Seeing ‘Jesus’ from below #37

In the Broadway dramatization of the legend about medieval England (Camelot), King Arthur objects to the logic that ‘might is right’. Instead, he envisions his Camelot as the heart of a new order of chivalry committed to the idea of ‘might for right’. Heralds announce Arthur’s dream and soon the map of England is covered with the royal seal as knights from across land and sea join the Knights of the Round Table. When Lancelot and Queen Guenevere betray Arthur “in their hearts”, he momentarily tilts toward revenge, but recovers, determined not to let passions destroy the dream. However, even as peasants report that their villages no longer need door locks and their children walk free on the roads, insurrection stirs among the knights. Finally forced to set punishment for Lance and Guenevere, Arthur sees the Round Table die. Once Lancelot rescues Guenevere from the stake and flees across the channel to his castle in France, battle is inevitable. The knights thirst again for what Arthur knows to be “that most worthless of causes -- revenge”.

While putting on his armor at dawn on the day of battle, Arthur despondently recalls to himself all they had been through for “the idea” and sees only folly. Then he hears rustling in the nearby brush and calls out, “Who’s there?” A young lad sheepishly steps out, expressing his intent to be a knight. Arthur asks the stowaway how he had decided on this “extinct profession”. The boy enthusiastically responds, “Only by the stories people tell -- might for right . . . right for right . . . justice for all . . . the round table where all knights will sit”. After knighting the boy Sir Tom of Warwick, Arthur -- the gleam in his eyes restored -- orders the boy:

Hide behind the lines till the battle is over. Then return to England alive to grow up and grow old. Ask every person if he has heard the story and tell it strong and clear if he has not. Don’t let it be forgot that once there was a spot for one brief shining moment that was known as Camelot. Now shout it out with love and joy!

To which inspired Tom responds, “Camelot! Camelot!”

The ‘gospel of Jesus’ is more than the memory of an idea; it is an announcement. In the Jewish man ‘Jesus’ of Nazareth, for a fleeting moment light shown uniquely in our midst, the will of ‘God’ was done on earth; mercy and justice merged. ‘Jesus’ sent his disciples into the world to keep alive, by life and thought, his good news of a way of life so extraordinary as to meet injurious aggression by the seemingly foolish and impossible standard of turning the other cheek.

That a trace of what he envisioned may endure is his legacy.

Seeing ‘Jesus’ from below #36

A few days into the Montgomery bus boycott, Martin Luther King, Jr. answered a midnight phone call and heard – “Nigger, we’re tired of you and your mess now. If you ain’t out of town in three days, we’re gonna blow your brains out and blow up your house.” Weary, frustrated, and fearful for his family, King told himself he had to “call on that something and person Daddy used to tell me about, the power that can make a way out of no way.” He discovered that “religion had to become real to me and I had to know God for myself.”

‘Jesus’ does not attempt to tell those who will listen what they should do in every situation involving adversaries. He does inform them that they will be distinguishable in their attitude and behavior toward their enemies. Even if forced to harm an enemy in defense of those for whom they have an overriding obligation, their process of decision-making and their reaction to the painful consequences that befall an enemy will be exceptional.

Seeing ‘Jesus’ from below #35

In the novel All Quiet on the Western Front, Erich Maria Remarque described the terror, the stench, boredom, the savagery, the courage experienced by a platoon of young German soldiers caught in the brutal trench fighting of the last chaotic days of World War I. In close combat, the longing to survive grips the main character:

We crouch behind every corner, behind every barrier of barbed wire, and hurl heaps of explosives at the foot of the advancing enemy before we run. Crouching like cats we run on, overwhelmed by this wave that bears us along, that fills us with ferocity, turning us into thugs, into murderers, into God only knows what devils; this wave that multiplies our strength with fear and madness and greed of life, seeking and fighting for nothing but our deliverance. If your own father came over with them you would not hesitate to fling a bomb into him.

Away from battle, reflection would slip back in. When guarding Russian prisoners, he pondered how “A word of command has made these silent figures our enemies.” Eventually a veteran of numerous attacks and counterattacks, the German youth was sent out at night to discover how far the enemy position had advanced. He played dead, dagger in hand, in a crater half-filled with water as the enemy rushed by in attack and then back-stepped in retreat. When a French soldier fell into the shell hole, the German soldier stabbed him madly three times. The crossfire kept him trapped with his French adversary through the night. During the daylight hours, he could not avoid his victim. Finally, he bandaged the dying man’s wounds and soaked up dirty water in a handkerchief to relieve his thirst. By mid-morning, the fatigued German soldier started talking to his victim:

I did not want to kill you. But you were only an idea to me before, an abstraction that lived in my mind and called forth its appropriate response. It was that abstraction I stabbed. But now, for the first time, I see you are a man like me. I thought of your hand grenades, of your bayonet, of your rifle; now I see your wife and your life and our fellowship. Why do they never tell us that you are just poor devils like us, that your mothers are just as anxious as ours, and that we have the same fear of death, and the same dying, and the same agony? Forgive me, comrade; how could you be my enemy?

