injury can challenge/threaten a patient’s balance and focus, thus raising crucial questions about the credibility of the spiritual foundation upon which she has built her life. A hospital is a particularly difficult setting in which to face this possibility. Sheer pain may eclipse a patient’s use of her spiritual resources. By being in a clinic exam room or in a hospital, she is distant from (or even cut off from) the activities and experiences essential to her spirituality. Then again, a patient’s spirituality may be contributing to her loss of balance and focus.
2.4 Loss of balance and focus may be a deeply significant process by which a patient’s spirituality is tested and eventually strengthened. My experience has led me to conclude that few individuals, before being confronted with (the possibility of) significant injury or disease, have ever taken seriously the existential hypothesis that facing one’s finitude is prerequisite to authentic living. Whatever the fraction who have, it is far too low for you to assume that a patient will retain her balance and focus when faced with (the real possibility of) life-threatening injury or disease. You thus may face a dilemma -- (1) on the one hand, you need your patient to be balanced and focused in order for management decisions to flow, (2) while on the other hand, you may have to give some of your patients time/opportunity to experience the spiritually refining/restructuring that may be necessary for them to again be centered.
Fragments #5 - Assessing Patients’ Spiritual Needs
(Part 1)
[Before presenting this manuscript as a Grand Rounds lecture for the faculty and residents of an Obstetrics and Gynecology Department in Phoenix (October 2001), I profiled for those in attendance my experience and training in three ways. First, I explained my three overlapping ‘on-the-field experiences’ (as distinguished from an ‘ethicist’ role) over the previous eight years – i.e., (1) as project coordinator and evaluator with an intervention project at the University of Miami for 125 cocaine-abusing women who had prematurely delivered cocaine-exposed babies (1993-97), (2) as residency coordinator and ethics educator while on faculty with the Ob/Gyn Department at Louisiana State University in New Orleans (1992-97), and (3) as a member of the executive leadership team for Dayspring Family Health Center (a not-for-profit community health center serving medically un(der)insured individuals/families in three poverty-ridden Appalachia counties of eastern Tennessee and Kentucky) (1994-2007). Second, I referenced professional experience (e.g., participating as an adjunct faculty member with Michigan State University’s Center for Ethics and Humanities in the Life Sciences in the development of a curriculum for addressing spirituality in medical education) and personal experience (e.g., my first wife’s fourteen-year struggle against her deterioration and eventual death in 1987 due to multiple sclerosis) in which the lecture’s reflections/observations were rooted. Finally, I mentioned the impetus to compose the thoughts later/fully developed in the lecture that came from preparing several months previous to the lecture to participate with a Vanderbilt University team in the creation of an educational video for hospital employees re assessing patients’ spiritual needs.]
1. When to consider a patient’s spiritual needs:
1.1 For the past few years, the senior physician – David McRay, MD -- at the Appalachia community health center where I work and I have been meeting weekly to review his most perplexing and burdening patient encounters – something of an ethics and spirituality approach to rounds. A few months ago, we discussed this case:
It was a busy Wednesday afternoon. The patient was in her late-20s, had four children, and was now 32-weeks pregnant. The fetus’ fundal height was smaller than expected. A colleague asked David to do an ultrasound. The patient was sitting on the edge of the exam table when David and his nurse entered the room. David got her into a supine position, covered with a sheet up to her blouse. The nurse turned down the light. As David began raising the blouse for the exam, the patient said barely above a whisper, “I have a lot of scars.” David’s first thought . . . surgery . . . perhaps a previous c-section. Once he saw the scars, he thought . . . accident . . . perhaps a burn. He asked, “In a car accident or . . .?” She interrupted and, as she starred at the wall, said quietly, “My mother set me on fire when I was three.” David had no response. It turned out the baby was fine. The patient asked, “Can you tell the race of the baby by ultrasound?” David had never been asked this question. He found in her chart that she came so late in the pregnancy for prenatal care because she had been on the road with truck drivers. And she had been with IV drug users during the pregnancy. As we reflected on the case, David explained to me, “Her life is so far removed from my range of experiences. I didn’t know how to respond. She would never be free of this childhood experience, these scars. If my mother had . . .” His voiced trailed off.
When the patient said “many scars”, she was making a figurative as well as a literal comment. Simply put, she was saying, “My story is broken. Can you help me fix it.”
1.2 Imagine you and your medical team are looking down a hospital or clinic hallway with patients in most of the rooms. Whether or not the patients in these rooms share similar definitions of or approaches to spirituality is immaterial to each patient. They are not present together in the hospital as a community. What does matter to each patient ultimately is her particular spirituality. However, you and your medical team – moving from room to room – need a definition of and an approach to spirituality that prepare you to meaningfully integrate the ‘spiritual’ and the ‘physical’ in caring for each patient. Embracing such a definition of and approach to spirituality is no simple task.
