‘the ethical dimensions of patient care’ -- #41

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

Justice/Fairness

It is simple enough to say “I am for justice”. Have you come across someone who says, “I am for injustice”. It is much more complicated to be just. One reason -- the sacrifices and the risks. Another reason – the reality that no single definition of what is ‘just’ is ethically sound and efficient for all situations.

Consider the experience of the leadership team for a non-profit community health center in a rural East Tennessee Appalachia service area burdened by generations of poverty. The leadership team takes seriously the resolve in the center’s mission statement to deliver comprehensive primary medical care in a fair and gentle manner. During one of their strategic planning sessions, they realize they had employed several different ways to determine what is fair. Can you see these different ways embedded in these decisions?

The seven physicians – all family medicine physicians credentialed to provide obstetrical care (including c-sections) -- receive the same compensation. There are no productivity incentives.
Fairness is: __________________________________________

The clinical and administrative support staff members are compensated near/at their ‘market’ potential, with the distance from ‘market’ increasing across the compensation spectrum to the physicians (whose compensation is @80% of ‘market’ for community health center physicians).
Fairness is: __________________________________________

End-of-the-year bonuses for non-physician employees are the same amount for all, whereas such bonuses for physicians are calculated using an equation that takes tenure into consideration.
Fairness is: __________________________________________

The center is committed to delivering the same access to and quality of care to all patients regardless of the patient’s ability to pay.
Fairness is: __________________________________________

The center gives disproportionate attention to the health care needs of the most disadvantaged patients in the service area.
Fairness is: __________________________________________

The leadership team makes decisions about the utilization of human and capital resources based on ‘public health’ funding priorities.
Fairness is: __________________________________________

Is it legitimate to use different interpretations of what is fair? If so, what integrates the varied results as ‘fair’? Should fairness be identified by such results as harmony, balance, reciprocity? Are the anchors for fairness (1) ‘treating equals equally’ and (2) ‘treating unequals with disproportionate regard for the less powerful’? If so, can complacency (or resignation) about inequalities be overcome? How do genetic and/or prenatal inequalities influence attempts to be fair? Should the interests, rights, and/or liberties of a few ever be sacrificed for the interests, rights, and/or liberties of the many? How far should consequences be tracked in assessing the fairness of a decision? How should deliberations about a fair distribution of benefits and advantages be affected by an organization’s being ‘for-profit’ or ‘not-for-profit’?


John Rawls’ Theory of Justice is a cornerstone study for deliberations about justice and public policy. The following exercise is an adaptation of Rawls’ ‘veil of ignorance’ exercise in a way that is specifically focused on clinically relevant considerations.

‘the ethical dimensions of patient care’ -- #40

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

Decisions About Aggressive/Intensive Management

I recently asked two residents a couple of weeks into their Medicine ICU rotation – “At any given time, how many of the management plans make no sense to you?” I explained my question did not have to do with the management plans’ internal medical reasoning, but instead the management plans’ link or lack thereof to feasible outcome expectations. They both responded – “50 %”.
Note: An order/action may make sense and indicate improvement when considered from a system/problem perspective, while neither making sense nor indicating improvement when considered from a macro/integrated management perspective. Patients and family members may mistake report of system/problem level progress for macro/integrated level progress (esp. when the latter is poorly communicated).

‘the ethical dimensions of patient care’ -- #39

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

Informed Consent and Decisional Capacity

In 1914 Judge Benjamin Cardozo made the pivotal argument 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 patient ‘consent’ in the practice of medicine expanded by the 1950s to ‘informed consent’ (with the patient still in a passive position in the decision-making) and since the 1970s to ‘informed choice’ (with the patient more actively participating in shared decision-making).

Informed consent is “an autonomous authorization by individuals of a medical intervention or of involvement in research” based upon 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 (Beauchamp and Childress, Principles of Biomedical Ethics). Informed consent is a communication process. Informed consent as an ethical dimension of patient care focuses on the protection of a patient’s right to self-determination (with legal protection for the physician being a secondary purpose).

