The ‘scrapheap’ Job -- #50

[5/1998] “__________ has such a wonderful attitude.” It is common to hear such said about individuals within the ‘religious’ sphere who, in reaction to devastating circumstances, raise no hard or persistent questions toward or about ‘God’ as understood within the ‘religious’ T/O paradigm. By not challenging/threatening the assumptions and expectations of the ‘religious’ T/O paradigm, such individuals are recognized/honored within the ‘religious’ sphere as exemplary. This approval in turn reinforces their attempt to see devastating experiences as interpreted by/within the ‘religious’ sphere.

The ‘scrapheap’ Job -- #49

[4/1998] The ‘non-religious’ approach to spirituality and ethics I am following necessitates sorting out and relentlessly critiquing the various meanings proposed for the word ‘God’. ‘Relentlessly’ (L., unwilling to melt or to soften in temper/resolve or to become less severe) is an aggressive but not overstated description of the necessary critique.

The ‘scrapheap’ Job -- #48

[6/1996] The story/play Job (specifically the dialogue sections and 42:7) and the essay of Ecclesiastes (minus the last paragraph) have become, for me, the windows into Jewish scripture and Christian scripture.

[Note: Without the series of exchanges between the prologue and epilogue, the 42:7 statement has no logical place in the story/play Job. So the statement is not part of the epilogue that -- together with the prologue -- forms the ‘happily ever after’ short version of the story/play Job. I think the composer surprises the audience with the implied task of searching back through the extended story asking, “What did Job say about ‘God’ that the composer thinks is right?”]

[Note: I started giving Ecclesiastes careful attention during my Louisville years (1976-79) when I saw the similarities with modern existential writings. I remember concluding that Ecclesiastes stands alone in Jewish scripture and Christian scripture in requiring so little commentary to be accessible. When I began offering a systematic theology graduate seminar (1981), the format I chose was to imagine a series of conversations between ‘Jesus’ and the author of Ecclesiastes. For many years, I read Ecclesiastes as the personal statement of Koheleth (the speaker in the text). More recently, I have come to regard Koheleth as a literary device created by the essay’s anonymous author. I see Koheleth as similar to a court fool – i.e., giving rather blunt analyses that those threatened can easily dismiss. Another analogy is Shostakovich’s precarious position before Stalin. Distinguishing Koheleth from the author aligns well with the tenuous place of the essay in the canon of Jewish scripture and accounts for the outlandish, even clownish, statements attributed to Koheleth in the essay (e.g., Koheleth’s excessive claims to know more than anyone else before him and to be the best student by far there had ever been).]

The ‘scrapheap’ Job -- #47

[9/2005] The senior physician and CEO for the Appalachia community health center where I work and I have volunteered to be deployed by the federal government’s Health and Human Services Department to assist with the recovery efforts in and around New Orleans. My physician friend’s broad training and experience in the practice of comprehensive primary care with a concentration on poor patients would make him a very valuable asset. The volunteer category nearest to how I might assist is ‘chaplain’. My physician friend feels that my special usefulness would be as a ‘chaplain’ to the medical professionals and other rescue personnel as they bear/process truly awful experiences. We both are anxious to help.

Looking closely at human experience -- without sifting or filtering out any events however severe -- makes me aware that my privileges (e.g., health, education, travel, economic liberties, . . . ) separate me from the vast majority of individuals in human history. Gazing at the devastation left behind by Hurricane Katrina has intensified this awareness.

‘Catastrophe’ . . . ‘disaster’ . . . ‘tsunami’ . . . ‘edge of the abyss’ . . . ‘nightmare’ . . . ‘tragedy’ . . . .

Where do you go in Jewish Scripture to find such raw expressions of trauma, agony, desperation? Several of the prophets lamented, groaned. Habakkuk ventured a protest. But they eventually returned to ‘God’ language within a theological paradigm that implicitly if not explicitly attributed devastating events directly or indirectly to “the Lord’s hands”. Only Ecclesiastes and the extended story/play Job – hardly weight bearing texts within the ‘religious’ sphere – persisted in questioning the intent/character behind “the Lord’s hands” and the underlying theological paradigm.