When the French soldier died that afternoon, the German soldier promised, “Today you, tomorrow me. But if I come out of it, I will fight against this that has struck us both down -- from you, taken life -- and from me? -- life also. I promise you. It shall never happen again.”

As he crawled away toward the German line that night, he repeated, “I will fulfill everything I have promised you”. But he knew he merely uttered these words to avert ill luck. He knew he would not do as he promised.

That fleeting moment of insight in the shell hole is the enduring effect ‘Jesus’ can have on anyone who dares to listen (and listen again). To say “yes” is to say “yes” to the unnatural and seemingly foolish resolve to see an enemy as a brother/sister, as a neighbor. ‘Jesus’ had found a reason to respect his enemy. ‘Jesus’ wants no wall between him and any fellow struggler in this life, even an adversary.

As a sign of this extraordinary covenant, ‘Jesus’ first asks, “Can you pray for your enemy? Can you seek God’s blessing for your enemy?” The rabbi in Fiddler on the Roof knew the limits most will tolerate. When asked, “Is there a blessing for the Czar?” the rabbi replies, “May God bless and keep the Czar . . . far away from us.” What familiarity do prayers today show with a Moses who five times interceded for the Pharaoh and the Egyptians who for four centuries had held the descendants of Joseph in slavery? What resonance do prayers today have with the prayer of ‘Jesus’ as he hangs dying on a cross -- “Forgive them for they do not know what they are doing”?

For a second indication of the ‘turn the other cheek’ spirit, ‘Jesus’ asks, “What will you do for your enemies?” The nearest parallel to ‘hate your enemies’ is found in the Dead Sea Scrolls’ instruction to “Love all the children of light and hate all the children of darkness.” Jewish wisdom warns, “Do not gloat when your enemy falls; when he stumbles, do not let your heart rejoice.” Instead, “If your enemy is hungry, give him food to eat; if he is thirsty, give him water to drink.” Rabbis in Jesus’ day did debate two texts in the Torah. One enjoins, “If you come across your enemy’s ox or donkey wandering off, be sure to take it back to him.” The textual parallel reads ‘brother’ rather than ‘enemy’. ‘Jesus’ reinforces the admonition to do good to an enemy. But who is remembered in Jewish scripture or Christian scripture for doing good to an enemy?

• What about David’s good deeds for troubled King Saul? Perhaps, but David said he acted out of respect for the office of king.
  
  
• What about the Apostle Paul and his co-worker Silas after the earthquake in Philippi? Perhaps, but the shaken jailer hardly remained a threat to them after the earthquake.

Joseph’s care for his brothers? Elisha’s intercession for the captured Arameans? Paul’s assisting the soldiers fighting a storm in the Adriatic Sea? These are perhaps more compelling examples.

Whether Galilean or American, hearers want to know -- What’s the point of swollen cheeks, empty closets, strained backs, closed-out bank accounts? In response, ‘Jesus’ makes no mention of waiting on divine vengeance as did the Psalmists, no mention of converting the foe into a friend by “heaping coals of fire on his head” as Paul did. Why love your enemies? ‘Jesus’ answers – because doing so is inseparable from the sort of person you are (i.e., “sons of the Father in heaven who causes his sun to rise on the evil and the good and sends rain on the righteous and the unrighteous”).

Seeing ‘Jesus’ from below #34

Interpreting such jolting statements as “turn the other cheek . . . love your enemies” is especially difficult because we are both the interpreters and the ones addressed by the text we interpret. With such power over a text, we can hardly resist the chance to defuse a text that is ready to explode in our lives. Wary of this temptation, I still must venture a few suggestions about what ‘Jesus’ does not mean:

• ‘Jesus’ is not expecting us to like everything about our adversaries. The action word agape rather than the more intimate phileo indicates that good deeds -- not feelings -- are enjoined.
• ‘Jesus’ is not instructing us to overlook evil with a smile or fold our hands in passive resignation. Moral farsightedness -- not cowardice -- led ‘Jesus’ to reject violent retaliation.
• ‘Jesus’ does not want a slavishly literal application of his illustrations. When struck by a servant of the high priest, ‘Jesus’ himself questions the motive of the attack rather than turn the other cheek.

Far from this text being harmless after all, I hasten to add that ‘Jesus’ is not reversing his insistence that justice is the measuring rod of human integrity/behavior. The prophets ‘Jesus’ so often references related covenant fidelity to economic and political behavior. Victims of oppression, senseless injury, or exploitation in his hearing have no cause to doubt his alignment with/for them. Whip in hand, ‘Jesus’ drives away from the temple those who had turned the Temple into a den of robbers.

