Fragment -- #158

[November 2000 journal entry]

What distinguishes an ‘authentic’ community?

1. Being penitent.
2. Being confessional with a strong rather than weak self-image.
3. Being socially engaged/invested in an honorable defeat.

Fragment -- #156

[September 2000 journal entry]

Hope for the Flowers is Trina Paulus’ tale about two caterpillars – Stripe and Yellow – has for many years been ‘canonical’ in our family discussions. The tale begins with Stripe doing what all caterpillars do. As soon as he is old enough, Stripe crawls with mounting excitement to the nearest caterpillar pillar. Those pillars -- rows and rows running to the horizon – seem to touch the clouds. Every caterpillar’s life goal? Make it to the top of one of those pillars. The method? Climb or be climbed. The rationale? No one knows or has time to think about that. Stripe quickly gets used to pushing and being pushed, to kicking and being kicked, to stepping on and being stepped on. There is no authentic communication. Only the outsides of the tangled caterpillars touch. From time to time, Stripe sees caterpillars falling to the ground below. At one point part way up the caterpillar pillar, he is muttering to himself -- “What’s at the top? Where are we going?” -- as he crawls over a little yellow caterpillar. Yellow gasps, “What did you say?” Stripe pauses. The more they talk, the less single-minded Stripe becomes. He wonders to himself, “How can I step on someone I’ve just talked to?” Stripe avoids Yellow as much as possible as they continue the climbing life, but one day she is blocking his only way up. He warns, “I guess it’s you or me”, and he steps squarely on her head. Something in the way Yellow looks at him makes Stripe feel awful about himself – “Can getting to the top be worth that?” He crawls off Yellow and whispers, “I’m sorry.” Yellow begins to cry. She suggests, “Let’s go down.” Stripe agrees. So they stop climbing, convinced there must be another way ‘up’. They decide to crawl down the pillar – a hard decision but the beginning of their search for another way of being. The remainder of the story tells how they pass through their existential cocoons into butterflies -- Yellow quickly and with little hesitation; Stripe eventually but only after being lured back for another aborted effort to climb to the top of a caterpillar pillar.

We have spoken often together as a family about how a single encounter forces Stripe to rethink carefully and radically his values, his goals, his habits . . . to rethink who he wants to be. Stripe and Yellow conclude their only option is to withdraw. We have discussed that it is not so simple for individuals who are resolved to care for the injured and ill, for individuals who are resolved to act consistently with a strong social conscience.

Fragment -- #154

[September 2000 journal entry]

My artist friend Dean recently described an experience that led me to think afresh about the way narratives form and are shared relative to the perspective of the storyteller. Very early one morning, Dean – in his pajamas and robe – let Lady (his black Lab) outside through the front door. Dean was standing on the front porch when he saw Lady dashing away from the house. Dean began shouting over and over, “Lady, you come here! Come here right now!” Then he noticed on the street in front of his house an older woman out for an early morning walk. She froze. Then she turned and fled. Dean had no chance then or later to correct her frightened interpretation. Dean’s narration and her narration of this shared experience are surely different.

Fragment -- #153

[September 2000 journal entry]

Variations to add to the ‘non-religious’ four-tier approach to ‘community’ I take: (1) in the ultimate and most radical experience of ‘community’ (i.e., initiating/demonstrating respect toward strangers and adversaries), strangers and adversaries who remain distant should be distinguished from those who respond favorably to the unconditional gestures of respect, (2) among the individuals found to be extending unconditional gestures of respect toward strangers and adversaries, those who choose to be near strangers and adversaries should be distinguished from those who had no such choice.

Fragment -- #152

[April 2006 journal entry]

2006 was our East TN Appalachia health center’s thirtieth year as a ‘community health center’. The community health center model for delivering medical care was devised in the 1960s as a tactic for fighting the ‘War On Poverty’ President Johnson on 16 March 1964 challenged the Congress to declare. This non-profit and community-led model for confronting the barriers poor/uninsured individuals face re access to primary medical care is one of three ‘War On Poverty’ initiatives still active. The other two – the Peace Corps and Head Start. I recently circulated among our medical, nursing, and administrative staff members a prayer I wrote many years ago about my awakening to the plight of those injured by poverty.

DISTURBED FROM PEACEFUL SLUMBER

O compassionate One, I shy from calling you ‘father’ now that my eyes and ears have opened to your other children – the abused, the displaced, the disabled, the destitute. I had no idea how many and how near are my sisters and brothers who scavenge garbage cans in search for food, who cannot (or need not) read the list of ingredients on food cans, who steal to survive, who wake each day to a violent ordeal. I had no idea how surely my closets, my refrigerator, my diet, my choices for work, my recreation, my morning shower, my education all settle any question about whether I am ‘rich’. I had no idea how entangled my lifestyle is with an economy that carelessly consumes the earth’s resources, that encourages selfish fantasies, that lures impoverished kids with ads holding out impossible dreams, that offers me an easy conscience by pointing to charitable gifts and taxes.