Where do you go in Christian Scripture for such raw expressions of trauma, agony, desperation? A slave army’s fight for freedom had been crushed. Rome had burned to the ground. Herculaneum and Pompeii had been buried. Jerusalem had been destroyed. What does it mean for there to be no trace of such events in Christian Scripture? no lament, groaning, protest? The theologians – Jewish or Christian – to whom one seeking a ‘face to face with the world’ spirituality and ethics can turn are the few for whom such raw expressions of trauma, agony, desperation keep the ‘God’ question open.

I am very hesitant about the ‘God’ language used -- especially toward the evangelical and fundamentalist end of the theological spectrum -- in reacting to or interpreting utter disasters. I wonder, “Is such ‘God’ language used to relieve the one/s speaking? to capitalize on the survivors’ plight? to defend or ‘clean up’ after ‘God’?”

The attempt to exclude events of immeasurable suffering (e.g., in modern times the 1755 Lisbon earthquake, American slavery, the carnage of World War I, the Nazi Holocaust, Hiroshima, Cambodia, the 2004 Tsunami, . . . Hurricane Katrina) from the reality within which each day is lived can seem worth the effort/cost to those experientially detached from such events. A ‘face to face with the world’ approach to spirituality and ethics fights against this temptation, determined instead to seek deeper consciousness of such events. The liberty (even instruction) in the ‘religious’ sphere -- especially toward the evangelical and fundamentalist end of the theological spectrum -- to keep faith/theology disconnected from and untested by events of immeasurable suffering results in such clashing statements as “The Lord had his reasons” (for permitting/causing Hurricane Katrina) and “We are caring for the evacuees because God expects us to”. A ‘face to face with the world’ approach to spirituality and ethics disagrees with this insulating method, being anchored instead by the resolve to hold only to ideas that are not overwhelmed by such events. The noble and generous expressions of compassion toward survivors when immeasurable suffering is compressed into specific events tend in time to wane as the initial burden of the harmed/displaced is met and as attention returns to less disturbing matters. A ‘face to face with the world’ approach to spirituality and ethics finds in such acute events of immeasurable suffering a reminder that similarly immeasurable suffering is encountered in all directions (diffused throughout) every day.

The ‘scrapheap’ Job -- #46

[7/1995] I want to live consistently with a human-affirming vision that does not require ultimate loyalty to any particular sphere (i.e., the missing character in the story/play Job). Freedom from all spheres (including ‘religion’) is necessary to be this sort of person.

The ‘scrapheap’ Job -- #45

[1994] The Congregational Church in Norwich, VT, where we lived invited me to guide a discussion about ‘remembering’. I prepared the following thoughts based on the story/play Job –

Prior to a devastating series of tragedies, Job held an exemplary and defining position within his various ‘communities’ (i.e., religious, family, economic, political, social). The meta-narrative within his ‘communities’ presumed that upright (merciful, fair, respectful) living resulted in blessed circumstances and that sinful (callused, manipulative, selfish, base) living resulted in cursed circumstances. Gathering with and around Job increased their sense of security. After a devastating series of tragedies, Job lost his exemplary and defining position within his ‘communities’. To them he was obviously cursed. He no longer confirmed the meta-narrative. To remain in ‘community’ with him would have threatened confidence in the meta-narrative. Those with shallow and quite conditional loyalty to Job ridiculed him, ignored him, gawked at him, spit on him, expected him to ‘repent’. Those more invested in Job – his wife, his family, and his closest friends – eventually failed him. ‘Communities’ must cross a critical and radical threshold in order to remain in community with a ‘scrapheap’ Job. That threshold entails the ability and courage to permit presumptions about the meta-narrative to be challenged. The ‘scrapheap’ Job refused to take this pressure off his ‘communities’. He maintained his innocence . . . and his integrity. When his closest friends began to speak, they knew only the language and responses characteristic of the meta-narrative. They did not know how to be with their friend. The story/play Job is so composed in its canonical form that the ‘communities’ receiving the story can remember without rethinking what it would mean to remain in community with a ‘scrapheap’ Job. The story ends with Job’s ‘communities’ gathering again around him. No doubt they had heard report that he had said, “I repent”. The socio-economic indicators of favor had returned to him. They interpreted this reversal to mean that the meta-narrative had been proven true and dependable. They are not forced to see that, for ‘communities’ to be able to risk remaining with a ‘scrapheap’ Job (and, thereby, to remember him with humility and gratitude), they must be modest in their presumptions about life’s meaning, grasp the place doubt, be penitent, be gathered by a cause/identity that makes holding together as ‘communities’ a significant but secondary goal, appreciate the art of silence.