Consider the following encounter –

An intern had written for the nurse to obtain several urine samples, including one for a drug screen. When the nurse asked for the urine sample, he told the patient what tests would be conducted. When a drug screen was mentioned, the patient did not consent to the drug screen. So the nurse did not send that sample. The nurse told the intern the patient would not consent. The intern told the nurse, “I don’t care that he doesn’t give consent, go back in there and get the urine and send it. I will deal with it later.” The nurse did not go back and collect/send the urine. His supervisor advised him to write a note stating, “Patient did not consent to urine drug screening.” Both the supervisor and the nurse felt the intern’s response and course of action were inappropriate. The supervisor spoke with the attending who stated he would follow-up with the intern.

The following diagram delineates four distinguishable choices – covering a spectrum from shared decision-making to no involvement – common to patient care re whether, when, and to what extent patients, surrogates, and family members share in decision-making.


Most caregivers are able to recall the components of truly/fully informed consent. This diagram calls attention to how few decisions/orders in ‘the plan for today’ involve shared decision-making and opens discussion of the choices other than shared decision-making by (1) identifying the factors that influence a medical team’s choices and (2) testing a medical team’s ability to give justification for each of the four choices for involving patients, surrogates, and family members in decision-making. This diagram also opens discussion about the significance of decisional capacity in determining whether to involve patients, surrogates, and family members.

A person with decisional capacity makes and communicates a decision that is based on a consistent comprehension of the decision’s benefits, risks, costs, and consequences for others. A person with decisional capacity is responsible for her decisions and actions. A person may not have the capacity to make decisions at all levels of complexity or consequence. Procedures should be explained to patients without decisional capacity in terms they can comprehend. The nearer a patient is to full decisional capacity, the more consideration should be given to the patient’s views. Prior to reaching the age of majority (i.e., the threshold of adulthood), a person is presumed not to have decisional capacity unless there is evidence to the contrary.

The attending physician is responsible – through discussion with the patient and with appropriate consultation – to assess a patient’s decisional capacity. If a patient is assessed not have decisional capacity, a substitute for the patient (i.e., a surrogate) is necessary. A surrogate’s decisional capacity must also be assessed by the same criteria (i.e., consistent comprehension of medical facts and communication of choices that reflect patient wishes/interests) plus attention to compromising conflicts of interest.

A surrogate’s minimal contribution to the compromised patient’s care is to advocate for management that is in the patient’s best interests. A surrogate’s optimal contribution to the compromised patient’s care derives from being sufficiently familiar with the patient’s values to express the patient’s wishes and expectations.

‘the ethical dimensions of patient care’ -- #38

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

“When does trust commonly break down in patient care?”

When I ask caregivers this question, they invariably respond – “failed communication”. A proactive and preventive approach to the ethical dimensions of patient care encompasses ‘communication’ within its scope.

Soon after beginning my position with Barnes-Jewish Hospital two years ago, I started rounding with Dr. Laureen Hill and her medical teams in the CT-ICU. One of our first collaborations was to identify vulnerable facets of patient care communication that, when they falter in some combination, result in a deterioration of trust and respect. As the following tool indicates, we eventually focused on three vulnerabilities -- i.e., (1) the information upon which patient care decisions are made, (2) the decision-making process, and (3) the goals/expectations that influence patient care decisions. This tool provides a construct for examining each vulnerability in two steps -- first with a description and then with a set of assessment questions.


The aim of this tool -- to aid in strengthening the ethical dimensions of patient care proactively and preventively by focusing attention on and raising accountability for the communication infrastructure upon which patient care depends. The hypothesis of this tool – If the overall assessment of these three facets of patient care communication in a given case is on the strong/reliable side of the threshold, it is safe to assume the ethical dimensions of the patient’s care are sound. If the overall assessment is on the weak/unreliable side of the threshold, it is safe to assume the ethical dimensions of the patient’s care need attention. If one of the three facets of patient care communication is assessed to be broken in a given case, the interconnectedness of the three facets of patient care communication makes it safe to assume the ethical dimensions of patient care associated with the other two facets are at significant risk.