What then is ‘Jesus’ saying when he says -- “turn the other cheek . . . love your enemies”? ‘Eye for an eye’ compensation for inflicting injury had been a step forward in legal justice. ‘Tooth for a tooth’ guaranteed proportional compensation for the injured party while restricting unwarranted penalty for the offender. However, ‘Jesus’ leads us even further away from ever-escalating retaliation. He puts restraint in place of an in-kind response to injury or abuse. Listen to his hyperbolic visual aids:

• “When insulted, facilitate a second blow.”
  
  
• “When sued falsely, ask the plaintiff if he expects your garment as well.”
  
  
• “When bent like a beast of burden with the baggage of a haughty Roman legionnaire, do more than you are commandeered to do.”
  
  
• “When beggars grab for loose change, give expecting no return.”

It is hard to resist ‘hyperbole’ to explain the hard text we are considering. Before sighing with relief as if reassured that ‘Jesus’ is not serious, remember that a hyperbole is an exaggerated comment designed to put in bold print the utter importance of the point being made. The four exaggerated illustrations underline the painful disengagement from self-importance and material possession that finding the ‘blessed’ way of life ‘Jesus’ proposes necessarily entails. Those truly/fully ‘blessed’ know no spirit of retaliation or revenge seeking. Those who bear the imprint of ‘Jesus’ will be liberated from a weak self-image that depends on material things. Thus freed, they will surpass an ‘eye for an eye’/‘tooth for a tooth’ reaction to ridicule or theft. Their criteria for being blessed will not be threatened by insult or material loss. They will not deny in word or deed the vision of ‘Jesus’ for fear of damaged reputation. They will take the victory out of violence by the tactic of restraint. They will stand against injustice without blurring the distinction between the offense of exploitation and the redeemable worth of the exploiter/s. They will appeal to conscience in the midst of power politics. They will not judge an evil deed as an expression of all the offender is. They will be angry, but not sin. They will not find the model for their actions in the behavior of their adversary/ies. They will find the strength and courage to love those who languish in the irresponsible habit of doing unto others only what benefits self-interest. They will break rank with the dehumanizing march of destructive self-promotion.

Am I in that number? Do I want to be . . . really?

Seeing ‘Jesus’ from below #33

[March 2006 journal entry] I wrote the original draft of these reflections for a 1987 public lecture I was invited to deliver on the ‘turn the other cheek . . . love your enemies’ section (5:38-48) in the ‘Sermon on the Mount’ material found in The Gospel of Matthew. I have reworked the original draft (minus the introduction and first section) a couple of times since beginning in 1992. The reference in the first sentence to ‘this text’ is to the ‘turn the other cheek . . . love your enemies’ section in the ‘Sermon on the Mount’ material.
__________________________

I confess two reasons why I balk at this text. First, I am a participating member of a society that rewards self-promotion, coercion, power, intimidation; a society with values that promote a weak benevolence at best; a society driven by a ‘survival of the fittest’ economic ethic. Predictably, but lamentably, the roots of self-preservation, retaliation, and revenge continue to taint my attitudes and habits.

Language reveals the heart. How often have we heard/felt/said -- “sweet revenge”, “even the score”, “I’ll get you”, “serves him/her right”, “just wait”, “your time is coming”, “make my day”, . . . ? Have we learned to dehumanize an adversary? Do we draw demonic caricatures of adversaries? Do we start each day poised like a boxer? Do we justify resisting evil with evil of like kind? Do we even relish the kill? Are we not ready for ‘Jesus’ to say, “Don’t fight back”?

Second, I balk at this text because so many collisions in life test me. Every day people who sit by us, live by us, work by us, or drive by us put us on the defensive:

• a couple walks out of a restaurant to find their car window smashed and possessions stolen;
  
  
• a teenager is taunted by classmates for refusing to participate in their ‘fun’;
  
  
• a local fisherman discovers that tourists have absconded with the prize fishing boat he lent them the night before;
  
  
• a WWII veteran, still offensive to look at after nineteen operations to minimize the damage from being shot in the face, returns to Iwo Jima;
  
  
• a Jewish physician, imprisoned by Soviet authorities for political reasons, has to do emergency surgery on a ruthless prison guard;
  
  
• a grief-stricken mother views the mutilated body of her son, beaten to death in Mississippi for noticing a white girl;
  
  
• a physician considers a counter-suit after three slanderous years weathering a frivolous lawsuit;
  
  
• a husband’s marriage is threatened by a third party who is trying to rekindle in his wife an old romantic flame.
  

I wonder – does every key in my pocket that opens a lock silently object to the admonition of ‘Jesus’ not to resist an evil person?

‘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?