Why had I not noticed the family resemblance with these sisters and brothers of mine? Was it embarrassment? haste? fear? economic prejudice? ignorance of ancient Israel’s prophets? the ease with which I spiritualized ‘rich’ and ‘poor’?

I am without excuse. Endless blows dull these sisters and brothers of mine. I have added to the wind that has blown out the light in their eyes. I have only now realized that the task is not to make them materially rich, yet another form of slavery. No, the task is to make them free -- free to dream, to hope, to risk, to rest, to love, to choose.

May my conscience be disturbed by the loss of dignity ‘getting rich’ and ‘staying rich’ imposes.

May my self endure the teaching of ‘Jesus’ against self-serving values and habits.

May my lifestyle maximize the diversity of individuals who feel welcome in my home.

May my possessions be rid of any thing I value more than “one of the least of these”.

May my prayers express dis-ease with being materially rich.

May my witness encourage a way of being together in which “there is neither rich nor poor”.

Amen

A ‘non-religious’ view of Dietrich Bonhoeffer -- #130

[December 2000 journal entry]

It is naïve to suggest/expect that societal spheres (including but not limited to the ‘religious’ sphere) with conventional traits (e.g., property, debt, constituency, tradition, . . . ) can/will permit or encourage radical (i.e., to the root) inquiry/thinking.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #129

[December 2000 journal entry]

I must identify and root out all vestiges of ‘Santa’ language in my ‘God’ language. I feel in the position of the first kids at elementary school who know there is no ‘Santa’ – what do you do with this realization?

A ‘non-religious’ view of Dietrich Bonhoeffer -- #128

[December 2000 journal entry]

A ‘come of age’ approach to ethics and spirituality is incompatible with the ‘religious’ use of such terms as ‘lord’, ‘king’, ‘shepherd’, . . . .

A ‘non-religious’ view of Dietrich Bonhoeffer -- #127

[November 2000 journal entry]

In a recent conversation with a family therapist, she asked, “So do you just not talk about God?” I responded, “I am very hesitant to use ‘God’ language. My speaking rarely and cautiously about ‘God’ stands in sharp contrast to the casual use of ‘God’ language within the ‘religious’ sphere. I think there is an essential difference between saying ‘I am loving’ and saying ‘God is loving’. What I call the ‘religious’ T/O paradigm (which I defined for her) works/holds for individuals (1) who are ‘normal’, (2) who are distant from tragedy, (3) who face acute pain/suffering far more often than chronic pain/suffering, (4) who will not risk the ‘religious’ T/O paradigm’s offer of security.”

A ‘non-religious’ view of Dietrich Bonhoeffer -- #126

[November 2000 journal entry]

It seems ironic that it takes being radically (i.e., to the root) repositioned outside the ‘religious’ sphere in order (1) to see ‘religion’ for what it is and (2) to find/form an alternative approach to ethics and spirituality.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #125

[November 2000 journal entry]

Using a ‘religious’ method -- the sequence flows from the ‘God’ language characteristic of the ‘religious’ T/O paradigm to a refusal to question the implications of such language to decisions re a way of being based on such language. Using my ‘non-religious’ method -- the sequence flows from reflection on the ‘more’ about being human to reflection on the sort of person to be to living consistently with that sort of being to a ‘God’ language (if any) that is guarded against idolatry and that has metaphorical meaning.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #124

[November 2000 journal entry]

The following quotation comes from an article in Nashville’s newspaper The Tennessean:

Sandy Phillips made an agreement with Brian Kelley when she first saw him just hours after his arrest in the killing of his 13-month-old daughter in August last year. Kelley told Phillips, a clinical psychologist at Cumberland Mental Health Service, that he had suffocated his daughter Erin on instructions from God as a way to bring about the Second Coming of Jesus Christ, who would arrive by sundown. “I said we would certainly see each other tomorrow – in heaven if he was correct or in the Wilson County jail if he was wrong,” Phillips told a jury yesterday in Kelley’s first-degree murder trial. Phillips was one of a line of mental health experts who testified yesterday that Kelley was anything but sane when he suffocated his daughter shortly after midnight on August 15, one day from his own birthday. . . . Kelley may have known that killing was illegal, but he was compelled by his delusion that God had instructed him to kill his child as an Old Testament-style sacrifice -- Farooque (another expert witness, DB) and the other experts testified. “He didn’t think what he did was wrong,” Farooque testified. “He was not able to appreciate the wrongfulness of the act.” . . . Martell (another expert witness, DB) said he came to the same conclusion as his local colleagues – that Kelley had suffered a psychotic breakdown. “It is a disorder that will continue to plague him the rest of his life,” Martell testified.

How does the ‘religious’ T/O paradigm not lead to the end to which Kelley went? On what basis would teachers/preachers within the ‘religious’ sphere – especially those toward the fundamentalist end of the theological spectrum – who uncritically exalt the Abraham and Isaac story referenced in the article as an example of ‘faith’ oppose Kelley’s thought and action without undermining the T/O paradigm itself?

