Meditation and Medical Ethics

Medical ethics and mindfulness have a lot in common. I reached that conclusion after a recent conversation with my long-time friend Charlie Halpern about his effort to introduce mindfulness into legal education.

Charlie has been doing this at the UC Berkeley School of Law for the past several years through classes and elective retreats. He's an enthusiast and a believer. He feels, and many legal educators and law schools agree with him, that mindfulness practice increases empathy, compassion, and the ability to really hear what clients and others involved in negotiation and litigation are saying. He described how a professor at Berkely has taken to starting his classes with three minutes of silence. The professor reports that "sacrificing" three minutes of class time leads to a richer, more thoughtful class experience.

I've taught meditation to patients in a medical setting and have recommended meditation to many of my patients over the years. And I've written in this blog about how mindfulness practice can be woven into busy practitioners' lives. (See here and here.) But until the conversation I had with Charlie, I hadn't recognized the obvious connection between mindfulness and the way I've taught medical ethics.

In the semester-long course medical ethics course that I taught at Harvard Medical School, in addition to the topics that formed the intellectual content of the course, I encouraged the students to hone their skill at (a) observing their cognitive and emotional reactions to clinical situations that raise ethical issues, (b) treating these reactions as "data," not "truths," and then (c) reflecting on the "data" presented by their experience as one piece of ethical analysis before (d) reaching a conclusion. Over time, as demonstrated by clinicians who we regard as models of ethical action, this set of actions can become reflexive, done automatically and recurrently.

What I realized is that steps (a) and (b) are close cousins to what meditation teachers encourage their students to do. The setting is different - deliberate quiet and inwardness in meditation versus to what I'm inclined to call "meditation in action" in learning to be an ethically sensitive clinician. But the outcomes the teacher hopes for in the student - empathic connection with others, compassion, and seeing the truths that underlie complexity - are the same.

Recognizing the kinship between mindfulness and medical ethics is a valuable insight for ethics educators. An increasing number of students know something about meditation and respect the practice. Recognizing that skill at meditation can enhance their grasp of medical ethics, and, that skill at medical ethics fosters some of the key skills for meditation, enhances both domains.

Atheism, Humanism and Secular Ethics at the University of Miami

Between September 10, 2007 and today, I've written 82 posts about religion and spirituality. I've been especially interested in the moral underpinnings of the health professions. I've thought of health care as a calling throughout my career. But where does the call come from?

Historically, the call has been seen as coming from god and god's servants - saints, bodhisattvas and other benevolent beings who urge us to care for others. But what about health care workers who do not derive their calling from a theology?

I hope this question will be high on the list of research topics when the newly endowed chair of "atheism, humanism and secular ethics" at the University of Miami is filled. I learned from the New York Times article about the chair that it was endowed by Louis J. Appignani, an 83 year-old retired businessman who supports non-theist causes. The University was uncomfortable defining the chair as one of "atheism" studies, but Mr. Appignani insisted that the "atheism" be part of the title, and accepted the addition of "humanism and secular ethics."

In an increasingly secular population it's crucial to deepen public understanding of morality that is not based on religious theologies. Over the centuries, religious communities have been powerful advocates for good causes (e.g., abolition of slavery) but also for evil causes (e.g., "holy" war). For atheists and secular humanists to make a full contribution to the moral arc of the future, we need a deeper understanding of how the non-theological domain functions. Let's hope that the University of Miami chair contributes to this process.

When the chair is filled, there will be a great deal to learn from studying those who are called to the vocation of health care!

Bringing the Best of Religion into Medicine

Yesterday I went to the funeral of my older daughter-in-law's mother. She was a much-loved person who was very active in her church. The beautiful Episcopal ceremony evoked her spirit with love and humor. The minister conducted the service in a spirit of inclusiveness and solidarity. The words from John 14:2 - "In my Father's house are many mansions" - were interpreted as reflecting love of all humanity, not as a promise to believers alone.

For me the service brought out what is best in religion. Three years ago I wrote that all liberal (i.e., inclusive) religions are comparably true and good and all fundamentalist (i.e., exclusive) religions are comparably false and bad. I continue to hold that view.

Even though I'm thoroughly in the secular humanist fold, over the years of medical practice I often found that religious language felt truer to the aims of clinical care than purely secular modes of expression. Here are four examples:

"Omniscient being." In all areas of medicine we often bump up against uncertainty. At times that my patient and I wished we knew what to do or what to expect, I might say something like "if we had access to an omniscient being, we wouldn't have to wonder about XYZ..." The concept of a god evoked our wish for the assistance that a benevolent god would give us, and at the same time, acknowledged our limitations.