A ‘non-religious’ view of Dietrich Bonhoeffer -- #110

[May 2000 journal entry

It seems to me that, if Bonhoeffer prior to 1939 considered his theology during his Confessing Church years to have been essentially true, then he would have been pressured either (1) to stay in the United States in 1939 where he could have maintained such theology or (2) to turn away from resisting the Nazis upon his return to Germany (i.e., taking ‘the inner line’ which, in the smuggled prison letters, he criticized the Confessing Church for adopting). Was Bonhoeffer, therefore, questioning the validity and credibility of his pre-1939 theology by criteria separate from whether or not the Confessing Church could/would put non-violent leverage on the Nazi regime? Or did he assess the credibility and validity of theological ideas/views (including his own) by the criterion of the Confessing Church’s ability to put non-violent leverage on the Nazi regime? I think that, in reference to my following a ‘non-religious’ path, the answer is ‘both-and’ rather than ‘either-or’. In other words, the ‘religious’ thought world did not for me prove to be intellectually/academically credible. Additionally and centrally, the ‘religion’ failed/died for me due to its incapacity to respect and to be truly present with the victims of tragic/innocent human suffering.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #109

[May 2000 journal entry]

Note: If Bonhoeffer had survived the war, no one would have yet read any of Bonhoeffer’s smuggled prison letters -- other than the Bethges -- thus making it conceivable he would have attempted to suppress/disregard/forget the radical ideas he had expressed in the smuggled prison letters.

Note: For both Bonhoeffer and the ‘scrapheap’ Job, they would have faced many re-entry opportunities into societal spheres (including but not limited to the ‘religious’ sphere). Some of these opportunities would have been pressed on them, whether or not they would have been drawn to them (analogous to Augustine of Hippo being pressed into the priesthood). Other of these opportunities would have been attractive to them.

Note: Bonhoeffer would have been misunderstood, pressured, and/or inwardly drawn back onto the ‘religious’ path (and, therefore, away/back from a ‘non-religious’ path). Note: Bonhoeffer returned to Germany in 1939 in order to be in a position to participate in the postwar reconstruction. To what degree (if to any significant degree) had he begun to consider the radical/seminal ideas expressed in his smuggled prison letters at the time he returned in 1939?

Note: How might Bonhoeffer and the ‘scrapheap’ Job have sustained a ‘wilderness’, ‘prison’, ‘isolation’ experience? How much of the initial/extremity experience needs to be sustained? What are the dynamics that need to be retained?

Note: With whom would Bonhoeffer or the ‘scrapheap’ Job have been able to talk re this experience/task and the related ideas? Eberhard mentioned several times in our conversations his struggle after the war with how to respond to the radical ‘non-religious’ ideas in the smuggled letters he received from Dietrich.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #108

[May 2000 journal entry]

The ‘wilderness’, ‘prison’, ‘isolation’ experienced by Bonhoeffer and the ‘scrapheap’ Job contributed directly to their seminal ideas. I have long pondered

1. whether Bonhoeffer would have remained/continued on the ‘non-religious’ path he was beginning to see/describe in his smuggled prison letters to Eberhard Bethge and
2. whether the ‘scrapheap’ Job should be interpreted as sustaining the radical insights/perspective he expresses in the exchanges with his three close friends.

A ‘yes’ answer to these questions would imply that they would have intentionally (had) to retain a ‘wilderness’, ‘prison’, ‘isolation’ experience (for Bonhoeffer, after prison; for the ‘scrapheap’ Job, after relief from his physical afflictions). I have attempted to retain a ‘wilderness’, ‘prison’, ‘isolation’ experience since my first wife’s death (e.g., taking advantage of isolation times, staying near individuals in desperate situations, taking actions that are consistent with being ‘with the world face to face’, . . .).

A ‘non-religious’ view of Dietrich Bonhoeffer -- #107

[May 2000 journal entry]

Who has remained on a ‘non-religious’ path re ethics and spirituality? Should the ‘scrapheap’ Job be envisioned to have done so? Would Bonhoeffer have done so had he survived the war? How/where would there be a record of the experience? As far as I know, a ‘non-religious’ path has not been worn down into an established and well-marked ‘way’. I have concluded that very few have looked or are looking for such a path.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #106

[April 2000 journal entry]

There seems to be a ‘saint’ status assigned to Bonhoeffer across much of the Christian ‘religious’ sphere. The 1939-45 Bonhoeffer is either dismissed or minimized or in other ways not treated seriously (i.e., as central and radical) other than to get to his execution. His 1939-45 years are interpreted ‘religiously’. I view his 1939-45 years as the core/focus, accenting the disjunction with his pre-1939 ‘religious’ years. I think it remains unclear whether Bonhoeffer, had he survived the war, would have followed through with the ‘non-religious’ path and ideas on which he reflected in the secret prison letters. In this same line of thought, I do not share the ‘saintly’ worship/adoration of ‘Jesus’ that formed during his life, increased after his death, and led to the ‘high Christology’ of ‘religious’ traditional/orthodox (T/O) paradigm theologies.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #105