In didactic sessions, I often introduce this tool by first showing the participants several photographs that illustrate various stages of bridge or building deterioration and asking them to explain the engineering concept of a bridge or a building having ‘structural integrity’ -- i.e., “the science and technology of the margin between safety and disaster” (e.g., fatigue/fracture of materials, crack initiation/growth, the capacity to handle unexpected/overloading stress). I then transition to the ethical dimensions of patient care by suggesting that bridges and buildings be considered metaphors for the delivery of a patient’s care from admission to discharge. Such visual aids are usually effective for preparing the participants to explore the link between the ‘structural integrity’ of the communication upon which patient care depends and the ethical dimensions of patient care. I close such discussions with the question – “Who is responsible for regularly assessing the communication upon which patient care depends?” The most common response – “We all are”. I remind them of the old adage/warning – “Something that is everyone’s responsibility often/easily becomes no one’s responsibility”. And I take advantage of the opportunity to reinforce recognition of nurses’ strategic position for assessing the communication upon which patient care depends.

‘the ethical dimensions of patient care’ -- #37

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

“What do we need/expect from patients and families?”

The trust upon which safe and effective healthcare depends is multi-dimensional, is a partnership, is a collaboration between healthcare teams and patients (with their families and friends).

The ‘follow through’ metaphor is especially vivid for a sports enthusiast. Baseball has held my attention from childhood. I still have a home-movie clip my father made of me as an aspiring teenage pitcher attempting to demonstrate in slow motion the components of a proper follow through. Perhaps your favorite sport is basketball, football, tennis, golf, fishing, soccer, or . . . -- the follow through is integral to success in each one. In order to follow through on what we invite patients and families to trust about us and the hospital, we need their cooperation, participation, assistance. Thus the question – “What do we need/expect from patients and families in order to follow through on what we invite them to trust about us and the hospital?”

These four answers serve as counterpoints (in the music composition sense of combining melodies) to caregivers’ intent to be very careful (non-maleficence), to make a valued difference in the patient’s well-being (beneficence), to honor the patient’s perspective/expectations (self-determination), and to discipline their biases and use limited resources wisely (justice). Each answer highlights the accountability patients/families bear for one of the four basic concepts of medical ethics.

‘the ethical dimensions of patient care’ -- #36

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

“What do we invite patients and families to trust?”

Do you have an experience or event that helps you visualize the concept ‘trust’? Mine is from childhood back in the late 1950s and early 1960s when I would accompany my father -- a Western Kentucky group manager for the phone company -- to work sites where linemen would be repairing, upgrading, or expanding the phone lines.


I remember being mesmerized watching a lineman strap heavy spikes around his work boots and loop a long leather belt around the utility pole before buckling it to his waist work belt that was full of tools. I had to crane my neck upward as I watched the workman ‘walk’ up the utility pole to his work station. I stood in amazement as the workman turned loose of the pole and leaned away from the pole. Each time my father patiently explained the workman’s counter-intuitive actions based on trust that the long leather belt wrapped around the pole would hold.

The basic tool I use when analyzing the ethical dimensions of patient care proposes four answers to the question – “What does the hospital invite patients and families to trust about you and your co-workers?”


Each answer puts into everyday and clinically familiar language one of the four standards of medical ethics -- i.e., non-maleficence, beneficence, autonomy, and justice. When those involved in a patient’s care are able to follow through on these four intentions in a balanced/integrated way, the ethical dimensions of the patient’s care are sound. And the caregivers’ comments indicate they have experienced what brought them into the medical profession. For cases in which the ethical dimensions of care are deteriorating, I use this basic tool as a starting point for determining which one or combination of the four intentions has failed to such a degree that respect has given way to loss of confidence, suspicion, adversarial defensiveness.

Re this tool’s four concentric circles –

The root meaning of ‘intention’ is ‘to stretch or reach toward’. ‘Intention’ is used here in place of the more common ‘principle’ due to the reservation clinicians often have about ‘principle’ (e.g., “the word ‘principle’ is cold, mathematical – like a geometry axiom” or “the word ‘principle’ is easy to stay detached from” or “the word ‘principle’ is abstract”).