The ‘scrapheap’ Job -- #44

[1994] What did Job have left – his integrity. And his closest friends were pressuring him to compromise his integrity.

The ‘scrapheap’ Job -- #43

[1994] Does the Job 6:14 vision of friendship relate to every relationship? to one relationship? to what number of relationships?

[Note: Translators/commentators have debated the proper translation of Job 6:14. My work with this text with the guidance of a Hebrew language and Wisdom Literature specialist has led to this translation – “A despairing man should have the devotion of his friend even if he (i.e., the despairing man) forsakes the fear of the almighty”.]

Fragment -- #60

[2/98] Rejoicing with those who rejoice and weeping with those who weep are difficult aims to achieve with full integrity. Envy, jealousy, . . . inhibit rejoicing. Insecurity, fear, shock, . . . inhibit weeping.

Fragment -- #59

[2/98] Words without power (i.e., substance or significance) are without power due to their source and their center. Therein is one reason for my attention to a Quaker-like emphasis on silence. Meaningful and powerful words emerge from an ‘engaged silence’ approach to life. Therefore, what happens in ‘silence’ is critical. One only speaks out of what is experienced in silence.

Fragment -- #58

[2/98] A key difference between C. S. Lewis and me (not to speak of numerous obvious differences!) is that I went through the trauma (spiritually and theologically) of a spouse’s chronic/degrading illness/death before and then simultaneous with my graduate education and subsequent thought formation whereas Lewis developed his thought and became ‘larger than life’ via his writings before his experience with his cancer-inflicted wife revealed to him the ‘house of cards’ weakness of his by then internationally acclaimed thought. (The writings that had made Lewis an anchor for faith for so many around the world – e.g., Mere Christianity, Miracles, The Problem of Pain, . . . – were written before Lewis married Joy Gresham in 1956. Her health was failing when they married. She died of cancer four years later. Lewis died in 1963.) His A Grief Observed – in which he admitted the hollowness of the views he brought to the experience of his wife’s illness/death -- is, for me, his most helpful writing. He had little to say after his wife died. (Question -- What effect did his World War I experiences as a soldier have on him?) I continue very intentionally to add to the initial experience with tragedy in my first wife’s illness/death (e.g., Down syndrome victims as with Ginny Elkins, Charity Hospital patients, abused children at K-Bar-B, cancer patients, University of Miami/Overtown cocaine-abusing women, Appalachia poverty, . . .). One consequence is my hesitancy to share with others my thoughts/views.

Fragment -- #57

[2/98] Are certain individuals innately gifted with the ability to handle confrontation? Perhaps to a degree, in that some personality types (e.g., more introverted or more structured) have additional anxieties about confrontation. However, everyone will be confrontational about what matters most to them. Otherwise, the subject does not matter so much after all. Variables that work against taking a stand are fatigue and loss of vision.

Fragment -- #56

[1/98] What is ‘after modern’? ‘Post-modern’ implies some meaning for and involvement with ‘modern’. At issue is paradigm decay. All paradigms – being human constructs -- must be subject to questions and criticism in order to avoid idolatry. The erosion of a paradigm does not in and of itself undermine the paradigm until a certain threshold of decay is recognized. ‘Post-modern’ points to deficiencies in the understandings of ‘modern’, but does not yet provide direction re what is beyond ‘modern’.

[Note: As several journal entries re ‘post-modern’ indicate, I struggle with the term – both ‘post’ and ‘modern’. ‘Post’ strikes me as too detached, too categorical, too dismissive. Otherwise, how could ‘pre-modern’ fundamentalists be emboldened by ‘post-modern’ postures against ‘modern’? Otherwise, how could political operatives such as those who have been driving the Bush administration be so unrestrained by facts and true debate, choosing instead to ‘create reality’? And is not every dominant paradigm ‘modern’ in its time/place? Perhaps ‘Imperial/Colonial’ or ‘Scientific’ or ‘Cartesian’ or ‘Capitalist’ or ‘Holocaust’ or . . . would be more to the point re the ‘modern’ in ‘post-modern’. Some innovations in method and interpretation since the eleventh century in Western Europe continue to be revised and used; others have been tested and discarded. And since the end of World War II, a monopoly on political voice/power has steadily slipped away from the presumptive Western nations. I would argue that the future of humankind depends on an unconditional commitment to critical reasoning. Would ‘post-modern’ proponents agree?]