A ‘non-religious’ view of Dietrich Bonhoeffer -- #123

[October 2000 journal entry]

Might ‘God’ be in a way analogous to ‘time’, ‘gravity’, ideas, . . ?

‘the ethical dimensions of patient care’ -- #48

CONCLUSION

Adding to patient care the responsibility of assessing patients’ spiritual wellbeing increases the likelihood that caregivers will often be in a position to share their beliefs and values with patients. Healthcare professionals who interpret the responsibility to assess their patients’ spiritual wellbeing as liberty to look for opportunities to impress their own beliefs and values on patients risk failing to respect or to be truly present with their patients. Pressing their beliefs and values may lead them to prejudge the spiritual wellbeing of patients whose beliefs and values differ from their own. Their attention span may narrow. Their diagnosis and/or management may be adversely influenced. Also, considerable diversity regarding ‘spirituality’ and ‘religion’ is usually found among the numerous professionals involved in a patient’s care. Liberty to impress one’s own beliefs and values on patients would not be restricted to the attending physician. Instead, all the professionals involved in a patient’s care -- including consultants, residents, medical students, nurses, social services personnel, et al -- could assume the same liberty, thus potentially putting patients in confusing as well as insecure situations. In order to guard against disrespecting patients and weakening their trust, caregivers should limit the way they share their beliefs and values with patients to discussions (1) they would summarize in the patient’s chart and (2) the medical team would consider part of the patient’s care.

‘the ethical dimensions of patient care’ -- #47

5. ‘Respect’ as the anchor for assessing patients’ spiritual wellbeing:

‘Respect’ is foundational to effective assessment of patients’ spiritual wellbeing. The root meaning of respect – i.e., ‘to look at again and again’ -- is very vivid. There is very little benefit from attempting to assess a patient’s spiritual centeredness or spiritual distress if the professionals responsible for the patient’s care do not genuinely respect the patient.

It should not be taken for granted that caregivers possess the skill/art of truly respecting their patients. I suspect that many caregivers have been born into and/or raised in fairly conservative religious and social settings. I was. In the religious and social setting into which I was born and in which I was raised, I remember being taught to doubt the motives and to avoid taking seriously the ideas of all others who differed with ‘us’. In time I came to see this instruction as instruction in disrespecting others. Variations on instruction in disrespecting others are implicit, if not explicit, to some degree in virtually all organized constituencies or spheres in our society (including the medical sphere).

‘Respect’ does not mean ‘cater to’. It does mean ‘take very seriously’. This clarification calls attention to the rather complicated process by which the attending physician and medical team work with the patient and family/friends in decision-making.

The following set of questions illustrates the skill/art physicians and other caregivers need in order to be fully informed about and respectful of hospitalized patients who are experiencing spiritual distress:

1. “What makes for a good day for you?” – with attention given to how ‘good’ is described
   
   
2. “What are your difficult days like?” – with attention given to how ‘difficult’ is described
   
   
3. “Do your good days help you make it through your difficult days?” – with attention given to indications of how firm a ‘yes’ is and whether the good:difficult ratio is diminishing
   
   
4. “Do you more often find yourself waking up in the morning hoping for a good day or hoping not to have a bad day?” -- with attention given to how encouraged or discouraged the patient is
   
   
5. “What do you want me to know as I and the team consider how best to take care of you? – with attention oriented toward acceptable or unacceptable outcomes rather than toward management plan details
   
   
6. “What outcomes do you want to keep fighting for?” – with attention drawn to feasible outcomes
   
   
7. “Are you concerned that your illness will interfere with your participation in any activities or events in the near future that are especially important to you?” – with attention given to what demands these activities or events would make on the patient, to how feasible it is for the patient to participate, to what condition the patient hopes to be in at the time of these activities or events
   
   
8. “Do you have any questions or worries that are hard to talk about with your family or friends?” – with reassurances that such can be discussed with you in complete confidence
   
   
9. “Patients sometimes tell me they find themselves thinking ‘that would be worse than dying’. Have you had this thought?” – with attention given to what such conditions would be
   
   

‘the ethical dimensions of patient care’ -- #46

4. Defining/distinguishing ‘spirituality’ and ‘religion’:

I suggest that caregivers begin with this premise – i.e., all individuals are more than the insights made possible through various empirical analyses. In the health care sphere, this premise implies that patients are more than potential or actual illnesses and accidents; professionals, more than highly skilled scientists/technicians. To consider this ‘more’, a vocabulary and a manner of discourse -- in addition to scientific/clinical language -- are required. I have found that most (perhaps all) individuals have, with varying levels of sophistication, such vocabulary and manner of discourse. Such vocabulary and manner of discourse disclose, in the most elemental and inclusive way, each individual’s spirituality. An individual’s spirituality reaches, shapes, and sustains his/her integrity (i.e., wholeness, oneness, character).