The focus is ‘patient/s’ and ‘families’ (pl). Caregivers appropriately take into account their other patients as they attend to any one patient.
‘Professional’ is in single quotes to indicate this subject should not be equated with ‘code/s of ethics’. To profess is to acknowledge openly before others (L., pro + fateri). For the care of patients to be a ‘profession’, caregivers use their base of knowledge and technical skills for the stated purpose of delivering healthcare services that contribute to the public’s well-being.

Those involved in a patient’s healthcare make ‘professional’ and ‘code/s of ethics’ commitments to the public as well as to their peers. These commitments should function as filters or lenses that orient caregivers toward alignment with the intentions patients and their families are invited to expect/trust when in their care.

Walking into the hospital in professional dress and with professional identification is an invitation to patients and their families to expect that we will be respectful/altruistic toward them. This professional dress and accompanying identification fit some of us more naturally/easily than they do for others of us. Self-care must not be ignored. Authentic interest in others’ well-being is an exhaustible disposition.

‘the ethical dimensions of patient care’ -- #35

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

“Why do well-intended individuals come to different conclusions about what ought to be done?”

Reworded for application to the patient care setting – “What might well-intentioned patients, family members, medical team members, administrative personnel, et al be considering when they disagree about what should be done in a patient’s care?” The ‘all things considered’ phrase in the previous post's definition of ‘ethics’ provides a way into the question. One reason well-intentioned individuals come to different judgments about what should be done in a situation has to do with what they are considering -- i.e., they may be considering quite different aspects of the situation and/or they may be assigning different weight, priority, value to considerations they share in common.

We make frequent use of the words ‘consider’ and ‘consideration’. Many etymologists think these words had their origin in a marvelously engaging Latin combination that means to gaze at the stars. Thus, to consider is to look intently at, to think carefully about, to pay attention to, to regard with respect.

I have the opportunity to round in various patient care settings two or three weeks of most months. I always take copious notes as I move with the medical team from patient to patient. It hardly ever fails that members of the medical team -- perhaps a resident, or a nurse, or a medical student, or . . . -- will pull me aside at some point to ask, “What are you writing down? What are you hearing?” I will often answer – “I am listening to how you and your colleagues are talking about the experience of caring for the patient. Not so much what you eventually write in the chart. But the discourse that includes your adjectives, your adverbs, your emotions, your metaphors, your narratives, your whispered exchanges, your humor, your editorial comments. That discourse -- not the note in the chart -- reveals far more completely what you and your colleagues consider important enough to influence what you think should be done in caring for the patient.”

So a few months ago, I created for didactic sessions the two-part exercise below. The exercise begins by asking the caregiver/s to imagine being in the middle of a busy day with a complicated/difficult patient. The first part of the exercise then introduces in clinically relevant wording several theories of ethics, with each one accompanied by a ‘marginal to ultimate’ scale of weight/importance. The second part of the exercise introduces several other considerations I routinely detect on rounds. The considerations introduced in the second part of the exercise are rarely addressed in textbooks or courses about ethics (including biomedical ethics). These considerations nonetheless often deeply influence the judgments medical team members make about what should be done in caring for a patient.

It is vitally important to encourage conflicted parties to cling to the ‘well-intended’ assumption about each other as long as possible and only surrender the assumption after careful/thorough examination produces overwhelming evidence to the contrary.

‘the ethical dimensions of patient care’ -- #34

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

Defining ‘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 filter 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. Judgments about what ought or ought not to be done 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 such situations, a reflective approach to decision-making -- i.e., ethics -- is necessary.

Ethics has to do with 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 gatekeeper 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 each other enough to listen carefully in order to recognize and understand these differences.