1.3 Most hospitals and clinics exist to respond to patients’ physical needs (in the context of psycho-social circumstances) and, therefore, are centered by empirical language and perspective. Empirical language is the ‘first language’ of health care settings. With symptoms, with injuries, with diseases, . . . – patients come (or are brought) anticipating that their physical conditions can be corrected or brought under control. The expansion/deepening of the scientific knowledge base and the introduction of increasingly sophisticated technologies continue to concentrate attention on patients’ physical interests in health care settings.
1.4 Patients hope that entering a hospital or a clinic will be no more than a pit stop or, at most, a repair shop delay in their day-to-day routines and life journeys. The circumstances that lead patients to seek medical attention are often superficial, acute, and/or benign. In these situations, assessing a patient from a spiritual perspective may remain (by patient choice and/or by your choice) on the periphery. By ‘periphery’ I mean that you do remain attentive to subtle or incidental indications that, in addition to the patient’s immediate problem, there may be a deeper ‘wound’. Such indications – which, for our physicians at the Appalachia community health center where I am working, are detected many times every day – put the caregiver in the tough position of deciding whether s/he has the time and emotional capacity to determine if indeed there is a deeper ‘wound’. And the circumstances that lead patients to seek medical attention may in fact have to do with a deeper ‘wound’. In these situations, a spiritual language/perspective should be more centrally and intimately present as you and your medical team attend to the patient’s needs.
1. When to consider a patient’s spiritual needs:
1.1 For the past few years, the senior physician – David McRay, MD -- at the Appalachia community health center where I work and I have been meeting weekly to review his most perplexing and burdening patient encounters – something of an ethics and spirituality approach to rounds. A few months ago, we discussed this case:
It was a busy Wednesday afternoon. The patient was in her late-20s, had four children, and was now 32-weeks pregnant. The fetus’ fundal height was smaller than expected. A colleague asked David to do an ultrasound. The patient was sitting on the edge of the exam table when David and his nurse entered the room. David got her into a supine position, covered with a sheet up to her blouse. The nurse turned down the light. As David began raising the blouse for the exam, the patient said barely above a whisper, “I have a lot of scars.” David’s first thought . . . surgery . . . perhaps a previous c-section. Once he saw the scars, he thought . . . accident . . . perhaps a burn. He asked, “In a car accident or . . .?” She interrupted and, as she starred at the wall, said quietly, “My mother set me on fire when I was three.” David had no response. It turned out the baby was fine. The patient asked, “Can you tell the race of the baby by ultrasound?” David had never been asked this question. He found in her chart that she came so late in the pregnancy for prenatal care because she had been on the road with truck drivers. And she had been with IV drug users during the pregnancy. As we reflected on the case, David explained to me, “Her life is so far removed from my range of experiences. I didn’t know how to respond. She would never be free of this childhood experience, these scars. If my mother had . . .” His voiced trailed off.
When the patient said “many scars”, she was making a figurative as well as a literal comment. Simply put, she was saying, “My story is broken. Can you help me fix it.”
1.2 Imagine you and your medical team are looking down a hospital or clinic hallway with patients in most of the rooms. Whether or not the patients in these rooms share similar definitions of or approaches to spirituality is immaterial to each patient. They are not present together in the hospital as a community. What does matter to each patient ultimately is her particular spirituality. However, you and your medical team – moving from room to room – need a definition of and an approach to spirituality that prepare you to meaningfully integrate the ‘spiritual’ and the ‘physical’ in caring for each patient. Embracing such a definition of and approach to spirituality is no simple task.
1.3 Most hospitals and clinics exist to respond to patients’ physical needs (in the context of psycho-social circumstances) and, therefore, are centered by empirical language and perspective. Empirical language is the ‘first language’ of health care settings. With symptoms, with injuries, with diseases, . . . – patients come (or are brought) anticipating that their physical conditions can be corrected or brought under control. The expansion/deepening of the scientific knowledge base and the introduction of increasingly sophisticated technologies continue to concentrate attention on patients’ physical interests in health care settings.
1.4 Patients hope that entering a hospital or a clinic will be no more than a pit stop or, at most, a repair shop delay in their day-to-day routines and life journeys. The circumstances that lead patients to seek medical attention are often superficial, acute, and/or benign. In these situations, assessing a patient from a spiritual perspective may remain (by patient choice and/or by your choice) on the periphery. By ‘periphery’ I mean that you do remain attentive to subtle or incidental indications that, in addition to the patient’s immediate problem, there may be a deeper ‘wound’. Such indications – which, for our physicians at the Appalachia community health center where I am working, are detected many times every day – put the caregiver in the tough position of deciding whether s/he has the time and emotional capacity to determine if indeed there is a deeper ‘wound’. And the circumstances that lead patients to seek medical attention may in fact have to do with a deeper ‘wound’. In these situations, a spiritual language/perspective should be more centrally and intimately present as you and your medical team attend to the patient’s needs.