The definition of ‘spirituality’ that has worked well over the years for me in opening discussions of this subject with health care professionals is:

‘Spirituality’ has to do with the sort of person a patient is, with the basis upon which her life has integrity and balance. A patient reveals her spiritual identity when she shares her core beliefs and life values and when she explains how she sustains these beliefs and values. Feelings of fear, loneliness, and guilt as well as happiness, contentment, and wonder are windows into a patient’s spirituality.

Some caregivers may question the absence of the word ‘God’ or a reference to a divine transcendence in this definition of spirituality. This definition represents an attempt to define spirituality so as to minimize the risk of eliminating individuals as ‘spiritual’ by definition. I strongly recommend against making either a reference to a divine transcendence or a claim of experience of/with a divine transcendence prerequisite to being considered ‘spiritual’. Instead, the transcendence that, in my judgment, is prerequisite to a fully inclusive approach to spirituality is the human spirit (i.e., the ‘more’ about human beings for which empirical analysis/explanation alone does not account). I am proposing (1) that this transcendent realm is present in/with all patients and (2) that this transcendent realm is very relevant to empirically-driven health care professionals who are expected to assess their patients’ spiritual wellbeing. With this transcendence – i.e., the human spirit -- in common, patients experience and express their spirituality in ways special/peculiar to each one (including but not limited to those who interpret their spirituality in terms of experience of/with a divine transcendence).

The definition of ‘religion’ that has worked well over the years for me in opening discussions such as this one is:

‘Religion’ has to do with the way many patients experience and express their spirituality. They center their lives on worshipful devotion to ‘God’ as a mystery that transcends human beings and the world. They are encouraged in their communities of faith to live this way through the study of sacred writings, the affirmation of core beliefs and life values, the sharing of inspirational stories, and the celebration of special rituals.

Some caregivers may express concern that this definition of religion is decidedly institutional in wording. There are certainly less institutional ways to define/nuance ‘religion’. However, in order to meet the Joint Commission regulations for assessing patients’ spiritual wellbeing and in light of the likely assumptions many caregivers hold re ‘religion’, it seems to me that an institutional definition of religion accomplishes the primary objective of distinguishing religion as a subset of the larger phenomenon of spirituality.

I suspect that a significant number of physicians and their support staff as well as most of their patients are more familiar with the following association of spirituality and religion:

‘Religious’ subdivides into --
‘Spiritual’ (a favorable assessment according to the particular religion’s criteria)
‘Not spiritual’ (an unfavorable assessment according to the particular religion’s criteria)

rather than:

‘Spiritual’ subdivides into --
‘Religious’ (in experience and expression)
‘Non-religious’ (in experience and expression)

The definition of and approach to spirituality followed by a hospital, in a clinic, and by a medical team need to be inclusive of all the patients for whom care is being delivered. Not all patients are religious. Not all patients are affiliated with a particular religion. Not all patients are members of any one sub-division of one particular religion. And crucial non-religious aspects of every patient’s spirituality are missed when ‘being spiritual’ is viewed as interchangeable with or a subset of ‘being religious’. Concerning these missed windows into a patient’s spirituality, here are some examples:

a morning/evening walk
participation in community/civic organizations
a refreshing hobby (e.g., photography or gardening or hiking or . . .)
participation in volunteer community service activities
reminders of life-changing experiences
travel opportunities
inspiring music
the company of a pet
a thought-provoking book
a favorite art gallery or museum
social pleasures (e.g., a glass of wine or a pleasant dinner or a theater outing or a sports event or . . .)
a special friend

‘the ethical dimensions of patient care’ -- #45

3. Understanding a patient’s spiritual distress:

The root meaning for ‘distress’ has to do with pressure, strain, . . . . To be distressed, therefore, is to be strained, tense, troubled, oppressed, threatened.

‘Spiritual distress’ has to do with the loss of peace, joy, hope, and resolve individuals experience (to varying degrees) when faced with unsettling life circumstances that threaten to overwhelm their core beliefs and values.

Responses to respiratory distress may range from ‘observe closely’ to ‘intensive intervention’. Caregivers are trained to think in terms of the least invasive/intrusive means (i.e., ‘do no harm’) to resolve a patient’s problem. The response to an asthmatic patient who is wheezing should be less intensive than the response to an asthmatic patient who is listless. The intervention should match the level of concern/danger. Caregivers should have an analogous framework by which to assess a patient’s spiritual wellbeing. Visualize a diagram with two paradigms – i.e., ‘spiritually centered’ and ‘spiritually distressed’ – separated by a threshold. Variations of the ‘spiritually centered’ paradigm range from ‘thriving’ to ‘holding’. Variations of the ‘spiritually distressed’ paradigm range from ‘troubled’ to ‘despairing’.

<-- ‘Spiritually Centered’ -------------|-------------‘Spiritually Distressed’----->


<--‘thriving’------------'holding’ ------|------‘troubled’ -----------‘despairing’-->


Caregivers cross a threshold when the paradigm or framework that most fully accounts for their observations about a patient shifts from ‘spiritually centered’ to ‘spiritually distressed’.