The intent is to place the subject of ‘ethics’ quickly/clearly near to individuals directly/actively involved in patient care. The words ‘ethics’ and ‘ethical’ are used frequently in routine discourse (and not, therefore, limited to intentionally/formally ‘ethics’ discussions). In seeking to understand how these words are being defined, I look for opportunities to draw attention to the phrase – “the ethical dimensions of patient care” -- in the BJH Basics poster re the hospital’s ethics consultation assistance. When appropriate I often ask caregivers what they understand to be the ethical dimensions of care in their patient care settings. The two linked definitions of ‘ethics’ above focus on the way we make decisions, first in reference to core values and then in reference to the interests of others affected by our decisions. If/when ‘ethics’ needs to reduce to a single concept, I invariably point to the resolve to be respectful. By pausing to consider the etymology and component parts of ‘respect’ (i.e., L., re + specere), this very common word regains its force as a prism by which to analyze our decisions. I find that many enjoy creating the cluster of words that share the root verb -- specere.

the ethical dimensions of patient care -- #33

[As written/circulated 2008-09 for the Barnes-Jewish Hospital Ethics Committee members]

Most days entail a series of encounters – turning a hallway corner, crossing a lane of traffic, reaching for an object, finding a place in line, looking up from a table, chasing a prize, competing for a position, . . . Encounters reveal the set of values and the sense of purpose out of which we each decide how to proceed. To treat someone humanely is to be artistic, subjective, freeing, reciprocal, gentle, engaged, holistic, attentive, patient, modest, trusting, graceful, reconciling. In short, to be treated humanely is to be respected. To treat someone inhumanely is to be rough, indifferent, curt, suspicious, selfish, alienating, exploiting.

Excellent medical care is scientific, being grounded in research results. Statistical associations and concentration on damage/diseased body parts objectify the patient. Differential diagnoses reflect plausible cause and effect explanations. The patient’s immediate problem receives more attention than the patient’s larger story. Caregivers must be sufficiently detached to maintain aequanimitas or balance. Only by keeping the ‘aim eye’ fixed on patients as individuals worthy of respect, compassion, and fairness can caregivers avoid the indifference that degrades patient encounters into self-serving alienation . . . the indifference that leaves patients bruised, manipulated, exploited.

Do educational and medical practice settings promote humane encounters? Listen closely to discourse during rounds, call-room conversations, doctors’ lounge conversations, grand rounds, morbidity-mortality conferences, evaluation sessions, faculty meetings, medical staff meetings, discussions about ranking residency candidates, depositions, productivity reviews, . . . .

Professionalism and ethics firmly rooted in a humane approach to patient encounters necessitate a fourth language integrated with the scientific/clinical, the legal/regulatory, and the business languages upon which patient care is based. This fourth language is the language of respect, compassion, and fairness. Fluency with the language of respect, compassion, and fairness is not required to complete medical education, to pass post-graduate boards, to be rewarded by practice management, to secure hospital privileges, to pass recertification examinations, to be promoted, to be elected to national positions of leadership, . . . . Fluency with the language of respect, compassion, and fairness is, however, essential for sustaining the experience of being a humane caregiver who cares deeply about patients – especially the most difficult patients – and who brings a resolute social conscience to the practice of medicine.

‘the ethical dimensions of patient care’ -- #32

[August 2000 journal entry]

I think of myself as a prompter, as leaven(ing), as an encourager re my presence with medical students, residents, academic physicians, and practicing physicians (especially with the ones with whom I am in ongoing/open-ended conversation). At the same time, I am very suspicious of the inner-workings of the medical education/practice sphere in which they/I work – to the point that ‘subversive’ or ‘revolutionary’ may be accurate descriptions of my presence. I sense that my suspicions -- or at least the time I invest in analyzing the medical education/practice sphere – exceed the suspicions of most. Perhaps my vision for medical students, residents, academic physicians, and practicing physicians exceeds the vision they have for themselves. In other words -- the more radical the vision, the less compatible with the medical education/practice sphere. I have had comparatively little experience with undergraduate pre-med students as they make the decision to pursue a medical career.

‘the ethical dimensions of patient care’ -- #31

[March 2000 journal entry]

I do not think a fundamentalist/evangelical thought world supports/nurtures the practice of medicine – due to the pre-modern and pre-scientific underpinnings of a fundamentalist/evangelical thought world, the anti-critical thinking inherent in a fundamentalist/evangelical thought world, opposition to consideration of ‘chance’ or ‘innocent’ suffering in interpreting life experiences, the preference/inclination for categorical rather than situational thinking, . . .