Ethical Dimensions of Patient Care #14
Ethical Decision-Making (part 3)
4. Does the decision promote the well-being of the patient?
A sound decision entails a concerted effort to promote the wellbeing of the patient. Since the formation of the Hippocratic traditions, beneficence (L., to do good for another) has been central to the motivations and purposes of medicine. The most basic form of beneficence is nonmaleficence (i.e., ‘do no harm’). This reminder is certainly relevant to the practice of medicine. Even though technological advances continue to strengthen a physician’s ability to repair injuries and cure diseases, the most important expression of beneficence remains to ‘do no harm’. ‘Can’ does not imply ‘should’. The harms to be balanced with benefits include intentional harms as well as those harms that can be anticipated to arise despite the best intentions (e.g., unwanted side effects of medication or complications of surgical treatment).
In balancing the promotion of a patient’s wellbeing with the promotion of self-determination, a physician should attempt to interpret a patient’s best interests as objectively as possible. An effort to override a patient’s wishes in order to pursue what her physician perceives to be in her best interests -- i.e., paternalism -- is rarely (if ever) justified.
5. Is the decision just?
A sound decision takes into consideration the implications a course of action has for third parties immediately affected and for the interests of the larger society. A democratic society is committed to freedom and justice. Accordingly, individuals are free to claim what they are due based on specified personal properties or characteristics. It is important that all members of the society participate in the ongoing responsibility to select criteria that are relevant to the benefits and burdens being assigned. For instance, in our society, such variables as ethnicity, gender, and religious persuasion are not considered to be legitimate criteria by which to determine the distribution of such benefits as housing, education, employment, or health care.
Individuals equally concerned about justice may use different theories of justice in determining what would be a fair distribution of benefits and burdens. Some might variously argue that the distribution should correlate with need, effort, contribution, merit, or ability to pay. Others might argue that benefits and burdens should be distributed equally or randomly. The approach taken in a given situation should be relevant to the benefits and burdens being assigned. Commitment to a just decision creates an obligation to treat fairly those who are alike according to the selected criteria. No one should receive unequal treatment unless it is demonstrated that s/he differs significantly from others in a way that is relevant to the treatment in question.
Achieving fairness is most difficult when constraints such as scarcity of resources force judgments about competing claims made by individuals who appear to have equal standing based on agreed-upon distribution criteria. For instance, a critically ill patient needs intensive care, but the intensive care unit is filled to capacity. All the patients in the unit meet the medical criteria for intensive care. If the available resources cannot be redistributed to accommodate another patient, additional criteria must be used in order to decide which patients receive intensive care and which patient is transferred to a less intensive setting. The selection of additional criteria (e.g., the increased risk if transferred or the likelihood of successful recovery) is itself an ethical issue.
6. Is confidentiality ensured?
A sound decision depends on the confidential handling of sensitive information. A patient’s freedom to make decisions about her health care includes the right to decide how and to whom personal medical information is communicated. Carelessness about patient privacy undermines patient trust. This hazard is especially acute when multiple professionals are involved in patient care, when patient care is delivered in an educational setting, or when insurance companies and HMOs are involved. In the near future, the increasing availability of genetic information will make confidentiality even more difficult to maintain.
In general, protecting a patient’s privacy takes precedence over other obligations. However, in some situations, maintaining confidentiality may result in harm to a third party immediately affected by the patient’s chosen course of action. In other situations, maintaining confidentiality may be challenged by accountability to society when faced with epidemic conditions. Since a breach of confidentiality may destroy the patient-physician relationship, the magnitude of risk to others must be actual and grave. Ethical judgment and legal regulations about reporting communicable diseases may not coincide. In the rare instances when breaking confidence is deemed justified, the physician should attempt to explain the circumstances to the patient, solicit the patient’s approval, and remain committed to the patient’s care.
A sound decision entails a concerted effort to promote the wellbeing of the patient. Since the formation of the Hippocratic traditions, beneficence (L., to do good for another) has been central to the motivations and purposes of medicine. The most basic form of beneficence is nonmaleficence (i.e., ‘do no harm’). This reminder is certainly relevant to the practice of medicine. Even though technological advances continue to strengthen a physician’s ability to repair injuries and cure diseases, the most important expression of beneficence remains to ‘do no harm’. ‘Can’ does not imply ‘should’. The harms to be balanced with benefits include intentional harms as well as those harms that can be anticipated to arise despite the best intentions (e.g., unwanted side effects of medication or complications of surgical treatment).
In balancing the promotion of a patient’s wellbeing with the promotion of self-determination, a physician should attempt to interpret a patient’s best interests as objectively as possible. An effort to override a patient’s wishes in order to pursue what her physician perceives to be in her best interests -- i.e., paternalism -- is rarely (if ever) justified.
5. Is the decision just?
A sound decision takes into consideration the implications a course of action has for third parties immediately affected and for the interests of the larger society. A democratic society is committed to freedom and justice. Accordingly, individuals are free to claim what they are due based on specified personal properties or characteristics. It is important that all members of the society participate in the ongoing responsibility to select criteria that are relevant to the benefits and burdens being assigned. For instance, in our society, such variables as ethnicity, gender, and religious persuasion are not considered to be legitimate criteria by which to determine the distribution of such benefits as housing, education, employment, or health care.