Fragment -- #55

[12/97] It seems to me there is a size beyond which cities cease to be ‘human’ or ‘natural’ (as self-interest, lack of accountability, anonymity dominate actions and encounters). Is ‘community’ (as I am coming to understand such from a ‘non-religious’ perspective) inherently in tension with a large-city social structure?

Fragment -- #54

[4/1997 journal entry] The approach to ‘spirituality’ I am seeking has to do with what energizes a person, with what gives orientation, with that without which one begins to shut down existentially and ethically.

Fragment -- #53

Fragment -- #53
[3/1997 journal entry] Most individuals still seem to be unaware of (or, in other words, take for granted) the paradigm within which they interpret life experiences. The paradigm is thus not subject to questioning. Once aware of one’s own paradigm (and, therefore, aware that others also interpret life experiences within some paradigm), most individuals continue to use a paradigm as long as the paradigm permits them to feel sufficient balance (1) through the greatest number of life experiences or (2) through the most difficult life experiences.

Fragment -- #52

[10/1996 journal entry] A reality that transcends the human is essentially without or beyond language, forms, institutions. I would argue that symbols (1) must serve to awaken a spiritual experience (past or present) and (2) should arise from within the experience of those sharing in that to which the symbol points and which the symbol opens. Corollaries are (1) that such language, forms, and institutions should be permitted to fade/die as well as be born and (2) that no competitiveness should occur about such symbols. As examples of such symbols, see Bonhoeffer’s reference to the gift of Barth’s cigar and his references to ‘the parcel’ in the prison correspondence

Fragment -- #51

[9/1996 journal entry] Why am I drawn toward silence as a centering spiritual exercise? (1) A Berdyaev-type analysis of ‘God’ language. (2) An Otto-type approach to ‘the sacred’. (3) A Habakkuk-type experience of being painfully/disturbingly conscious of the tragic, offensive, violent, hopeless, . . . .

[Note: The reference here is to Nicolai Berdyaev (1874-1948) – a controversial Russian philosopher and theologian who lived as an exile in Paris from 1922 to his death. He wrote prolifically. He stood with the French resistance against the Nazi occupation. He is usually classified as an existentialist, though he called himself a ‘personalist’. I first encountered Berdyaev’s thought (especially through The Philosophy of Freedom and Truth and Revelation) in the late 1970s as I prepared to teach a course on trends in current theology. He insisted that ‘spirit’ is that which is impossible to define, that which is situated beyond the limits of thought. He extended my critical analysis of ‘God’ language by sensitizing me to the sociomorphic and cosmomorphic (in addition to the more familiar anthropomorphic) critiques/limitations of ‘God’ language.]

[Note: The reference here is to Rudolf Otto (1869-1937) – an influential German Lutheran theologian and political activist who advocated liberal strategies for international peace and justice and who worked tirelessly for a renewal of Protestant liturgy. I included Otto’s 1917 Das Heilige (published in English as The Idea of the Holy) in the readings for a classics in spirituality literature course I taught. I especially appreciate his description of ‘the sacred’ as, beyond ideas of goodness, a ‘mysterium tremendum’ – ‘mysterium’ leading to silence and ‘tremendum’ leading to awe.]

ethical dimensions of patient care #22

Narrative

Our physician had passed the mid-point in his career. He had resisted temptations to finish his career on the comfortable fringes of his field with those who rallied around ‘Not in my practice!’ He considered patient and practice changes -- e.g., better educated patients, group practice, enthusiasm for ‘natural childbirth’, fathers in delivery rooms, female obstetrician-gynecologists -- through the lens of professional excellence and patient dignity. Though no activist or enthusiast on either side of the abortion issue, he sympathized with the view that being unwanted can be worse than never being born. He dreaded more regulation and scrutiny in the wake of ‘Baby Doe’, while questioning a single-factor ‘Is the heart beating?’ criterion for aggressively intervening in cases involving critically ill newborns. He learned to work under the threat of lawsuits.