A ‘non-religious’ view of Dietrich Bonhoeffer -- #114

[July 2000 journal entry]

What meaning (if any) remains (for me, at least) for the concept ‘lord’ (in reference to ‘God’ or ‘Jesus’) from a ‘non-religious’ approach to ethics and spirituality? (Related terms include ‘master’ and ‘king’.) I have considerable reservations about using the term ‘lord’. Reasons?

1. The concept ‘lord’ is sociomorphic language and, therefore, vulnerable to the idolatrous use of ‘God’ language characteristic of the ‘religious’ sphere.
   
   
2. The concept ‘lord’ as used in the ‘religious’ sphere necessitates an assumption about ‘revelation’ that also is anthropo-/cosmomorphic language and vulnerable to the idolatrous use of ‘God’ language characteristic of the ‘religious’ sphere.
   
   
3. The concept ‘lord’ as used in the ‘religious’ sphere leads to a passive spirituality and ethics (with a decidedly stronger sense of authority for ‘lord’ than for ‘shepherd’). My methodology is ‘from below’ and, therefore, grounded in the sense that I am accountable for my life decisions/actions as well as grounded in the recognition that human beings are meaningfully (not absolutely) ‘autonomous’.
   
   
4. The concept ‘lord’ as used in the ‘religious’ sphere implies comprehensive authority for the sanctioned views in Jewish scripture and Christian scripture. To deviate in the realms of politics, science, medicine, . . . is to weaken/diminish the meaning and usefulness of the concept ‘lord’.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #113

[June 2000 journal entry]

If ‘God’ language within the ‘religious’ traditional/orthodox (T/O) paradigm is analogous to ‘Santa’ language, then there should be insight re ‘non-religious’ prayer through studying the language changes (e.g., sending wish lists to ‘Santa’) that occur when children cease to believe in a literal ‘Santa’.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #112

[June 2000 journal entry]

How far should Bonhoeffer, the ‘scrapheap’ Job, or ‘Jesus’ be seen as going when measured by ‘non-religious’ criteria? I would argue that, once the threshold separating ‘religious’ from ‘non-religious’ has been decisively crossed, there is no way back across that threshold into the ‘religious’ sphere without violating one’s integrity (analogous to the spikes at a rental car return gate that make it impossible to reverse without damaging the tires). No adult returns to a childish belief in Santa Claus. Once the curtains had been pulled back, the wizard could no longer awe Dorothy and her friends.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #111

[June 2000 journal entry]

Proposition: that a ‘from below’ approach to ‘God’ language has less risk of idolatrous language than the ‘from above’ ‘God’ language sanctioned/used within the ‘religious’ sphere.

Fragment -- #146

[July 2000 journal entry]

I have experienced three ways to consider Jewish scripture and Christian scripture in forming life-views, establishing values/aspirations, and making decisions. Imagine a circle representing the ‘religious’ sphere. Two of the three ways are inside this circle; one is outside this circle. Imagine widening circles around three points – i.e., Interpretation #1, Interpretation #2, and Interpretation #3.

I was born and raised with Interpretation #1 (which is located deep within the ‘religious’ sphere) taken for granted. This disposition/approach begins and ends with final authority assigned to Jewish scripture and Christian scripture (including the historical, cultural, and contextual records/expressions of ‘religious’ faith found therein). The received ‘canon’ collection -- also taken for granted -- is considered the authoritative text for cosmology, scientific questions, political decisions, history, marriage/family, sexuality, social laws/mores, . . . (essentially the equivalent of a set of educational texts for a school curriculum). The interpretation of Jewish scripture and Christian scripture is assumed to be clear and without ambiguity. My public school experience – though hardly cutting edge in rural West Kentucky – revealed other views to me as a youth and planted questions in my mind re Interpretation #1.