Individuals equally concerned about justice may use different theories of justice in determining what would be a fair distribution of benefits and burdens. Some might variously argue that the distribution should correlate with need, effort, contribution, merit, or ability to pay. Others might argue that benefits and burdens should be distributed equally or randomly. The approach taken in a given situation should be relevant to the benefits and burdens being assigned. Commitment to a just decision creates an obligation to treat fairly those who are alike according to the selected criteria. No one should receive unequal treatment unless it is demonstrated that s/he differs significantly from others in a way that is relevant to the treatment in question.
Achieving fairness is most difficult when constraints such as scarcity of resources force judgments about competing claims made by individuals who appear to have equal standing based on agreed-upon distribution criteria. For instance, a critically ill patient needs intensive care, but the intensive care unit is filled to capacity. All the patients in the unit meet the medical criteria for intensive care. If the available resources cannot be redistributed to accommodate another patient, additional criteria must be used in order to decide which patients receive intensive care and which patient is transferred to a less intensive setting. The selection of additional criteria (e.g., the increased risk if transferred or the likelihood of successful recovery) is itself an ethical issue.
6. Is confidentiality ensured?
A sound decision depends on the confidential handling of sensitive information. A patient’s freedom to make decisions about her health care includes the right to decide how and to whom personal medical information is communicated. Carelessness about patient privacy undermines patient trust. This hazard is especially acute when multiple professionals are involved in patient care, when patient care is delivered in an educational setting, or when insurance companies and HMOs are involved. In the near future, the increasing availability of genetic information will make confidentiality even more difficult to maintain.
In general, protecting a patient’s privacy takes precedence over other obligations. However, in some situations, maintaining confidentiality may result in harm to a third party immediately affected by the patient’s chosen course of action. In other situations, maintaining confidentiality may be challenged by accountability to society when faced with epidemic conditions. Since a breach of confidentiality may destroy the patient-physician relationship, the magnitude of risk to others must be actual and grave. Ethical judgment and legal regulations about reporting communicable diseases may not coincide. In the rare instances when breaking confidence is deemed justified, the physician should attempt to explain the circumstances to the patient, solicit the patient’s approval, and remain committed to the patient’s care.
Ethical Dimensions of Patient Care #13
Ethical Decision-Making (part 2)
When ethical concerns require careful analysis, the decision-making process and the resulting decision’s soundness should be measured by at least six obligations -- i.e., Does sufficient trust exist among the involved parties for truthful and adequate information to be exchanged? Is the patient’s right to self-determination protected? Is the patient’s consent truly informed? Does the decision promote the wellbeing of the patient? Is the decision just? Is confidentiality ensured?
1. Does sufficient trust exist among the involved parties for truthful and adequate information to be exchanged?
A sound decision requires that truthful and adequate information pass between patients and their physicians. For this communication to occur, the physician must be truly present in mind with his/her patient in order to listen with interest for insight and to avoid steering the patient toward predetermined conclusions. It is the physician’s responsibility to recognize when competing demands for his/her attention so weaken the attempt to listen that important information may be missed.
Both patient and physician should be free to express concern that adequate information has not been shared. A physician should not assume that s/he rather than the patient knows what information needs to be shared. In general, a patient benefits from an understanding of her medical condition, its prognosis, and the treatment/s available. A perception that essential information has been concealed or distorted undermines trust.
A substantial history of continuity of care usually establishes trust between a patient and her physician. Without such experience together, patients and physicians may approach each other more as strangers or even adversaries. This hesitancy is exacerbated when physicians are wary due to the present litigious atmosphere surrounding medicine and when patients are unnerved by the impersonal effect of hospitals. Perhaps the most difficult circumstances in which to establish trust occur when the initial contact between a patient and her physician happens during an emergency.
The ability to establish trust is central to practicing the art of medicine. There will be patients with whom, for a variety of reasons and after considerable effort, trust cannot be established. In such circumstances, the physician should assist the patient in the transfer of her care to another qualified medical professional.
2. Is the patient’s right to self-determination protected?
A sound decision requires respect for a patient’s right to self-determination. This right derives from her broader societal liberty to set personal values of conduct and to choose voluntarily a course of action consistent with those values. Such freedom necessitates that others avoid interfering, except when the individual is not competent to make decisions or when the chosen course of action infringes on the freedom and interests of others. It is a purpose of law to clarify the boundaries within which individuals exercise their autonomy (L., self-law or self-rule).
It is the physician’s responsibility to maximize his/her patient’s liberty to choose the direction, nature, and consequence of her health care. To do so requires restraint. A physician may have to consider an alternate management plan if the patient rejects the course of treatment that the physician judges to be in the best medical interests for the patient. For instance, a physician who advises a woman with a history of life-threatening peripartum cardiomyopathy to avoid future pregnancy is restricted from taking further steps to interfere with her reproductive choices.
3. Is the patient’s consent truly informed?
A sound decision requires that the patient consent to the course of action and that her consent be truly informed. Informed consent is defined as “the willing and uncoerced acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits”. The argument for the informed consent process in medical practice focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).