[April 2000 journal entry]

Analogies for my continuing to test ‘God’ language and to remove ‘religious’ nuances from my thinking in search of firm/healthy language/ideas are –

1. cleaning/cutting out a tumor as well as all surrounding diseased tissue,
   
2. drilling out all of a tooth’s decay before putting in a filling,
3. looking for healthy tissue from which to begin a hernia repair,
4. tearing out all rotten wood before repair/remodeling begins.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #104

[April 2000 journal entry]

All ‘religious’ language is metaphorical. One difference between ‘religious’ and ‘non-religious’ approaches to spirituality and ethics is that a ‘non-religious’ approach acts radically (i.e., to the root) on this realization.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #103

[May 2001 journal entry]

During a recent visit with Renate Bethge, she asked if I might have some ideas/suggestions re a presentation she has been invited to give to International Bonhoeffer Society members attending the American Academy of Religion annual meeting in Denver. She has been asked to speak about ‘Memories and Perspectives’. At various times during these days together, I offered and we discussed the following ideas/suggestions (listed in no particular order) --

1. How Dietrich is remembered is linked to the perspective/s of the one/s remembering.
   
   
2. Consider working off of Dietrich’s prison correspondence thoughts about memory and remembering. Discuss the indications in the prison letters (a) that Dietrich anticipated being remembered and (b) how he wanted to be remembered.
   
   
3. To be studied is not necessarily to be remembered in a way that calls for a verdict.
   
   
4. It is ironic that organizations such as the International Bonhoeffer Society and the American Academy of Religion make it difficult for the Letters and Papers Bonhoeffer to be remembered in a radical, vibrant, and challenging way.
   
   
5. Drawing from Dietrich’s exchange in New York City with the young French pastor who aspired to become a saint (Dietrich’s 21 July 1944 letter to Eberhard), challenge the beatification or making into a saint/icon that has occurred in the ‘religious’ recollection/treatment of Dietrich.
   
   
6. Develop Dietrich’s ‘from below’ perspective (e.g., the paragraph attached to Dietrich’s December 1942 Ten Years Later essay).
   
   
7. Reconstruct how confusing and ambiguous Dietrich’s 1939-45 Abwehr conspiracy involvement was to those after the war who viewed him from a Confessing Church/Finkenwalde perspective.
   
   
8. Point to Dietrich’s sense of accountability to the next generation (e.g., the frequent references in his December 1942 Ten Years Later essay).
   
   
9. Critique various perspectives of Dietrich in light of Dietrich’s perceptions of himself as indicated in his ‘Who Am I?’ prison poem/prayer.
   
   
10. Note that how Dietrich has been remembered is somewhat analogous to the interpretations that developed around the life of ‘Jesus’ soon after his death.
    
    
11. Very soon no one will remain who knew Dietrich – his eyes, his manner, his scents, his tone, his habits, his touch, . . . .
    
    
12. Dietrich will be remembered. The question is – How will he be remembered?
    
    
13. Eberhard and Renate have invested their postwar lives to making it possible for Dietrich to be accessible to subsequent generations.
    
    
14. Consider beginning with personal memories before shifting to more prophetic reflections.
    
    
15. Eberhard knew Dietrich in ways unique to being the ‘friend in the singular’. What stands out in how Eberhard remembered Dietrich?
    
    
16. Were there detectible/significant transitions after the war in the ways Eberhard and Renate remembered Dietrich? in the ways immediate family members remembered Dietrich?
    
    
17. Should Dietrich be remembered as who he was or as who he was on the verge of becoming? according to familiar categories (i.e., pre-1939 categories) or according to unfamiliar categories (i.e., post-1939 categories)?
    
    
18. Perspectives by which Dietrich is remembered – e.g., religious, Jewish, immediate family, scholar, historian, Finkenwalde student, fellow conspirator, friend, Maria, fellow prisoner, Confessing Church colleague, . . . perspectives.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #102

[March 2000 journal entry]

With a statistical ‘standard deviation’ curve as a reference point, the individuals who are ready and motivated to pursue a ‘non-religious’ approach to ethics and spirituality correlate with 2+ standard deviations from the mean. These individuals are sifted out by such variables as

1. the resolve to think consistently,
2. multidisciplinary reading/perspective,
3. the decision to live and think ‘from below’,
4. the experience of a language/paradigm ‘meltdown’ early enough in life and thoroughly enough not to hesitate to respond radically and irreversibly,
5. the availability of sufficient time and energy.

Fragment -- #141

[May 2000 journal entry]

After 1987 my repositioning outside the Churches of Christ denomination and the larger ‘religious’ sphere became complete and final as I radically (i.e., to the root) reconstructed my thinking. My integrity as a person was and continues to be clarified/determined by where this ‘outside’ experience takes me.