By the time my first wife had been diagnosed with multiple sclerosis (1973) and I had begun graduate studies (1974), I had moved to Interpretation #2 – variations of which are also located within but toward the outer edge of the ‘religious’ sphere. This disposition/approach also begins and ends with final authority assigned to Jewish scripture and Christian scripture. However, the results of critical scholarship re historical, cultural, and contextual records/expressions of faith found therein alter what is considered normative or feasible. Interpretation is seen to be far more complicated. More and more exceptions to the conclusions of Interpretation #1 arise. Interpretation #2 moved me far from the ‘religious’ tradition in which I was raised. I found examples of Interpretation #2 as early as Origen of Alexandria in the history of Christian thought, though Interpretation #2 did not become a clearly defined alternative until well into the 19th century in response to the rapidly expanding results of scientific inquiry.

By our 1992 move to Vermont, I had moved to Interpretation #3. Other than Bonhoeffer’s prison correspondence, I had found no direction for Interpretation #3 (which is located outside/beyond the ‘religious’ sphere). Interpretation #3 begins and ends with observation and judgment in the concrete ‘present’ of life experience as understood (1) from the perspective/angle of alignment with the most vulnerable and existentially threatened/ing individuals and (2) with foundational weight given to insights into life experiences gained through ‘from below’ inquiry. Jewish scripture and Christian scripture are considered seriously in my peripheral vision and through this two-dimensional ‘grid’. My movement toward Interpretation #3 was prompted/sustained from five directions:

First, I matured into a historian who consciously and intentionally inquires into a subject/question without predetermined paradigm allegiances (in contrast to the ‘confessional historians’ who are permitted/sanctioned within societal spheres including but not limited to the ‘religious’ sphere). The earliest evidence of this approach to historical inquiry I remember is a 1974 conversation I had with a fellow graduate student. We were both enrolled in a ‘Critical Introduction to the New Testament’ course. It was my second graduate course. My research topic was to study the “that it might be fulfilled” sayings in the Gospel of Matthew. In a conversation about the implications of our research for viewing Jewish scripture and Christian scripture as inspired, the student (name long since forgotten) told me he intended to make his research fit his already settled view of inspiration. I told the student it would be the reverse for me – i.e., that my thought about the inspiration of Jewish scripture and Christian scripture would be altered by the results of my research. A couple of years later, I read for the first time David Fischer’s Historians’ Fallacies. I have since worn out several copies reinforcing my caution and resolve as a historian. Soon after the exchange, I accepted that every attempt at historical interpretation is ‘a history’, never ‘the history’. Since that time, every historical question/subject has remained open to further examination.

Second, the experience with my first wife (d. 1987) as she fought multiple sclerosis opened my eyes to the breadth and depth of human suffering. In graduate classes I taught (1979-92), I had students do their assignments in hospital waiting rooms or other such settings rather than in a library or at dormitory desks in order to expose them to my conclusion that human suffering is the place/angle from which to think about ethics and spirituality. Since that time, it has been of highest priority for me to be so positioned when thinking about ethics and spirituality.

Third, I first read Dietrich Bonhoeffer’s prison letters in Spring 1976 and soon embarked -- oriented by his analysis -- on a radical (i.e., to the root) critique of ‘religion’. My critique of ‘religion’ – which remains ongoing – eventually resulted in the discrediting of ‘religion’ as a reliable paradigm or sphere within which to think about ethics and spirituality.

Fourth, my friendship and collaborative relationship with Tom Elkins, MD, began in the early 1980s an expanding opportunity to be present inside the medical sphere with medical students, residents, academic physicians, and practicing physicians. I quickly felt (and continue to feel) accountable for the authenticity and justification of every word/thought I express in their midst (a level of accountability that far exceeds the level of accountability I had experienced within the ‘religious’ sphere). Also, a deep collegiality/fellowship developed with a circle of physicians (some while they were still in medical school or residency) who, without encouraging incentives in the medical environment, retained the aspiration to be humane physicians who care deeply for their patients and who bring a strong social conscience to the practice of medicine.

