Rebirth in the Clinic
The incorporation of spirituality into health care requires a theoretical foundation. Such a foundation serves several critical functions. To establish spirituality as the fecund ground for the rebirth of the clinic, one must have a sustainable source. To judge the moral limits and moral requirements for incorporating spirituality into practice, one must have a framework for making the necessary moral assessments. To avoid the pitfalls of charlatanism, one must have criteria by which to judge the authenticity of any proposal for incorporating spirituality into health care. The aim of part I
of this book is to provide such a theoretical foundation.
The first three chapters are very general. They set forth the scope of the spiritual in health care. Chapter 4
sets forth how the ancient Jewish wisdom literature tackled the question. Chapter 5
provides my own theoretical foundation. Chapter 6
describes the role that oath-taking might play in the spiritual rebirth of the clinic.
Many good things have been happening in the field of spirituality and health care. Several initiatives, however, have suffered from a lack of focus. I start by examining the spirituality and health care movement through a theoretical lens, beginning with a look at the most basic aspects of spiritual experience in the clinic and constructing a framework for understanding what has already happened and what needs to happen next.
Why 3Surgeons Must Be Very Careful
More than 150 years ago Emily Dickinson wrote a poem that succinctly illuminates many of the spiritual aspects of practicing the healing arts.1
She lived and wrote when the modern scientific clinic was just coming into its own. She had a keen sense of diagnosis; she understood immediately what ailed the clinic. She wrote, in her typically pithy style:
Surgeons must be very careful
When they take the knife!
Underneath their fine incisions
Stirs the Culprit—Life!
Whenever this poem creeps into the contemporary medical literature, as it sometimes does, it usually is an epigraph at the beginning of an article that emphasizes the importance of good surgical technique. These days, however, this poem might sound more like a stern warning from a risk manager or advice from a newspaper reporter, a judge, a politician, or perhaps an angry patient—or someone else who distrusts physicians and surgeons and is skeptical about their competence, sincerity, or commitment to patient welfare. Be careful, doc!
We should be more careful readers, however, because Dickinson was a very careful poet. She chose each of her words very carefully to be richly suggestive and highly evocative. Moreover, her insights are important for all health care professionals—not just surgeons.
Begin with the word take
. This word evokes the power one has as a physician, surgeon, or nurse—a power to heal or to harm, even to kill. A clinician’s knowledge, as Bacon observed, also is power. Clinicians wield knowledge over their patients, who are at the mercy of that knowledge. Like all power, the power clinicians hold can be used for good or evil—and mostly, if we are honest, for some admixture of both.
The word take also suggests the verb phrase take up, and this interpretation makes the word more interesting. Medicine is a craft (in Greek, techne). One takes up the medical craft, in some ways, just as one says that someone has taken up gardening or pottery. Physicians, however, do not make anything in their craft. The product of their craft is not something of their own making, like a piece of clothing or furniture or a utensil. The patient is given to a physician, and the physician gives the patient back to herself and to her family. Although medicine is a genuine craft, it is, one must admit, a funny sort of craft.
Consider also Dickinson’s use of the word fine. This word suggests the precision of the physician’s work. Technical specialties and subspecialties—such as head and neck surgery, neurosurgery, and invasive cardiology—are especially precise crafts, dealing with the delicate sense organs and the myriad fragile nerves and vessels that traverse the body. Yet even a general internist, pediatrician, or nurse must be precise. An error of a decimal point in dosing can mean the difference between cure and death.
Yet the word fine also evokes a sense of the beauty of what clinicians do. Surgery can restore the beauty of a face deformed by genetic processes gone awry or palliate the distortions of injury or cancer. Medication can erase the disfigurement wrought by diseases such as Kaposi’s sarcoma or leprosy. Often there is a beauty to the intervention itself—an aesthetic of the craft. Surgical incisions can have their own beauty, running down the natural folds of the neck or the linea alba so that no one who looks at the patient in a few years will discern that a surgeon was ever there. Even case presentations have a beauty—at least if they are done well. Crispness, clarity, brevity, vitality, and precision characterize a good presentation of a case. There is a genuine aesthetics of case presentations.
Dickinson’s poem itself has all the qualities of a good case presentation. Yet perhaps it is better to say that a good case presentation is like one of Dickinson’s poems. In each art form, every word counts. So we may also read her “fine incisions” as a reminder that all clinicians must be incisive. A pediatrician must know how to sense when something is askew in a parent’s reaction to a child’s fractured bone. An internist must recognize those moments when therapy is required even in the absence of a precise diagnosis. A surgeon must make incisions, not just cuts. The difference between an incision and a cut must be part of the surgeon’s character. Yet the best surgeons are always conscious as they dissect a path through tissue planes and remove diseased nodes that they are opening up more than flesh. Surgeons also expose the persons
of their patients in a psychosocial and even a spiritual sense. All good clinicians are as incisive about persons as they are about malignancies.
Dickinson therefore seems to be urging the clinician to get “underneath” what he or she is doing—not just underneath the skin (in the anatomical-pathological sense of Foucault’s clinic) but underneath the experience that the physician shares with the patient. One might read Dickinson as imploring physicians (or, more broadly, anyone who applies technology to human beings) to resist the urge to be callous or superficial or to trivialize what they do. Such reactions might appear to help in the short term but will return to haunt the practitioner in the long term.
The work of all health care professionals is fraught with deeper meaning than they often realize. Clinicians and pathologists alike often experience the patient in frozen sections—thin slices of flesh, frozen in time. Dickinson seems to urge all health care professionals to remember that the moment of the clinical encounter is also but a frozen section: a thin slice of the patient, frozen in time, revealing nothing about the hopes and fears and loves and sorrows the patient brings to the encounter at levels far deeper than any surgeon can ever reach with any knife, deeper than any medical imaging technique can ever bring to light.