Patients who are spiritually centered are capable of participating meaningfully in the decisions about their care and can be counted on to be diligent in fulfilling their responsibilities. Some of these patients may appear to be undisturbed by their condition. They come across as attentive, hopeful, and self-confident. They ask insightful questions, make accurate comments about their condition, and have a sense of humor. Other of these patients may be struggling to maintain their balance and focus. They show signs of being fearful, upset, disoriented, and impatient. As these dispositions strengthen, they are moving toward and may eventually cross the threshold into the ‘spiritually distressed’ paradigm.

Patients who are spiritually distressed complicate the decision-making process and the management of their care. Some of these patients are troubled for inward as well as circumstantial reasons. They are losing confidence, motivation, hope. They may appear despondent or panicky. They may deny the reality of their situation. Other of these patients are despairing. They are immobilized, depressed, apathetic, fatalistic. Their spiritual distress may surpass in urgency their injury or disease. Professionals with special training for such situations (e.g., social workers, psychologists, chaplains, ethicists, . . .) may need to be more central to the medical team’s care for these patients.

‘the ethical dimensions of patient care’ -- #44

2. Objectives for considering a patient’s spiritual wellbeing:

Given the immediate attention in health care settings to patients’ physical needs, the objectives for integrating attention to spiritual wellbeing into patient care need to be precise and appropriately circumscribed. Hospitals and outpatient clinics do not have purposes parallel to spiritual retreat centers, synagogues, churches, mosques, . . . . What would be objectives for attending to a patient’s spiritual wellbeing that are consistent with the purposes of health care settings? Possible answers might be (1) to insure effective communication, (2) to show respect for and understanding of patient preferences regarding their medical care, (3) to maximize the health benefits associated with patients having the heart of a fighter, (4) to search for factors contributing to a patient’s failing health, (5) . . . .

Attending to a patients’ spiritual wellbeing, then, has to do with minimizing the spiritual disturbance she is experiencing due to being in a hospital and/or due to injury/illness in order to maximize the benefits from her spiritual resources (1) for making decisions about her care and (2) for realizing her full measure of healing. To make the objectives for assessing a patient’s spiritual wellbeing concrete, think in terms of assessing a patient’s centeredness – her balance and her focus. It is crucial that the patient has (or recovers) sufficient balance and focus to communicate well (which requires listening carefully, thinking courageously, and speaking clearly) and to participate appropriately in decisions about her care.

Assisting patients in the recovery of balance and focus is, in my judgment, the primary goal/consequence that makes giving attention to spirituality pertinent to caring for patients. (Fear of) serious illness or injury can challenge/threaten a patient’s balance and focus, thus raising crucial questions about the credibility of the spiritual foundation upon which she has built her life. A hospital is a particularly difficult setting in which to face this possibility. Sheer pain may eclipse a patient’s use of her spiritual resources. By being in a clinic exam room or in a hospital, she is distant from (or even cut off from) the activities and experiences essential to her spirituality. Then again, a patient’s spirituality may be contributing to her loss of balance and focus.

Loss of balance and focus may be a deeply significant process by which a patient’s spirituality is tested and eventually strengthened. How many individuals, before being confronted with (the possibility of) significant injury or disease, have ever taken seriously the existential premise that facing one’s finitude is prerequisite to authentic living? Whatever the fraction who have, the number is far too low for caregivers to assume that patients will retain their balance and focus when faced with (the real possibility of) life-threatening injury or disease. You, thus, may face a dilemma -- (1) on the one hand, you need your patients to be balanced and focused in order for management decisions to flow, (2) while on the other hand, you may have to give some of your patients time/opportunity to experience the spiritually refining/restructuring that may be necessary for them again to be centered.

‘the ethical dimensions of patient care’ -- #43

1. When to consider a patient’s spiritual wellbeing:

For several years, the senior physician at the Appalachia community health center where I worked before coming to Barnes-Jewish Hospital and I met weekly to review his most perplexing and burdening patient encounters. Below is a summary narrative of one such case:

It was a busy Wednesday afternoon. The patient was in her late-20s, had four children, and was now 32-weeks pregnant. The fetus’ fundal height was smaller than expected. She had sought no prenatal care. A colleague asked David to do an ultrasound. The patient was sitting on the edge of the exam table when David and his nurse entered the room. David helped the patient into a supine position. She was covered with a sheet up to her blouse. The nurse turned down the light. As David began the exam, the patient said barely above a whisper, “I have a lot of scars.” David’s first thought – “surgery . . . perhaps a previous c-section”. Once he saw the scars, he thought – “accident . . . perhaps a burn”. He asked the patient, “Did you have a car accident or . . .?” She interrupted and, as she starred at the wall, said quietly, “My mother set me on fire when I was three.” David had no response. It turned out the baby was fine. As we later reflected on the case, David explained to me, “Her life is so far removed from my range of experiences. I didn’t know how to respond. She will never be free of this childhood experience, these scars. If my mother had . . .” His voiced trailed off.