A patient’s right to make her own decisions about medical interventions extends to her liberty to refuse recommended medical treatment. In 1914 Judge Benjamin Cardozo pointed to the future when he argued that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”. The meaning of consent -- itself still a novelty in 1914 -- expanded by the 1950s to informed consent and by the 1970s to informed choice.
At times, a patient’s capacity to comprehend and process the information presented to her may be in doubt. The physician should, through consultation and further discussion with the patient, attempt to clarify the patient’s capacity to consent. If a patient is unable to consent, a substitute decision-maker should be sought.
1. Does sufficient trust exist among the involved parties for truthful and adequate information to be exchanged?
A sound decision requires that truthful and adequate information pass between patients and their physicians. For this communication to occur, the physician must be truly present in mind with his/her patient in order to listen with interest for insight and to avoid steering the patient toward predetermined conclusions. It is the physician’s responsibility to recognize when competing demands for his/her attention so weaken the attempt to listen that important information may be missed.
Both patient and physician should be free to express concern that adequate information has not been shared. A physician should not assume that s/he rather than the patient knows what information needs to be shared. In general, a patient benefits from an understanding of her medical condition, its prognosis, and the treatment/s available. A perception that essential information has been concealed or distorted undermines trust.
A substantial history of continuity of care usually establishes trust between a patient and her physician. Without such experience together, patients and physicians may approach each other more as strangers or even adversaries. This hesitancy is exacerbated when physicians are wary due to the present litigious atmosphere surrounding medicine and when patients are unnerved by the impersonal effect of hospitals. Perhaps the most difficult circumstances in which to establish trust occur when the initial contact between a patient and her physician happens during an emergency.
The ability to establish trust is central to practicing the art of medicine. There will be patients with whom, for a variety of reasons and after considerable effort, trust cannot be established. In such circumstances, the physician should assist the patient in the transfer of her care to another qualified medical professional.
2. Is the patient’s right to self-determination protected?
A sound decision requires respect for a patient’s right to self-determination. This right derives from her broader societal liberty to set personal values of conduct and to choose voluntarily a course of action consistent with those values. Such freedom necessitates that others avoid interfering, except when the individual is not competent to make decisions or when the chosen course of action infringes on the freedom and interests of others. It is a purpose of law to clarify the boundaries within which individuals exercise their autonomy (L., self-law or self-rule).
It is the physician’s responsibility to maximize his/her patient’s liberty to choose the direction, nature, and consequence of her health care. To do so requires restraint. A physician may have to consider an alternate management plan if the patient rejects the course of treatment that the physician judges to be in the best medical interests for the patient. For instance, a physician who advises a woman with a history of life-threatening peripartum cardiomyopathy to avoid future pregnancy is restricted from taking further steps to interfere with her reproductive choices.
3. Is the patient’s consent truly informed?
A sound decision requires that the patient consent to the course of action and that her consent be truly informed. Informed consent is defined as “the willing and uncoerced acceptance of a medical intervention by a patient after adequate disclosure by the physician of the nature of the intervention, its risks and benefits, as well as of alternatives with their risks and benefits”. The argument for the informed consent process in medical practice focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).
A patient’s right to make her own decisions about medical interventions extends to her liberty to refuse recommended medical treatment. In 1914 Judge Benjamin Cardozo pointed to the future when he argued that “every human being of adult years and sound mind has a right to determine what shall be done with his own body”. The meaning of consent -- itself still a novelty in 1914 -- expanded by the 1950s to informed consent and by the 1970s to informed choice.
At times, a patient’s capacity to comprehend and process the information presented to her may be in doubt. The physician should, through consultation and further discussion with the patient, attempt to clarify the patient’s capacity to consent. If a patient is unable to consent, a substitute decision-maker should be sought.
Ethical Dimensions of Patient Care #12
ETHICAL DECISION-MAKING (part 1)
[These reflections were first drafted 1997 when I prepared -- in collaboration with Fidelma Rigby, MD, a Maternal-Fetal Medicine specialist at LSU’s School of Medicine – a response to an invitation from the American College of Obstetricians and Gynecologists’ Technical Bulletin Committee to submit a revision of the committee’s 1989 bulletin entitled ‘Ethical Decision-making in Obstetrics and Gynecology’. I have subsequently used these reflections in numerous didactic sessions with physicians (in training) and with nurses.]
Values, Morals, and Ethics
Each individual forms a personal sense as to what is of ultimate value and what is of lesser value. These core values serve as a prism through which information is interpreted before being applied to life’s decisions. Certain relationships, experiences, circumstances, and objects are thus regarded to be of such importance to an individual that s/he is prepared to suffer great loss rather than to violate them.
Morals are common ideas about what is right or wrong, about what ought or ought not to be done. Such views are taken for granted in daily activities and can usually be acted upon safely without much conflict. However, some situations require a collective judgment from a number of individuals with competing goals or divergent viewpoints. In order to avoid a harmful abuse of power (e.g., a physician attempting to manipulate the transfer of information in order to steer a patient into agreement or a patient threatening a lawsuit), a reflective approach to decision-making -- i.e., ethics -- is necessary.