This, then, is what “stirs” beneath the surgeon’s knife. Even when a patient is sedated, paralyzed, and ventilated, the mystery of a person
stirs dynamically at the tips of the surgeon’s fingers. It is the profound mystery of the person that stirs—not just blood, but Life.
Life is what stirs—in all its richness, power, and mystery. It is Life that health care professionals serve. Clinicians understand this perspective best when they come to understand the way their own lives are deeply connected with the lives of their patients. Yet life in the modern clinic can make this concept difficult to comprehend. Particularly in delivering highly technical medical care—in the endoscopy suite, in the cardiac catheterization laboratory, in the surgical theater—one may be so bound up with the patient that one scarcely notices anything more than the concentration, tension, and exactitude of one’s work. Well, one should be fixed on the technical, clinical moment, as such, while it is unfolding. Yet this necessary focus does not excuse any health care professional from the duty to reflect on what he or she actually does, day in and day out. All health care professionals are at the service of Life. It stirs at the bottom of the surgical field. It courses through the physician’s veins as surely as it flows through those of the patient.
Dickinson does not suggest that one should worship this Life. She is not a vitalist. Her poem is not a call to never cease treatment, nor is she delivering a moral mandate to maintain the ventilator even if the patient is brain dead. She calls modern practitioners to an attitude that Albert Schweitzer once called “reverence for life.”2
This attitude is one of awe and respect. It commands action to heal and preserve Life—but true reverence for Life is tempered by realism. One should not desecrate Life for the sake of preserving mitochondrial oxidative phosphorylation.
Hence, Dickinson observes that Life is a culprit—and she is right. One might take up the knife or the syringe and think one wields its power, but Life steals that power back. Life ought to make one humble and steal away one’s arrogance. Physicians and surgeons ought to grasp (as they are in turn grasped by) the paradox of this Life. Life itself brings both illness and health to everyone. Life by its very nature is finite: Every patient will die one day, and surgery, medicine, and nursing ultimately are powerless to stop it.
Life holds within it the seeds of death—apoptosis. Life is the context of illness. If there were no Life, there could be no illness. Life is
defined over and against Death—the ultimate expression of our finitude. Illness is the mark of the finitude of life. Things go wrong for living things. That is their nature. Illness arises because living things (all living things, including physicians) are marked by mistakes—biochemically, physiologically, socially, intellectually, morally, and spiritually.
Thus, like Life itself, the medical craft is marked by its finitude. Everyone makes mistakes. This is why clinicians feel so much more hurt than angry when their mistakes become the headlines of bad press and the source of lawsuits. Imperfection marks the healing crafts. Yet in the face of the inevitability of every patient’s ultimate dissolution, and with the full knowledge of their own metaphysically certain insufficiency for the task, health care professionals serve Life.
Health care professionals sometimes forget that Life itself is the healer, not them. Where there is any success, the craft only contributes to the healing that Life itself offers. Life is the source of all illness and the source of all healing. Health care professionals help, but they are not the source of healing. No matter how sophisticated surgery may be, it would not even be possible if the body did not heal itself.
So, Life is a culprit. Life gives, and Life takes away. Life deals out both healing and sickness. Life deals out birth and death. Life gives health care professionals the power to heal and snatches it away when they become too possessive.
Perhaps the reader might be thinking that this discussion is all too abstract—the irrelevant musings of an internist with a PhD in philosophy who happens to be a Franciscan friar and thinks he can interpret poems. This notion became very real for me in 2003, however. In April of that year my uncle was diagnosed with squamous cell carcinoma of the tongue. In May he was admitted to my hospital, where he underwent partial glossectomy and radical lymph node dissection, followed by radiation therapy.
My uncle asked all the questions such patients ask. “What does this mean?” First, “Is it serious?” Later, “What are my chances?” “How did this happen?” “Should I blame the dentist who kept telling me for six months that the sore on my tongue was due to ill-fitting dentures?”
“Was it my smoking and drinking? But doc, I’ve been sober for 25 years, and I quit smoking 30 years ago.”
I wondered whether my uncle’s experience brought up memories of his son, who had died at the age of five of acute lymphoblastic leukemia. Would he blame God again? Would he start drinking again? His wife said simply, “He don’t talk about things like that.”
Life is a culprit. Life gives, and Life takes away.
I helped my uncle navigate the overly bureaucratic U.S. health care system. I ran down a radiologist friend in the hallway just to print out a copy of my uncle’s CT scan for him to bring to his PET scan, scheduled for the following day. Apparently a hospital clerk had informed my uncle that the hospital was out of film and would not be able to supply the copy of the CT scan that the insurance company and clerks at the PET scan office had said would be necessary for him to have his PET scan. The PET scan was scheduled for the following morning. I didn’t share with my uncle that the reason our hospital was out of film was that the vicissitudes of market medicine had rendered the hospital nearly bankrupt, so it couldn’t pay its bills, leading the X-ray film company to refuse to deliver us any more film on credit. I begged and pleaded, and the radiologist and I found some film not already designated for emergencies. We printed a copy of the CT scan for my uncle and thereby avoided a tense and confusing situation for him.
Later that night, however, my uncle called me in a panic. The PET scan center now said they were canceling his scheduled PET scan because the proper managed care authorization form had not been filled out. I called his surgeon, who promptly filled it out and faxed it to the billing clerk at the for-profit, freestanding PET scan center. Stage two of my uncle’s potential bureaucratic nightmare had been averted. I wondered, however, what happens to patients who don’t have a nephew on the medical staff?