As age 70 and a third generation of babies approached, his literature seemed to be signaling the time had come to step aside. Articles such as ‘Whither electronic fetal monitoring?’ questioned the technology he had championed. Two lengthy articles about ‘Interpreting the literature in obstetrics and gynecology’ hinted that his generation might not be able to keep up. An article on ‘Retirement patterns of obstetricians and gynecologists’ provided a frame of reference. In carefully chosen conversations, he admitted, “It’s not fun anymore”. ‘Private practice’ had become an anachronism. He was exhausted. He retired in 1991 . . . almost. He continues to staff a uro-gynecology clinic with residents one day each week. I asked him what he thought about today’s residents. He said cautiously, “I’m encouraged”.

Commentary

1991. If 1951-1971 warranted images of modern medicine such as ‘explosion’ and ‘expansion’, 1971-1991 requires a word such as ‘constriction’. Physicians have become ‘providers’, ‘expert witnesses’, ‘gate-keepers’. Physicians’ discretionary space in clinical decisions has shrunk. ‘Managed care’ has put physicians in a position with patients uncomfortably analogous to real estate agents who represent the seller as they work with potential buyers. HIV infection has ended the assumption -- widespread since the introduction of penicillin -- that medicine is a risk-free profession. The consequences of changing the delivery of health care to extend access and contain cost are yet to be determined. It seems safe to conclude that maintaining integrity between patients and physicians is not getting easier.

And ‘ethics’? During the early ‘70s, ‘bioethics’ emerged within the medical sphere as a discipline of study in search of a voice in a conversation already underway. With patient confidence in physicians eroding, the first generation of bioethicists made its most noticeable contribution by providing justification for placing patient autonomy as the cornerstone in medical decision-making.

It is encouraging to see that the subjects of values and virtue have now reentered medical and ethical literature. More is being heard of casuistic reasoning and attention to the ethical significance of patient histories. We are recognizing that reducing decisions to patient self-determination missed the complexity of hard clinical choices and offered little guidance for public health concerns. ACOG’s Ethics Committee is carefully crafting revisions of earlier statements on such subjects as informed consent, physician responsibilities in an era of HIV epidemic, and end-of-life decision-making.

And so we are left to ask, “Can medical students and residents be taught how to be with patients?” I think the answer is ‘yes’ if the question has to do with what is sometimes called ‘minimalist ethics’ -- i.e., where what ought to be done is equivalent to what by law has to be done. I think the answer is ‘yes’ if the question has to do with communication skills or recognizing varying points of view. I think the answer is ‘no’ if the question has to do with ‘ethos’ -- i.e., with integrity, with character, with virtue, with vision. But I must quickly add that ‘ethos’ can be identified, protected, nurtured, recovered, encouraged, healed, prompted, matured in the medical education/practice settings. The ‘ethics’ that transcends a minimalist threshold essentially derives from and is clarified by one’s defining life experiences.

To illustrate: If the obstetrician-gynecologist whose professional career we have profiled today were asked to account for his consistent and impassioned advocacy of doing what is best for the patient, he would at some point contrast his participation in the indignities and death of battle during World War II with his participation in bringing healthy life into the world as an obstetrician.

To illustrate: Another physician (with whom I have worked closely) began a pediatric practice in 1954 but, a dozen years later, devoted his full attention to disadvantaged inner-city critically-ill newborns who were dying two-to-three times as often as advantaged suburban critically-ill newborns. When asked at an award ceremony to account for his resolve, he said simply, “My grandfather’s toes” and then went on to recount how each evening as a young boy he would meet his Yiddish
grandfather -- a 1901 immigrant to New York’s Lower East Side from Czarist Russia -- in front of the dining room buffet. With unequal strides, the two made their way to the living room where the weary blacksmith settled down in his chair. The stocky, spectacled lad would begin his nightly ritual of unwinding the laces from around the hooks on his grandfather's work boots. Pulling off the boots and socks, he would run his fingers over each foot's single chunk of nailless flesh that had once been separate toes and prod his grandfather to recall the painful memories always just a thought away: “Papa, tell me again. What happened to your toes.” “Son, Cossacks chased me. I hid in the forest for a long time. My toes froze off in my shoes.”