Ethics has to do with serious reflection on and the determination of what ought to be done in a given situation, all things considered. Some differences in judgment can be traced to variations in reasoning patterns. For instance, one person may be very logical, deductive, abstract. Another person may be more intuitive, pragmatic, affective. Other differences in judgment can be traced to variations in what is taken into consideration and the value given to what is taken into consideration. For instance, one physician may support a woman in her desire to obtain treatment for her infertility, while another physician -- the “gate-keeper” for the patient’s health maintenance organization -- may be most concerned with providing cost-effective primary care for a large number of patients. Before a thorough analysis of options can be undertaken, the participants in the decision-making process must respect (L., to look again) each other enough to listen carefully in order to recognize and understand these differences.
An ethical dilemma arises when compelling value-based justifications exist for two or more conflicting courses of action. On initial examination, the possible choices may appear equally strong. For example, a physician caring for a patient who is refusing surgical treatment of a large pelvic mass may be torn between promoting what appear to be the patient’s best medical interests and respecting the patient’s personal choice to refuse therapy.
Ethics, as a discipline within medicine, involves three steps. First, a framework is established for analyzing differing points of view. Second, a determination is made as to whose interests are most critical in the situation. Third, a course of action is adopted that promotes those interests with the least imposition of compromise or harm on those affected by the decision.
[These reflections were first drafted 1997 when I prepared -- in collaboration with Fidelma Rigby, MD, a Maternal-Fetal Medicine specialist at LSU’s School of Medicine – a response to an invitation from the American College of Obstetricians and Gynecologists’ Technical Bulletin Committee to submit a revision of the committee’s 1989 bulletin entitled ‘Ethical Decision-making in Obstetrics and Gynecology’. I have subsequently used these reflections in numerous didactic sessions with physicians (in training) and with nurses.]
Values, Morals, and Ethics
Each individual forms a personal sense as to what is of ultimate value and what is of lesser value. These core values serve as a prism through which information is interpreted before being applied to life’s decisions. Certain relationships, experiences, circumstances, and objects are thus regarded to be of such importance to an individual that s/he is prepared to suffer great loss rather than to violate them.
Morals are common ideas about what is right or wrong, about what ought or ought not to be done. Such views are taken for granted in daily activities and can usually be acted upon safely without much conflict. However, some situations require a collective judgment from a number of individuals with competing goals or divergent viewpoints. In order to avoid a harmful abuse of power (e.g., a physician attempting to manipulate the transfer of information in order to steer a patient into agreement or a patient threatening a lawsuit), a reflective approach to decision-making -- i.e., ethics -- is necessary.
Ethics has to do with serious reflection on and the determination of what ought to be done in a given situation, all things considered. Some differences in judgment can be traced to variations in reasoning patterns. For instance, one person may be very logical, deductive, abstract. Another person may be more intuitive, pragmatic, affective. Other differences in judgment can be traced to variations in what is taken into consideration and the value given to what is taken into consideration. For instance, one physician may support a woman in her desire to obtain treatment for her infertility, while another physician -- the “gate-keeper” for the patient’s health maintenance organization -- may be most concerned with providing cost-effective primary care for a large number of patients. Before a thorough analysis of options can be undertaken, the participants in the decision-making process must respect (L., to look again) each other enough to listen carefully in order to recognize and understand these differences.
An ethical dilemma arises when compelling value-based justifications exist for two or more conflicting courses of action. On initial examination, the possible choices may appear equally strong. For example, a physician caring for a patient who is refusing surgical treatment of a large pelvic mass may be torn between promoting what appear to be the patient’s best medical interests and respecting the patient’s personal choice to refuse therapy.
Ethics, as a discipline within medicine, involves three steps. First, a framework is established for analyzing differing points of view. Second, a determination is made as to whose interests are most critical in the situation. Third, a course of action is adopted that promotes those interests with the least imposition of compromise or harm on those affected by the decision.
Ethical Dimensions of Patient Care #11
Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 5)
PROPOSITIONS FOR DISCUSSION
If this four-part analysis for distinguishing dispositions toward euthanasia is used:
1. The dispositions toward euthanasia among Dutch physicians will be more accurately understood and more appropriately referenced in our society’s public and professional discussion of physician-assisted dying and euthanasia.
2. The discussion of physician-assisted dying and euthanasia now taking place in our society will not so easily devolve into polarized and disrespectful positions.
If this four-part analysis for distinguishing dispositions toward euthanasia is used:
1. The dispositions toward euthanasia among Dutch physicians will be more accurately understood and more appropriately referenced in our society’s public and professional discussion of physician-assisted dying and euthanasia.
2. The discussion of physician-assisted dying and euthanasia now taking place in our society will not so easily devolve into polarized and disrespectful positions.
Ethical Dimensions of Patient Care #10
Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 4)
4. The ‘bar keeper’ disposition
4.1 Summary: Physicians with this disposition are predisposed to consider managing a patient’s death by euthanasia when the patient is convinced his/her suffering is unbearable and when they are convinced the patient is competent to make this request.