Fragment -- #140

[May 2000 journal entry]

Thesis: That the human points of reference in ‘God’ language are more meaningful, significant, and experienced than are the metaphorical/morphic adaptations of those points of reference into ‘God’ language.

Fragment -- #139

[May 2000 journal entry]

My intent is to approach life (given the uncertainties re health, longevity, . . .) in such a way that my centering goals/intentions are realized to a significant degree each day and can be so realized in the widest variety of circumstances in which I find myself.

Fragment -- #138

[May 2000 journal entry]

Note: ‘majority’ is not equivalent to ‘consensus’. Key differences include

1. how a group or society moves forward re the contested issue, and
2. the way those with deep objections to the contested issue are handled.
   

The Dutch handling of assisted dying from the late-1960s forward is an excellent study for distinguishing ‘majority’ and ‘consensus’.

Fragment -- #137

[May 2000 journal entry] I cannot regard statements that claim to be factual and interpretations of events recorded in Jewish scripture and/or Christian scripture as credible when I would not regard such statements and interpretations as credible if they were expressed or proposed by someone today.

Fragment -- #136

[May 2000 journal entry]

Is my attempt to salvage/retain the term ‘spiritual’ linked to my being born/raised in the ‘religious’ sphere? Is the term ‘spiritual’ laden with too much baggage to be effective/useful for those not raised/experienced in/with ‘religion’? Is it too much to ask/expect secular individuals to add/use a term that may appear to them to be a ‘religious’ term? Is this analogous to asking/expecting them to move near the edge of the ‘religious’ black hole?

Fragment -- #135

[May 2000 journal entry]

I am realizing there can be no ‘God’ language that is safe from idolatry. ‘God’ language seems inevitably to fall back into idolatrous use. The alternative – finally – is silence.

Fragment -- #134

[April 2000 journal entry]

‘Liberal’ representations of the Christian ‘religious’ sphere stop short of radically (i.e., to the root) addressing and challenging the flawed core of the ‘religious’ T/O paradigm.

Fragment -- #133

[April 2000 journal entry]

Re ‘God’ language – I think we are by analogy in the “there’s no Santa” phase without the ability to construct an ‘adult’ alternative language. Virtually all individuals I know sound like ‘Santa Claus’ believers when they use of ‘God’ language. Why are they?

1. Perhaps they lack the ability and education required to think critically through the ‘God’ language questions.
   
   
2. Perhaps the tragic human suffering they have experienced and/or have been pressed to take seriously is limited.
   
   
3. Perhaps they place more value on acquiring/holding a place in one or more of societal spheres (which do not encourage, much less build upon, critical inquiry).

If ‘God’ language is used in ways analogous to ‘Santa Claus’ language (which I think is the case), what are the ‘Santa believers’ claiming to be experiencing re ‘God’?

Fragment -- #132

[March 2000 journal entry]

Every person’s views/decisions are relative and situational – i.e., (1) relative at least in the sense that every person’s views derive from some perspective or angle on the subject and (2) situational at least in the sense that every person’s previous experiences influence the manner and degree to which present situations are engaged. Therefore, the question is not whether views/decisions are relative/situational, but from what perspective/angle and set of experiences do one’s views/decisions derive.

If one’s perspective/angle for forming views/decisions is essentially ideological, then individuals whose life experiences make the ‘subjects’ concrete/real will inevitably be viewed/treated within the parameters of the observer’s ideology and will be forced to confirm the credibility of that ideology. The observer’s views/decisions will often and easily be expressed as obvious, clear, and categorical . . . at the expense of objectifying or disrespecting individuals whose life experiences make the ‘subjects’ concrete/real.

Treating as most basic (i.e., cornerstone or anchoring) the responsibility/art/practice of being truly present with individuals whose life experiences make the ‘subjects’ concrete/real creates an alternative perspective/angle from which views/decisions derive. The observer’s views/decisions from this perspective/angle will rarely be obvious, clear, or categorical and individuals whose life experiences make the ‘subjects’ concrete/real will not be objectified or disrespected by the observer.

Fragment -- #131

[March 2000 journal entry]

Reflections on ‘faith’ and ‘doubt’ after hearing a sermon based on the Mark 9:14-29 text by the senior pastor for a Presbyterian USA congregation --

1. ‘Religious’ options move across a spectrum – from ‘faith’ vs. ‘doubt’ with no place for critical thinking to inquiry permitted/expected in order to confirm predetermined and unconditionally accepted views to inquiry permitted to test/cleanse pre-established views.
   
   
2. For the ‘non-religious’ approach I am discovering, ‘doubt’ centers and shapes what I trust.
   
   
3. I do not accept the Mark 9:14-29 story’s ‘religious’ way and am not seeking help in overcoming ‘unbelief’ in this ‘religious’ or T/O paradigm sense.