To illustrate: I spoke recently with one of our third-year Ob/Gyn residents at LSU about the explanation he had given in his residency application’s ‘personal statement’ for becoming a physician. After getting past the shock that someone had actually read his ‘personal statement’, he remembered clearly what he had written: “Open the door, please! Get out of the way! We need to see the doctor right away!” Curious to find out what was happening, I -- only six-years-old at the time -- rushed down to my father’s office as the metal door was dragged open to reveal a haggard, panic-stricken man carrying a lady in her mid-sixties. She was pale and almost lifeless. My father quickly stepped out to greet them and immediately started to take her pulse. “How is she, doctor? How is my mother?” the young man asked anxiously. “Don’t worry. She will be fine. We need to get her to the hospital. I will come with you.” As soon as my father spoke, I could see a change in the man’s expression, from panic and insecurity to calm and trust. I can never forget the relief on that man’s face as his terror resolved in response to my father’s words. Simply by being calm and decisive, my father was able to ease his suffering. I remember telling myself that day, “I want to help people the way my father is doing.”

Such defining experiences -- if remembered -- can sustain a motivation that embraces more than family, friends, neighbors; more than patients for whom a physician has cared for many years. Such defining experiences -- if remembered -- promise to keep us in place when secondary motivations -- e.g., personal gratification, intellectual stimulation, financial reward, even societal reform -- fail.

Concluding Remarks

In a few minutes or hours, we will each be back in our niches within the vast health care sphere. I hope our time together has encouraged each of us to ask again – “Can there be integrity between patients and physicians? between patients and physicians who are strangers? who approach each other with suspicion? who need each other but will never know each other? who are assigned to each other?” Those are the most common -- and, I would argue, the toughest -- ethical questions facing today’s clinician. The reflections I have shared with you today can be reduced to three core propositions.

1. The central ethical issue facing clinicians is how a patient and a physician form a relationship and how they actually relate to/with each other in the delivery of care. Multiple specific issues either are ways into this central issue (e.g., informed consent, confidentiality, patient self-determination) or are ‘outside’ issues that add complexity to this central issue (e.g., allocation of limited resources, HMO expectations/regulations, third-party disclosure).
   
2. Patients and physicians embody the peculiarities of their time and place. However, in every time and place, ‘respect’, ‘trust’, and ‘gentleness’ sustain patient-physician relationships that retain the humaneness without which medicine ceases to be an art or a profession.
   
3. Various metaphors make vivid the ways physicians relate to patients (e.g., healer, counselor, advocate, friend, mechanic, provider, stranger, entrepreneur, adversary). Physicians would do well to view themselves essentially as guests in their patients’ life-stories. A guest enters another’s space with a grateful disposition, expresses respectful interest, departs gracefully.

Thank you for your attention. And thank you, Dr. Wall, for your enduring example.

ethical dimensions of patient care #21

Narrative

In 1955 he moved his family to form with two other physicians a group practice that in time would expand to five partners. Wedded to obstetrics, he soon earned the reputation of being a meticulous and hard-working clinician. He delivered all his patients. Resolved to remain current as the specialty broke new ground, he was among the first in his location to perform laparoscopic tubal ligations. He introduced fetal monitoring. His boys remember going with him to the family farm to practice the fetal monitor on pregnant cows.

During years of social upheaval, he quietly but consistently participated in his hospital’s obstetric service for indigent patients and provided coverage for a nearby home for unwed mothers. Residents rotating with him saw the same high standards of care and the same respect for patients, whether the patients were socially advantaged or not.

Yet by 1971 -- the midpoint in his career -- he could identify with the question raised in an Ob/Gyn editorial -- “What happened to the old-fashioned physician and the old-fashioned patient?” He was at a critical juncture. Would he limit his practice to the shrinking number of ‘old-fashioned patients’? Would he shift his practice away from obstetrics by focusing on the gynecologic needs of the women he had delivered in previous years? Or would he pay the personal and professional price to remain in the middle rather than on the periphery of his specialty?

Commentary

1971. When your own kids are leaving for college and you start delivering the babies of babies you delivered, it is time to look up from the exhausting day-to-day work and take a deep existential breath. The task and the profession to respect the patient -- to observe and listen closely -- remained central to being a trustworthy physician. But patients and physicians had changed. Hospitals had changed. Medicine had changed. Society had changed. Maternal and infant mortality and morbidity had dramatically declined. Ironically, so had patient and physician satisfaction. Respect and trust could no longer be taken for granted. Harm? Strangers do not notice and adversaries do not hesitate.