4.2 Metaphor: The bar keeper is responsible for insuring that individuals ordering alcoholic drinks (1) are of legal age and (2) do not so compromise their competency to the point that s/he or others are put at risk.
4.3 Commentary: No Dutch physician in this study represents this disposition. However, the Dutch professional and public literature I have reviewed suggests that some Dutch physicians practice with this disposition. They would all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. For them, such patients would most often be patients whose suffering is associated with a somatic condition. However, they need not be so classified. The patient’s assessment of the magnitude of the suffering is the decisive factor in crossing the threshold from ‘managing life/recovery’ to ‘managing death/dying process’. In contrast to physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions, these physicians do not form a judgment about or seek agreement with the patient about the criteria by which to conclude that the suffering is unbearable. Instead, these physicians accept the patient’s assessment, regarding the matter to be too subjective to do otherwise. The question for which they accept responsibility is the competency of the patient who is persistently requesting euthanasia. These physicians are prepared to provide euthanasia to competent patients. They would agree to provide euthanasia for all patients for whom physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions would provide euthanasia. They also would consider not providing euthanasia in cases in which they are convinced the patient is not competent. They do not experience the level of moral dissonance in agreeing to perform euthanasia common among physicians with ‘back against the wall’ or ‘peripheral vision’ dispositions. Though not often politically active themselves, these physicians hold a disposition toward euthanasia that corresponds most closely with one or more of the parties that have comprised the governing coalition since 1995. Physicians with a ‘bar keeper’ disposition toward euthanasia support efforts to legalize this practice.
4.4 Distribution: Among the Dutch physicians in this study, none have identified themselves with this disposition. The more removed their dispositions are from the ‘bar keeper’ disposition, the more certain they tend to be that the end-of-life management of as many as 20% of current Dutch physicians corresponds most closely with the ‘bar keeper’ disposition. It is my impression that as early as 1973 few (if any) Dutch physicians held a ‘bar keeper’ disposition. By 1984 perhaps a small number of Dutch physicians had concluded that a patient’s ‘quality of life’ is too subjective for physicians to question a patient’s conclusion that their suffering is not bearable and were, thus, prepared to provide euthanasia to patients unless uncertain about their competency. By 1993 it is my impression that the percentage had grown to perhaps 5-10% of Dutch physicians. This percentage seems to have remained constant to the present time.
4.1 Summary: Physicians with this disposition are predisposed to consider managing a patient’s death by euthanasia when the patient is convinced his/her suffering is unbearable and when they are convinced the patient is competent to make this request.
4.2 Metaphor: The bar keeper is responsible for insuring that individuals ordering alcoholic drinks (1) are of legal age and (2) do not so compromise their competency to the point that s/he or others are put at risk.
4.3 Commentary: No Dutch physician in this study represents this disposition. However, the Dutch professional and public literature I have reviewed suggests that some Dutch physicians practice with this disposition. They would all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. For them, such patients would most often be patients whose suffering is associated with a somatic condition. However, they need not be so classified. The patient’s assessment of the magnitude of the suffering is the decisive factor in crossing the threshold from ‘managing life/recovery’ to ‘managing death/dying process’. In contrast to physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions, these physicians do not form a judgment about or seek agreement with the patient about the criteria by which to conclude that the suffering is unbearable. Instead, these physicians accept the patient’s assessment, regarding the matter to be too subjective to do otherwise. The question for which they accept responsibility is the competency of the patient who is persistently requesting euthanasia. These physicians are prepared to provide euthanasia to competent patients. They would agree to provide euthanasia for all patients for whom physicians with ‘backed against the wall’ or ‘peripheral vision’ dispositions would provide euthanasia. They also would consider not providing euthanasia in cases in which they are convinced the patient is not competent. They do not experience the level of moral dissonance in agreeing to perform euthanasia common among physicians with ‘back against the wall’ or ‘peripheral vision’ dispositions. Though not often politically active themselves, these physicians hold a disposition toward euthanasia that corresponds most closely with one or more of the parties that have comprised the governing coalition since 1995. Physicians with a ‘bar keeper’ disposition toward euthanasia support efforts to legalize this practice.
4.4 Distribution: Among the Dutch physicians in this study, none have identified themselves with this disposition. The more removed their dispositions are from the ‘bar keeper’ disposition, the more certain they tend to be that the end-of-life management of as many as 20% of current Dutch physicians corresponds most closely with the ‘bar keeper’ disposition. It is my impression that as early as 1973 few (if any) Dutch physicians held a ‘bar keeper’ disposition. By 1984 perhaps a small number of Dutch physicians had concluded that a patient’s ‘quality of life’ is too subjective for physicians to question a patient’s conclusion that their suffering is not bearable and were, thus, prepared to provide euthanasia to patients unless uncertain about their competency. By 1993 it is my impression that the percentage had grown to perhaps 5-10% of Dutch physicians. This percentage seems to have remained constant to the present time.