Fifth, during the last and most tragic three years before my first wife died, a very deep spiritual relationship formed with the one individual who was able to be fully/truly present with me – Sheldon Korones, MD. Shelly is Jewish. This relationship has remained central and weight bearing for me to this day. My approach to ethics and spirituality has, from 1985 forward, formed in a way that welcomes and celebrates the affirmation/maturing of my relationship with Shelly.

Fragment -- #145

[June 2000 journal entry]

Re the ‘fork in the road’ I faced after my first wife’s death (d. 1987) – one direction led back into the conventions of societal spheres (including but not limited to the ‘religious’ sphere) and the other direction pointed into unmarked territory beyond the boundaries/norms of societal spheres. The ‘radical’ (i.e., to the root) impact of her illness and death left me with only one choice I could make with integrity – i.e., into the unmarked territory. One reason I have been wrestling so intensely with the ideas tracked in these journal entries has had to do with leading my family and with parenting minus knowing where we have been headed.

Fragment -- #144

[June 2000 journal entry]

While having my cast changed at Vanderbilt’s Orthopedic Clinic (tendon and ligament repair), I heard in the next room the nurse say to a patient “You have a purpose” in response to the patient telling her how his broken leg resulted from being run over by a car. The nurse’s comment parallels the interpretation given to Hitler’s surviving the 20 July 1944 attempt on his life. Any ‘God’ language that has such elasticity in meaning must be rejected.

Fragment -- #143

[June 2000 journal entry]

To what degree (if at all) do animals have any level of freedom? volition? memory? feeling?

Fragment -- #142

[June 2000 journal entry]

Exceptions/deviations for me from Jewish scripture and Christian scripture (as interpreted and sanctioned within the ‘religious’ traditional/orthodox (T/O) paradigm):

1. I oppose slavery,
2. I oppose capital punishment,
3. I oppose a political theory/structure based on royalty/nobility,
4. I reject a pre/non-scientific interpretation of the universe’s beginning and function,
5. I reject witchcraft and demon possession,
6. I endorse a political theory/structure based on individual freedom,
7. I endorse an equal/non-discriminating treatment of women,
8. I reject homophobia,
9. I reject the use of casting lots and similar activities to decipher ‘the will of God’,
10. I apply historical/contextual hermeneutics consistently and without restriction.

As these and other exceptions/deviations began to accumulate for me during my graduate studies, I initially treated each exception/deviation as an isolated matter that could be filed away as tolerable while I continued to hold/use some variation of the ‘religious’ T/O paradigm. Eventually I came to realize the collective weight of the accumulated exceptions/deviations, which led me to move deliberately and intentionally away from the fundamentalist/evangelical traditions of the ‘religious’ T/O paradigm. In time, the accumulative weight of these exceptions/deviations undermined the credibility/integrity of the entire theological spectrum of the ‘religious’ T/O paradigm for me. As examples of the results, I took such radical (i.e., to the root) steps as

1. framing and studying all questions from a ‘from below’ perspective/position,
2. permitting and speeding my experience of the deconstruction (meltdown) of the ‘religious’ T/O paradigm,
3. constructing a ‘non-religious’ approach to ethics and spirituality,
4. resolving to thoroughly tease out the differences between this approach and the ‘religious’ T/O paradigm.

The ‘scrapheap’ Job -- #72

[June 2000 journal entry]

The epilogue to the story/play Job suggests the ‘scrapheap’ Job should be viewed as being drawn back into conventional societal and ‘religious’ spheres. When compared to the opening paragraph of the story/play, the formerly ‘scrapheap’ Job is presented in the epilogue as even ‘greater’ than in the prologue. What does the epilogue mean for affirming/interpreting the story/play’s pivotal text (42:7-9)? Must one or the other be rejected? If so, I reject the epilogue. The epilogue raises question about ‘re-entry’. Bonhoeffer died before facing such decisions.

The ‘scrapheap’ Job -- #71

[April 2000 journal entry]

How parallel are Koheleth’s concept of ‘God’ in the Ecclesiastes essay and the whirlwind concept of ‘God’ in the story/play Job?