Fragment -- #130

[February 2000 journal entry]

“No one is innocent” – the polite but emphatic response of a physician to a colleague who had shared his views about tragedy, innocent suffering, and “the silence of God”. I think the theology implicit in the statement “No one is innocent”, when examined vigorously and critically, implicates ‘God’ and must be challenged if human suffering is to be considered innocent. Anchored by a literal view of ‘original sin’, the ‘religious’ Traditional/Orthodox (T/O) paradigm (1) makes human suffering a consequence and punishment for ‘the fall’ and (2) requires a pre-modern/pre-scientific interpretation of Genesis 1-3. I think everyone has to contend with forces that pull strongly away from a commitment to contribute to and advocate for the relief/recovery from physical, mental, and socio-economic suffering.

Fragment -- #129

[February 2000 journal entry]

‘Freedom’ (understood as individual choice and responsibility) makes my short list of great ideas and highest values, meaning that ‘freedom’ has been/is central to my intellectual efforts and that to diminish my ‘freedom’ is to diminish my ‘self’ (and, therefore, my integrity or identity).

The establishment/protection of ‘freedom’ in a society such as the United States is analogous to the concentration in medical school and residency training on the mastery of the core scientific/medical knowledge base and the technical skills prerequisite for practicing medicine. These tasks have to be treated – at least temporarily – more as ‘ends’ than as ‘means’. However, as special knowledge and technical skills do not equal being ‘professional’ or result in ‘the art of medicine’, neither does the establishment/protection of ‘freedom’ necessarily result in a ‘well-lived life’.

I would propose (1) that the Christendom era (@600-1600 AD) had no foundational or weight-bearing place for ‘freedom’ (understood as individual choice and responsibility) and (2) that, in the modern era to date, the establishment of ‘freedom’ (understood as individual choice and responsibility) still remains more an ‘end’ to be achieved than a ‘means’ by which to achieve other ends. Reaching back for and attempting to recreate medieval Christendom are neither realistic nor appealing aspirations. Instead, using the above analogy of medical education/training, I see the modern era at present as analogous to recently graduated residents who face the realization that they are not yet ‘professionals’ or able to practice in a seasoned way the ‘art of medicine’. The context in which they mature is often not particularly helpful/encouraging. Nor is the present context in the United States very supportive for maturing from treating ‘freedom’ as an ‘end’ to treating ‘freedom’ as a ‘means’.

Fragment -- #128

[February 2000 journal entry]

I recently listened to a group of physicians discuss the concept ‘grace’ in a way that associated experiencing grace with the confession of spiritual weakness. The discussion led me to realize more clearly I have come to think --

1. of grace as an invitation/opportunity to step into (even seek out) new, unfamiliar, intimidating, challenging, threatening circumstances and experiences without fearing the inevitable stumbling, falling, trembling, . . . ;
   
   
2. ‘the gospel of Jesus’ has essentially to do with daring to live as he embodies and teaches (i.e., being profoundly radical or ‘to the root’) and, therefore, entering new, unfamiliar, intimidating, challenging, threatening circumstances and experiences;
   
   
3. those who overcome their fear of failing by remaining safely within the familiar ironically remain far removed from the ‘presence of God’ – a consequence that seems to me to be inseparable from interpretations that link experiencing grace to the confession of spiritual weakness and that make childlike dependence the spiritual ideal and a prerequisite for experiencing grace.

Fragment -- #127

[February 2000 journal entry]

Though in certain ways I was a ‘child of the 60s’ re resistance to established institutions (as much as was possible in the rural western Kentucky small town in which I was raised), my aim/goal eventually became centered on being truly present with individuals with whom it is very difficult and existentially dangerous to be truly present. Initially, this resolve took a very personal and concrete form – i.e., being truly present with my first wife (d. 1987) in her struggle with multiple sclerosis. However, in time she and that experience brought light/attention for me on the breadth/depth of human suffering. I have never recovered (in the sense of being peaceful) from this realization. It is from this perspective/angle that the ideas and propositions I have to offer have been and continue to be crafted/tested. One consequence/cost has been that I have become an ‘outsider’ to societal spheres, being left with ‘guest’ rather than ‘member’ privileges. This consequence/cost leaves me wondering if these ideas and propositions have circulation potential inside societal spheres or only for other ‘outsiders’. I think the answer may be a selective ‘yes’ re inside circulation. But I do not take this for granted, nor do I assume such communication is simple.

Fragment -- #126

[February 2000 journal entry]

My answers to “Who am I?” and “What (if anything) do I have to offer?” continue to come from the convergence of two core variables – i.e.,

1. an unwavering commitment to radical (i.e., to the root) and indiscriminate inquiry (with scholarly/professional expertise in the history of ideas and in the ethical/spiritual realities of chronic illness and medical education) and
   
2. an early and sustained existentially dangerous alignment with individuals for whom life experience is tragic and offensive.
   