"Blessing." Historically, to be "blessed" meant having god's favor. Our perfunctory"God Bless You" when someone sneezes goes back to pre-antibiotic days when sneezing might presage pneumonia and pneumonia could mean a rapid death. Even though I don't believe in a god who might intervene, comments like "let's hope that you will be blessed with better health" felt like a stronger expression of hope and possibility than they would with purely secular phraseology.

"Prayer." Many years ago, a patient of mine who conducted himself courageously despite significant impairment from chronic schizophrenia, ended an appointment by asking me to remember him in my prayers. Without thought or hesitation, I said I would. I took my patient to be requesting that I care about him deeply and feel for him  what I've written about as "the right kind of love between doctors and patients." Since I did feel that way about him I felt I was speaking truth in committing myself to remembering him in my prayers.

"Calling." In its original meaning, a "calling" came from god in the literal form of god's voice. The clinicians I respect most among physicians, nurses, social workers, and other health professionals ("profession" is another term that comes from a religious context) all think of health care as a "calling." Many religious clinicians understand the calling to health care as a call from god - literally, to do "god's work." But when I've used the concept of "calling" with first year medical students in the ethics class, it gets a mixed reception. For some it rings true. They feel "called" to a sacred profession, whether they're believers or not. But others have chided me for being too moralistic. For them, medicine is a "job." I don't try to talk them out of this view, but I do suggest that when they're with patients at the bedside, the "job" may be transformed into a "calling."

When my mother experienced the cerebral hemorrhage from which she died a few days later, the ambulance took her to a Catholic hospital. I was impressed and comforted by the spiritual wisdom of the care she and her small family (me and my father) received, especially from the nurses. And when I visited the Swami Vivekananda Hospital in Saragur, India, in 2009, I learned that twice a week they conducted a non-denominational prayer service for patients and staff. Religious language and "liberal" religious practice make superb partners for the enterprise of health care!

Sharing our Experience of Illness

In the last couple of month I've developed a problem involving circulation to my toes and foot. The formal name is "acrocyanosis." Colloquially it's called "blue [or purple] toe syndrome." Though the medical literature describes it as painless, what I have hurts. It's commonest in younger people and uncommon in someone my age.

I'm a strong believer in the potential value in learning from others who have a similar condition, but Google didn't produce much, and the diagnosis was not listed on the excellent Patients like Me website. I respect the physicians I've been dealing with, but I was hoping for practical tips about coping from people who have experienced the condition themselves.

While I was musing about the topic of peer networks, my friend and former colleague Al Martin published a post exemplifying what I had in mind in his always engaging Age with Spirit blog. I don't have the condition Al is writing about (Parkinson's Disease), but if I did his post would be a treasure.

Years ago a patient of mine who was about the age I am now developed post herpetic neuralgia, a painful condition that can follow shingles. The pain added to the depression I was treating her for. Like Al, she was an activist, and she wrote about her experience on the web. A young woman from the UK contacted her. My patient, a wise and generous person, "coached" the younger woman on coping with chronic pain. I assume the coaching was helpful to the woman in the UK, but I know it was helpful to my patient.

The famous "twelfth step" in AA is perhaps the best known expression of the idea of peer support: "Having had a spiritual awakening as a result of these steps, we tried to carry this message to alcoholics..." Here's what AA says about the twelfth step:

Here we turn outward to our fellow alcoholics who are still in distress. Here we experience the kind of giving that asks no rewards. ..When the twelfth step is seen in its full implication, it is really talking about the kind of love that has no price tag on it.

My patient with post herpetic neuralgia felt a kind of love for the young person in the UK. If I had Parkinson's Disease, I would feel a spirit of solidarity and love coming to me through Al Martin's post:

This posting is a personal look at my experiences with a chronic brain disease -- Parkinson’s Disease (PD) -- in contrast to the way that the experience looks to others. We view problems that affect the brain with particular dread, because we see the brain as the determinative of who we are as people. Diseases may seem fearful or tragic to those who don’t have them, but the experience may be quite different for the person with the problem. Friends often aren’t comfortable asking about the details, and the person with the problem may not feel comfortable volunteering them spontaneously. As a result, an important part of someone’s interactions can be governed by assumptions. In the following paragraphs are some of my experiences with PD. This posting is a personal look at my experiences with a chronic brain disease - Parkinson’s Disease (PD) -- in contrast to the way that the experience looks to others. We view problems that affect the brain with particular dread, because we see the brain as the determinative of who we are as people. Diseases may seem fearful or tragic to those who don’t have them, but the experience may be quite different for the person with the problem. Friends often aren’t comfortable asking about the details, and the person with the problem may not feel comfortable volunteering them spontaneously. As a result, an important part of someone’s interactions can be governed by assumptions. In the following paragraphs are some of my experiences with PD.My story begins in 2008-09.