When the patient said “I have a lot of scars”, she was making a figurative as well as a literal observation. Simply put, she was saying, “My story is broken. Can you help me fix it.” (Howard Brody, MD/PhD, is my source for this way to frame a patient’s meaning.)

Imagine you and your medical team are looking down a hallway with patients in most of the rooms. Whether or not the patients in these rooms share similar definitions of or approaches to spirituality is immaterial to each patient. The patients are not together in the hospital as a community. What does matter to each patient ultimately is her own particular spirituality. However, you and your medical team – moving from room to room – need a definition of and an approach to spirituality that prepare you to meaningfully integrate the ‘spiritual’ and the ‘physical’ in caring for each patient. Finding/embracing such a definition of and approach to spirituality is no simple task.

Most hospitals and outpatient clinics exist to respond to patients’ physical needs and, therefore, are centered by scientific/clinical language and perspective. Scientific/clinical language is the ‘first language’ of health care settings. With symptoms, with injuries, with diseases, . . . – patients come (or are brought) anticipating that their physical conditions can be corrected or brought under control. The expansion/deepening of the scientific knowledge base and the introduction of increasingly sophisticated technologies continue to concentrate attention on patients’ physical interests in health care settings.

Patients hope that entering a hospital or a clinic will be no more than a pit stop or, at most, a repair shop delay in their day-to-day routines and life journeys. The circumstances that lead patients to seek medical attention are often benign and/or quickly resolved. In these situations, assessing a patient from a spiritual perspective may remain (by patient choice and/or by caregivers’ choice) on the periphery. By ‘periphery’ I mean that caregivers remain attentive to subtle or incidental indications that, in addition to the patient’s immediate problem, there may be a deeper ‘wound’. Such indications put the caregivers in the tough position of deciding whether they have the time and emotional capacity to determine if indeed there is a deeper ‘wound’. And the circumstances that lead patients to seek medical attention may in fact have to do with a deeper ‘wound’. In these situations, a spiritual language and perspective should be more centrally and intimately present for caregivers as they attend to the patient’s needs.

‘the ethical dimensions of patient care’ -- #42

With entries #42-#48, I want to share most recently revised draft of a Grand Rounds lecture on the subject of assessing patients’ spiritual wellbeing I was invited to deliver in August 2000 for the Obstetrics and Gynecology residents in the Phoenix area. I did not know personally any resident or faculty member in the Phoenix audience. In an attempt to justify why I had been asked to speak on this subject, I began by profiling my experience and training in four ways. First, I explained my three ‘weight-bearing’ positions (as distinguished from an ‘ethicist’ role) on the medical education/practice ‘field’ over the previous eight years – i.e., (1) as project coordinator and evaluator with an intervention project at the University of Miami for 125 cocaine-abusing women who had prematurely delivered cocaine-exposed babies, (2) as residency coordinator and ethics educator while on faculty with the Department of Obstetrics and Gynecology at Louisiana State University in New Orleans, and (3) as a member of the executive leadership team for a non-profit community health center serving medically un(der)insured individuals and families in three poverty-ridden Appalachia counties of eastern Tennessee and Kentucky. Second, I referenced my participating as an adjunct faculty member with Michigan State University’s Center for Ethics and Humanities in the Life Sciences in the development of a curriculum for addressing spirituality in medical education. I had corresponded for several years with Howard Brody, MD, PhD, at Michigan State as he attempted to keep his course in the medical school curriculum on ‘spirituality and the practice of medicine’ from collapsing into a ‘religion’ course. Third, I recalled my first wife’s fourteen-year struggle against her deterioration and eventual death due to multiple sclerosis. Fourth, I mentioned the impetus for clarifying my thought re ‘spirituality and medicine’ that came from preparing to participate in the creation of an educational video at Vanderbilt for hospital employees re assessing patients’ spiritual needs.

The ‘scrapheap’ Job -- #77

[August 2000 journal entry]

Is it plausible to see the composer of the story/play Job most thoroughly represented in the Tempter/Accuser? This idea recently crossed my mind as I have moved to the conclusions (1) that the ‘scrapheap’ Job did in essence/spirit curse ‘God’ and (2) that the ‘scrapheap’ Job had lost his rationale/motive for acting altruistically/sacrificially toward others. Concerning #1, it seems to me that this conclusion can only be avoided by arguments based on technicality re the definition of ‘cursing’. Concerning #2, I have not yet found indication in the story/play that the ‘scrapheap’ Job –- either in thought or action – has other than the ‘religious’ T/O paradigm in his rationale/motive for acting in the interests of others. In other words, the Tempter/Accuser was pretty much on target re Job’s character.

The ‘scrapheap’ Job -- #76

[August 2000 journal entry]

Can correlations be seen between the prologue picture of ‘God’ in the story/play Job and pictures of ‘God’ in other texts in Jewish scripture or Christian scripture?