Ethical Dimensions of Patient Care #9
Dispositions Re Euthanasia Among Dutch Physicians: An Interpretation (part 3)
2. The ‘backed against the wall’ disposition
2.1 Summary: Physicians with this disposition intend and expect not to manage a patient’s death by euthanasia, even though the patient and his/her family/friends as well as a majority of professional peers would judge the case to satisfy the professional and legal criteria prerequisite for doing so. However, they may judge the circumstances peculiar to some cases to be exceptional enough to result in the decision to override their reservations and to perform euthanasia.
2.2 Metaphor: KNMG position statements as late as 1984 recommended that physicians who seriously consider (and, in some cases, perform) euthanasia view themselves as ‘backed against the wall’ by the patient’s unbearable and unmanageable suffering. This metaphor suggests that the physician has been cornered by extreme circumstances and only has morally unsettling choices by which to respond.
2.3 Commentary: The Dutch physicians in this study with this disposition all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. They would limit such patients to patients whose suffering is associated with a somatic condition and are usually considered terminally ill. The suffering these patients experience cannot be made bearable by standard pain management and has reduced them to an undignified/humiliating state. These physicians find themselves ‘backed against the wall’ by competent and persistent requests for euthanasia from such patients. The most frequently referenced example among the Dutch physicians in this study is the patient with bowel obstruction due to a large abdominal tumor who is experiencing terrible pain and who is repeatedly vomiting fecal waste. In such extreme cases and once passive or indirect methods for hastening the dying process (e.g., withholding/withdrawing life-sustaining interventions) have failed, these physicians are prepared to experience considerable moral dissonance in agreeing to perform euthanasia. The critical question for these physicians is, “Are there compelling reasons to provide euthanasia?” They often suspect that depression lies behind the longing for death and expect proper pain management to make the patient’s pain bearable with very rare exception. Several of these physicians are active in providing hospice care. Though not often politically active themselves, these physicians hold a disposition about euthanasia that corresponds most closely with the Christian Democratic Party. Until the 1993 elections, CDA had been in the Parliament’s governing coalition throughout the 20th century and, now as the strongest minority party, intends to keep euthanasia on the Dutch penal code.
2.1 Summary: Physicians with this disposition intend and expect not to manage a patient’s death by euthanasia, even though the patient and his/her family/friends as well as a majority of professional peers would judge the case to satisfy the professional and legal criteria prerequisite for doing so. However, they may judge the circumstances peculiar to some cases to be exceptional enough to result in the decision to override their reservations and to perform euthanasia.
2.2 Metaphor: KNMG position statements as late as 1984 recommended that physicians who seriously consider (and, in some cases, perform) euthanasia view themselves as ‘backed against the wall’ by the patient’s unbearable and unmanageable suffering. This metaphor suggests that the physician has been cornered by extreme circumstances and only has morally unsettling choices by which to respond.
2.3 Commentary: The Dutch physicians in this study with this disposition all acknowledge that they cross the threshold from ‘managing life/recovery’ to ‘managing death/dying process’ with some patients. They would limit such patients to patients whose suffering is associated with a somatic condition and are usually considered terminally ill. The suffering these patients experience cannot be made bearable by standard pain management and has reduced them to an undignified/humiliating state. These physicians find themselves ‘backed against the wall’ by competent and persistent requests for euthanasia from such patients. The most frequently referenced example among the Dutch physicians in this study is the patient with bowel obstruction due to a large abdominal tumor who is experiencing terrible pain and who is repeatedly vomiting fecal waste. In such extreme cases and once passive or indirect methods for hastening the dying process (e.g., withholding/withdrawing life-sustaining interventions) have failed, these physicians are prepared to experience considerable moral dissonance in agreeing to perform euthanasia. The critical question for these physicians is, “Are there compelling reasons to provide euthanasia?” They often suspect that depression lies behind the longing for death and expect proper pain management to make the patient’s pain bearable with very rare exception. Several of these physicians are active in providing hospice care. Though not often politically active themselves, these physicians hold a disposition about euthanasia that corresponds most closely with the Christian Democratic Party. Until the 1993 elections, CDA had been in the Parliament’s governing coalition throughout the 20th century and, now as the strongest minority party, intends to keep euthanasia on the Dutch penal code.
2.4 Distribution: Among the Dutch physicians in this study, 46% (11/24) have identified themselves with the ‘backed against the wall’ disposition. It is my impression that by 1973 perhaps 60% of Dutch physicians were prepared to admit that, when ‘backed against the wall’, they would consider it ethically justifiable to provide euthanasia. This majority continued for a decade. However, it is my impression that by 1993 the percentage had dropped to @35% of Dutch physicians as the percentage of Dutch physicians with a ‘peripheral vision’ disposition (introduced below) grew. This percentage seems to have remained constant to the present time. Some of the Dutch physicians in this study predict that the percentage will drop a bit in the next ten years; but others predict that the percentage will rise somewhat.
Saturday, December 15, 2007
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.
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.
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