What had happened? What centrifugal forces were pulling patients and physicians apart? Social mobility? A more educated population? The move to protect individual rights? A sexual revolution? All these and still other factors contributed. But the most plausible interpretation points centrally to the tension between two honorable goals -- i.e., on the one hand, doing what is best for each patient and, on the other hand, insuring adequate care for the greatest number of patients. One strategy -- some might say, the traditional strategy -- would have a physician care for as many patients as possible without compromising the standard of care for each patient. Many physicians followed this strategy. Of course, moneymaking motivated some. And ethnic or economic prejudices could still go unchallenged. But many physicians genuinely struggled with the tension between individual and societal responsibilities.

However, all around them medicine was being reshaped by developments that drew attention away from individual patients. Such serious public health concerns as population control and indigent patient care had to be addressed. Research and experimentation -- propelled by wartime successes -- changed public expectation as ‘miracles’ moved from kidney dialysis to transplanted hearts, from polio vaccines to ‘the pill’. Statistical significance and randomized controlled trials reshaped medical education, medical literature, and clinical decision-making patterns. Government legislation and programs so defined the issues that Dr. Roy Parker, in his 1975 presidential looking forward to the year 2000, predicted, “The future of [obstetrics and gynecology] resides in the government”. The trend toward utilizing nurse midwives and other non-physician ‘extenders’ for routine tasks promised to increase the reach of obstetric care.

Obstetrics and gynecology had enjoyed startling advances -- as does a rapidly growing tree according to one observer. By the mid-‘60s, academicians estimated that the best medical education became obsolete in five years. The specialty expanded in fetal medicine, geriatric gynecology, endocrinology, gynecologic oncology, . . . . A chronology of editorial opinions highlights the gradual reformation taking place:

1959: In attempting to stay near the front of the [knowledge] race, there has been a tendency to forget or neglect some qualities of man as desirable as knowledge -- i.e., wisdom, dignity, and faith. Specialization is an evil, but an unavoidable one. We know more and more about less and less. We must avoid the easier method of treating the disease and neglecting the patient.

1963: All efforts not ultimately directed toward more competent and compassionate patient care are valueless.

1965: Programmed learning is in sharp contrast to the traditional pattern of education in medicine that utilizes a close association between student and preceptor for the transmission of skills from one generation to the next.

1966: Devoted to the concept of the responsibility of a particular physician for an individual patient, we are initially repelled by the impersonal, even amoral, nature of statistics and the collective approach. . . . [We should] try to comprehend the ways of the ‘monster’ and, by becoming to a degree part of it, attempt to guide its progress and so preserve some of what seems essential in the traditional ideals of medicine.

1969: Individuals want, need, and trust their physicians; at the same time, the patient generally favors and supports social reforms adverse to the physician and his ability to function as a personal doctor.

1971: Is this to be a point in time when we are expected to acknowledge our responsibility to the community in which we live – and, as a result, perhaps find ourselves doing what needs most to be done -- even though it may not be what we individually would have liked most to be doing?

By 1971 the curtain had been pulled back on female and fetal health. Medicine was in public view. But the public -- suspicious of social institutions and traditions -- had seen a darker side to their medical ‘gods’. The 1962 thalidomide scandal sparked congressional hearings over regulating drug companies and monitoring informed consent. Then came the 1966 exposé of twenty-two research projects authored by Dr. Henry Beecher (a University of Kansas graduate). And finally, news broke of the US Public Health Service’s Tuskegee research on syphilis.

Hospitals began displaying copies of ‘The Patient Bill of Rights’. The 1972 Canterbury Case shifted the focus of informed consent from what a physician should disclose to what a patient needs to know to make an informed choice. The widely-read Our bodies, Our Selves advised women to be wary consumers of health care. Another title put it more bluntly -- Rid Yourself of Your Gynecologist. 1973 saw the formation of a President’s Commission to address the perplexing questions modern medicine had created but alone could not manage. As Dr. William Bartholome of the University of Kansas School of Medicine explained in a 1971 letter – “There is need to involve not only the medical profession, but lawyers, sociologists, moralists, and society at large to resolve complicated medical issues”. Dr. Bartholome had just released a film that recreated a 1969 Johns Hopkins case in which he had been the resident who was told to pull the feeding tubes on a baby with Down syndrome and an intestinal blockage.