The ‘scrapheap’ Job -- #75

[August 2000 journal entry]

What does the ‘scrapheap’ Job’s offering a sacrifice (in the epilogue) for his three close friends suggest for how his post-tragedy reentry should be imagined/portrayed? Is there any reason to interpret the story/play to suggest that others than the three close friends should be thought of as hearing or knowing Job’s remarks from the ‘scrapheap’? Is there any reason to interpret the story/play to suggest that anyone other than the three close friends knows of the sacrifice in their behalf? Is the sacrifice in the epilogue suggesting that the ‘scrapheap’ Job is endorsing the ‘P’(riestly) perception of ‘God’?

The ‘scrapheap’ Job -- #74

[August 2000 journal entry]

Perhaps – in addition to silent presence -- the courage to say “I don’t understand either” and then quickly return the ‘scrapheap’ Job’s questions to him for further comment would be the way the missing character in the story would gently but persistently prompt the ‘scrapheap’ Job. To do so, s/he would have to possess a radically (i.e., to the root) different perspective from the ‘religious’ T/O paradigm that is of ultimate importance to the ‘scrapheap’ Job’s three close friends.

The ‘scrapheap’ Job -- #73

[August 2000 journal entry]

Is there any indication in the story/play Job that the ‘scrapheap’ Job continues -- after the tragedies had struck him and those immediately around him -- to pursue the altruistic values attributed to him before the tragedies struck? that altruistic values are so rooted in him that he continues to think and react -- during as well as after the tragedies – in a manner consistent with the unique friendship he expects from his three close friends (see 6:14 in the text)? Or does his dependence on the ‘religious’ T/O paradigm turn him inward, take away his incentive/motive for being this sort of person, and leave him inattentive to other sufferers around him? Are all references to his virtues in the past tense? The story/play leaves the impression that the ‘scrapheap’ Job is abandoned and alone except for the painful presence of his three close friends. Is there any indication that his mind’s eye sufficiently clears/focuses to see and identify himself with other sufferers? Or is he stuck in the “There’s been a big mistake! I don’t belong here!” mindset created by his dependence on the ‘religious’ T/O paradigm?

Fragment -- #151

[September 2000 journal entry]

What anchors a well-lived life? For me, the anchors are (1) a simple/unambiguous statement re who I am and intend to be, (2) the realization that I am finite, (3) a ‘from below’ alignment with and respect for the most vulnerable.

Fragment -- #150

[September 2000 journal entry]

By what criteria should an experience be called ‘tragic’ – e.g., timing? severity of circumstances? quantity/quality of lost potential?

Fragment -- #149

[July 2000 journal entry]

In a recent conversation with my new artist/theatre friend Dean, he asked me to explain my use of the ‘wilderness’ metaphor. Among the reflections I shared with Dean were – (1) the centrality of silence/solitude, (2) being in natural (rather than artificial) surroundings, (3) the necessity of simplicity, (4) the absence of conventional societal spheres, (5) the necessity to be self-reliant, (6) the dangers, (7) the pressure to concentrate, (8) the importance of imagination, (9) . . . .

‘Wilderness’ experiences may come suddenly/abruptly. They may not. ‘Wilderness’ experiences may be entered willingly. They may not. ‘Wilderness’ experiences may be entered naively. They may not. ‘Wilderness’ experiences may become home. They may not.

For me, the transition from a sense of place within societal spheres to the existential isolation of the ‘wilderness’ was gradual enough to adjust to living without the assumptions and props of the various societal spheres within which I was raised and continued to live until several years into my first wife’s illness. Perhaps this gradualness is the reason I did not think of ‘terror’ (as did Dean) when explaining to him my use of the ‘wilderness’ metaphor. He proposed that I had been a bit naïve in hoping/striving for some radically different direction to be possible within the ‘religious’ sphere. I told him that, looking back, I agree. It took me so long to get past this naiveté for several reasons, not the least of which was my awareness that to act consistently would leave an unbridgeable chasm between me and those closest to me.

Fragment -- #148

[July 2000 journal entry]

What centers/anchors who I am (aspire to be)?

1. To be(come) the character absent in the story/play Job (i.e., the character who is able to be with the ‘scrapheap’ Job without harming him).
   
2. To be the sort of person who can be truly present with the most vulnerable, difficult, troubled, harmed, shunned, displaced.
   
3. To consider my most essential/radical ‘community’ experiences to be found in extending gestures of respect toward individuals from whom there is no reason to expect similar gestures in return.
4. To be intellectually critical and thorough without restrictions re previously held ideas.
   
5. To be consistent re who I am (perceived to be) across/within the various situations in which I find myself.
   
6. To be consistent in how I participate in the multiple conversations and discussions central to my work and life experience.

Fragment -- #147

[August 2000 journal entry]

The premise of the song The Rose is again being proven true for me – i.e., it is not possible to have the richness of an unconditional relationship without also having the piercing pain that may be caused either

1. by accident or injury,
2. by the end of circumstances within which such a relationship has developed, and/or
   
3. the eventual end of such a relationship in death.