For some time, I had noticed a deterioration of my handwriting, which I attributed to the kind of tremor and unsteadiness that lots of older people get when they try to do fine work   I also noticed trouble buttoning my buttons. In fact, I asked a friend of mine, a neurosurgeon, if he noticed any similar difficulty with aging. He laughed that his terrible handwriting had gotten worse, and passed it off as normal aging. In the latter part of 2008, I began to notice chronic fatigue and over the next few months, the fatigue worsened, and I began to lose weight. My immediate concern was some hidden form of cancer, and in early 2009, I saw my internist, who, although he didn’t say it, had the same concern. He began ordering tests, at first a panel of blood tests and a chest x-ray, and eventually a CT scan of the abdomen. All of them were normal, and we were stumped.

On a chance, I mentioned the trouble that I had over two years, deteriorating handwriting and poorer coordination of my right hand.   He referred me to a neurologist, who within 10 minutes told me that I had PD. Among other things, he could see the stiffness in my movements and noticed that I didn’t swing my arms when I walked. He referred me to a Parkinson’s specialist, who confirmed the diagnosis and started me on one of the milder drugs for the disease.   It helped. My symptoms were very mild at the time. No one else noticed them. I could do virtually everything that I used to do, and my fatigue lessened. I was surprisingly incurious about the disease. I had, of course, learned a little about PD in medical school, the rhythmic tremor (which I didn’t have), the stiffness, rigidity, lack of facial expression, and the tiny shuffling steps. I didn’t want to know any more. As long as I was functioning well, I wasn’t interested in knowing more details about where this train was going.

Although tremor is the best-known symptom of PD, its hallmark is what is called bradykinesia, a slowing of movement and stiffness of muscles that eventually can result in immobility. PD is due to death of nerve cells that produce the neurotransmitter Dopamine, particularly in a midbrain collection of deeply pigmented neurons called the Substantia Nigra (black substance). This lack of Dopamine results in the typical symptoms of PD, tremor, bradykinesia, rigidity and difficulty with balance. As PD has become better understood, it is clear that the disease causes much broader symptoms including difficulty with speech, voice, swallowing, constipation, weakness, double vision and in some dementia. It is a disease that is readily treated with medication early on, but which progresses despite treatment with medication eventually becoming less effective.

My reaction to being told I have PD was very consistent with the well-known process of grieving any loss. The first stage for me was denial. I was told that I had PD. I knew what it was supposed to do, but I felt almost no emotion. The long-term consequences were abstract to me. My symptoms were mild; I could do almost anything that I used to do, and it wasn’t visible to others. I didn’t speak about it to friends. The few times that I did, the friend would look like I just said I had untreatable cancer and say something like, “Oh my god; I’m so sorry,” which I wasn’t ready for at that point. At times, I questioned whether I needed the Dopamine medication or even whether the diagnosis was correct. Maybe I would be the one where it didn’t progress or would spontaneously go away. When I saw someone with severe PD, I might be briefly shaken, but then put it out of my mind.

After 3-4 years, it became evident that the disease was slowly progressing, and the diagnosis was undeniable. I threw myself into an exercise program in the hope that through muscle strength, it could be overcome. I read that exercise, particularly that which involves movement, like biking, swimming, walking or tai chi, is important because it does help loosen the muscles, but I couldn’t exercise my way out of the disease. What started as a little stiffness, at times has become the sensation that my muscles are in glue and that any sustained physical effort is very hard. My voice has become soft; I tend to walk with a stoop and my face transmits less expression unless I pay attention to it. When I get up from a chair, I have to take several shuffling steps to get my balance and my legs moving. With PD, one’s muscles don’t automatically cooperate as they used to. It is said that you are damned to a conscious life, because you need to concentrate on everything you are doing and how to do it.

I am aware of what advanced PD looks like to others. Moving slowly with stuttering steps, a trembling hand and a blank stare showing no emotion makes it appear that the person is not really there. I am not at that point, but if I live long enough I probably will be. Similar to someone who has had a severe stroke, outside impressions may be worse than the reality. The disability is real, but most PD patients are mentally intact despite responding more slowly. Most PD patients are quite ‘with it’ and anxious to be engaged socially.

PD seems to hold a particular place in people’s minds as a terrible progressive disease from which there is no recovery. True as that is, most people with Parkinson’s live long and productive lives, albeit with handicaps that must be addressed. But as with any chronic disease, one manages the best one can and usually remains the same person inside of all of the daunting, outward physical signs. It is important to patients like me that people around us realize that, or one can become socially isolated.

Eventually, as with any chronic disease, I have to plan for the future. Planning for later is of course wise, but it confronts me with a reality that I would just as soon forget. As the complications worsen, I have to deal with more limitations. As much as the limitations may look terrible to someone on the outside, one learns to live within them and find new sources of satisfaction. It may sound Pollyannaish, but in some ways, it is a good time to grow internally, a time to appreciate life in a deeper way, to take one day at a time and to appreciate the companionship of people I care about. We don’t get to choose our diseases, and the worst curse is to withdraw and become isolated because your illness makes people anxious.