The interplay and inseparability of these two core variables have left me with two observations that stand in some degree of tension – i.e.,

1. I have a growing confidence that some of the ideas and proposals coming to maturity after 25+ years ‘gestation’ are credible and compelling not only to me but to at least some others, yet
2. I am uncertain how many others have the urgency, resources, energy, and/or time necessary to make the ideas and proposals their own other than by testing them in their life experiences. (In other words, do the ideas and proposals themselves ‘ring’ sufficiently authentic or self-validating not to necessitate a similar 25+ year ‘gestation’?)

I know the core ideas and propositions that have formed for me over the past 25+ years are radical (i.e., to the root), unorthodox (by the standards of social spheres/institutions including but not limited to the ‘religious’ sphere), and unsettling/disturbing for many. I have drawn this deduction from

1. the reactions I have received from certain friends, family members, former students, and peers,
   
2. my thorough study of the history of ideas that have shaped western societies,
   
3. the constructive counsel I have received from Dr. Hinson (my doctoral supervisor and mentor) and from the Bethges.

Fragment -- #125

[February 2000 journal entry]

Thesis: That an association exists between

1. indiscriminately critical thinking/inquiry and
2. alignment with the most vulnerable ‘from below’ victims/circumstances.
   

If critical thinking/inquiry is narrowed in order to protect one’s paradigm (including but not limited to the ‘religious’ T/O paradigm), then alignment with the most vulnerable ‘from below’ victims/circumstances is diminished/reduced. If one withdraws from the most vulnerable ‘from below’ victims/circumstances, then critical thinking/inquiry narrows.

Fragment -- #124

[February 2000 journal entry]

Note how quickly pastors have to settle/plateau in their thought (method as well as content), after which they at most are permitted/expected to speak or write only within the limits/expectations of the ‘religious’ traditional/orthodox (T/O) paradigm. My resistance to this restriction eventually and inevitably resulted in my separation from the ‘religious’ T/O paradigm/sphere.

Fragment -- #123

[January 2000 journal entry]

The ‘non-religious’ approach to ethics and spirituality I am discovering requires that the four Gospels be critically read through two filters – i.e.,

1. modern and scientifically informed thinking and
2. the ‘in fact’ (rather than ‘apparent’) tragedy of human suffering.

Re the first filter -- it seems to me that the four Gospels reinforce and presuppose a pre-modern/pre-scientific worldview/cosmology. ‘Jesus’ is most often presented as thinking/speaking within that thought worldview/cosmology.

Re the second filter -- the tone/intent of the narrative re Herod having the infants slaughtered reflects an insensitivity to suffering/tragedy. However, several texts do encourage thoughtful attention to suffering/tragedy -- e.g.,

1. texts that challenge an institutional/ritual approach to spirituality,
2. the Beatitudes,
3. Matt. 25:31ff,
4. the reduction of the law and prophets to ‘love’,
5. the “my God, my God, why have you forsaken me?” question from the cross,
6. the focus on the poor and the vulnerable in Luke,
7. the stories about lepers,
8. . . . .

Fragment -- #122

[January 2000 journal entry]

Instead of considering the premises and vision of ‘democracy’ cautiously and only up to the point the ‘religious’ Traditional/Orthodox (T/O) paradigm is threatened, I am resolved to be aligned unconditionally and existentially with the premises and vision of ‘democracy’ with the realization that little (if any) of the social, economic, and political underpinnings of Jewish scripture and Christian scripture is compatible with the premises and vision of democracy.

Instead of considering modern/scientific ideas/insights cautiously and only up to the point the ‘religious’ T/O paradigm is threatened, I am resolved to be aligned unconditionally and existentially with modern and scientific interpretations of human experience as the basis for determining what can be retained from pre-modern and pre-scientific traditions.

Instead of considering the breadth/depth of human suffering cautiously and only up to the point the ‘religious’ T/O paradigm is threatened, I am resolved to be aligned unconditionally and existentially with innocent sufferers/ing without regard for the theological or spiritual risk/cost of such alignment.

Fragment -- #121

[January 2000 journal entry]

A ‘fundamentalist’ mindset today is parallel to Galileo’s opponents who refused to even look at or consider his evidence because the ‘religious’ traditional/orthodox paradigm’s dogma to which they were loyal and which Galileo challenged made consideration of his evidence unnecessary.

Fragment -- #120

[January 2000 journal entry]

The ‘from below’ perspective I am discovering builds on a two-fold foundation – i.e.,

1. an indiscriminately and unreservedly critical methodology for thinking and
2. a resolve to take seriously the truly tragic realities of human suffering.

One result has been the realization that the ‘God’ language within the ‘religious’ sphere could not remain weight bearing for me. I could not claim the experience implied or assumed by such ‘God’ language. I do regard a ‘noumenal’ dimension beyond the human ‘spirit’ to be a reasonable derivative of what is weight bearing for me.