And the converse of the premise is also being confirmed again for me – i.e., the piercing pain does not outweigh the sacred experience of an unconditional relationship. The circumstances and roles are changing. But the essence remains real and true.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #122

[August 2000 journal entry]

I plan to think in a more penetrating way about Bonhoeffer’s observation in his prison correspondence addressed to Eberhard Bethge that he had become more at ease speaking of ‘God’ with ‘non-religious’ than with ‘religious’ individuals (see the 30 April 1944 prison letter). What was the nature of the ‘God’ language he thought was credible with ‘non-religious’ individuals? How does this observation square with his proposition later in his prison correspondence with Bethge that “God as a working hypothesis in morals, politics, or science has been surmounted and abolished; and the same thing has happened in philosophy and religion” ( see 8 June 1944 and 16 July 1944 prison letters)? Was his ‘God’ language with ‘non-religious’ individuals less vulnerable to idolatrous use?

A ‘non-religious’ view of Dietrich Bonhoeffer -- #121

[August 2000 journal entry]

It seems to me neither Job’s ‘scrapheap’ thoughts/insights nor Bonhoeffer’s prison ideas should be seen as having had sufficient time to mature when they (including Bonhoeffer had he survived the war) would be facing the pull/pressure to conform associated with reentering societal spheres (including the ‘religious’ sphere).

A ‘non-religious’ view of Dietrich Bonhoeffer -- #120

[August 2000 journal entry]

A ‘non-religious’ approach to ethics and spirituality is distinguishable from a ‘religious’ approach in that the former requires a ‘from below’ rationale/justification rather than the ‘from above’ appeal to ‘revelation’ characteristic of the ‘religious’ sphere re the core for being human from which ethics and spirituality form. For me, this core has to do with the presence/exercise of such traits as

1. language, memory, imagination, creativity, . . . ;
   
2. finitude, vulnerability, death;
   
3. pain and suffering;
   
4. ease, comfort, peace.

The ‘non-religious’ path I am experiencing is distinguishable from a ‘religious’ path on each of these four sets of traits. It is characteristic of societal spheres (including but not limited to the ‘religious’ sphere)

1. to permit such traits as language, memory, imagination, and creativity only to the point that the credibility of the sphere is threatened,
   
2. to deny or diminish the reality of finitude, vulnerability, and death,
   
3. to consider pain and suffering only to the point that the credibility of the sphere is threatened.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #119

[August 2000 journal entry]

It seems to me that Bonhoeffer’s decision to join the Abwehr circle of conspirators entailed a course of action that implied a ‘without God’ approach to ethics and spirituality in that he joined a direct, definite, and final attempt to end the Hitler-driven tragedy for which neither the ‘religious’ T/O paradigm nor his pre-1939 ‘Confessing Church’ perspective could justify/support.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #118

[July 2000 journal entry]

It seems to me the experiences claimed within the ‘religious’ sphere (e.g., “personal relationship with God”, “knowing God”, “the Lord led me”, . . .) make numerous assumptions that are not (and cannot be) validated/established (e.g., the canon, the implied view of ‘God’, the resulting interpretations of life events, . . .). In other words, it is as if the claimant is saying, “If you grant with me that . . . , then my claim is credible and the experience was real/actual.” By analogy, consider the movie Harvey. Those around Elwood P. Dowd begin to wonder if there is a six-foot rabbit named Harvey and eventually begin to try/long to think so. However, Elwood is convinced he sees and is talking to Harvey. The experience claims made within the ‘religious’ sphere are different from the anchoring assumption upon which my approach to a ‘non-religious’ ethics and spirituality is based – i.e., the ‘more’ about being human.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #117

[July 2000 journal entry]

Having more than twenty years experience within the medical education/practice sphere, I am convinced the pressure I have felt to weigh every word carefully and radically (i.e., to the root) is not found/felt within the ‘religious’ sphere (or within the ‘medical’ sphere to the extent I anticipated). Discourse within the ‘religious’ sphere is neither conducted so as either to include or to be accountable to the criteria/perspectives of ‘secular’ hearers/participants. I find the absence of pressure within the ‘religious’ sphere to weigh every word carefully and radically (i.e., to the root) to be the case even in the minority of churches where there would be some level of concern.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #116

[July 2000 journal entry]

In order to be consistent and complete re the transition to and re retaining direction on a ‘non-religious’ path, I must press all ‘God’ language past an initial/elementary acknowledgment that such language is ‘morphic’ (i.e., anthropo-, socio-, cosmo-) and ‘metaphorical’. Why? (1) The existential pressure to do so has been/is sufficiently penetrating and personal to sustain the effort. (2) The stark and solitary pressure associated with a ‘wilderness’ existence tests every thought with immediate consequences. (3) The pressure to weigh every thought/idea (even every word) in order to have a meaningful presence within the medical education/practice sphere has been constant and strong.

A ‘non-religious’ view of Dietrich Bonhoeffer -- #115

[July 2000 journal entry]

Being ‘non-religious’ re ethics and spirituality is demonstrated, evident, and clarified (in distinction from ‘religious’) at the methodological level. It is, therefore, important to delineate in as much detail as possible ‘non-religious’ and ‘religious’ methodologies.

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.