 

Physicians as "Counsellors"

One of my favorite moments in music is the spectacular chorus in Handel's Messiah:

For unto us a child is born, unto us a son is given, and the government shall be upon His shoulder; and His name shall be called Wonderful, Counsellor, the mighty God, the Everlasting Father, the Prince of Peace. Within the chorus, I find the word "Counsellor" especially moving. An article I recently read in JAMA - "The Physician's Counsel" - helps me understand what moves me so powerfully. The author, Donald Misch, tells how at the end of his mother's life, he was the decision-maker for whether to prolong treatment or "pull the plug." He felt an intense need to talk with his physician, who was also a friend, about the decision:  I did not need another physician to assess the situation intellectually and medically, and yet it was clear that my [physician] friend’s words were critically important to me. I needed a physician’s counsel to let my mother die. This was true even though I was, and am, a physician, dually trained  in internal medicine and psychiatry, and I had on many other occasions helped other families struggle with similar decisions. I needed a physician—not simply other family members or friends or advisors (although all of these were helpful as well)—to tell me that under the particular circumstances of my mother’s situation, my conclusions were reasonable. Because all decisions about significant others in one’s life are laden with emotion, conscious and unconscious meaning, and history, I needed to be sure that my motives for making this irrevocable and lethal decision were not contaminated by my longstanding conflictual relationship with mother. I needed a physician to assure me that my judgment was consistent with my mother’s wishes and her best interests. I've often written about health care as a "calling." (For examples, see here, here , here, and here.) I think the need Dr. Misch felt reflects the patient's side of what "calling" means. When we're feeling vulnerable we long for a "Counsellor." In Christian faith, it's "the mighty God, the Everlasting Father, the Prince of Peace." In health care it's the caretaker who we trust and rely on. Many years ago a religious couple from another state came to see me. A friend who they trusted had been my patient, and gave them my name. Their daughter was involved with a man who was less religiously observant than they were. They asked me - should they cut off contact with their daughter? I was startled. This wasn't the kind of issue I was accustomed to dealing with in my psychiatric practice. I asked why they didn't consult their pastor at home. They said, "he's new, and we don't respect him." After a moment of internal debate I decided to accept the "Counsellor" role they had given me. Was their daughter's potential spouse an honest seeming person? Yes. Was he a drug user? No. Did he treat their daughter well? Yes. Was she happy? Yes. After some more discussion I gave them my counsel. They should not sever ties with their daughter. The family relationship was more important than their views of proper religious practice. The woman in the couple jumped up. "See - that's what I told you!" Her husband looked a bit crestfallen, but accepted my advice. I never saw them again, but 10-15 years later I heard indirectly that their daughter was happily married to the man I'd been told about. Dr. Misch's article reminded me of another - Dr. Franz Ingelfinger's 1977 medical ethics lecture, unfortunately titled "Arrogance." Dr. Ingelfinger, editor of the New England Journal of Medicine and one of the world's experts on esophageal cancer, developed esophageal cancer. He tells us that with regard to the difficult question of whether to undergo chemotherapy and radiation after surgery: I received from physician friends throughout the country a barrage of well-intentioned but contradictory advice. As a result, not only I, but my wife, my son and daughter-in-law (both doctors), and other family members became increasingly confused and emotionally distraught. Finally...one wise physician friend said, "What you need is a doctor." He was telling me to forget the information I already had and the information I was receiving from many quarters, and to seek instead a person who would dominate, who would tell me what to do, who would in a paternalistic manner assume responsibility for my care. When that excellent advice was followed, my family and I sensed immediate and immense relief." Medical practice has its mundane moments, but at it's best it embodies what the chorus in the Messiah is singing about. What a privilege it is to be allowed to be a "Counsellor"!

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Dreams of the Dying

A fascinating New York Times article about the dreams of people who are close to death brought to my attention a study of end of life dreams and visions carried out by clinicians at a Cheektowaga (a suburb of Buffalo) hospice and published in the Journal of Palliative Medicine.

The researchers systematically followed 66 hospice patients to ask them on a daily basis about dreams and visions. 87% reported having these experiences. The majority were comforting. The brief summaries cited in the article are moving.

28 days before his death, Barry (age 88) dreamt of driving somewhere unknown and was comforted by hearing his mother say, ‘‘It’s all right. You’re a good boy. I love you.’’ 

4 days before his death, Roger (age 73) dreamt about his best friend from childhood and saw him running out of the house with his glove and bat while laughing. They had shared a love of baseball throughout life. 

37 days before her death, Barbara (age 52) dreamt of her deceased father and brothers, hugging her and ‘‘welcoming her to the dead.’’ They seemed to be preparing to go somewhere but ‘‘they haven’t said’’ where.

The researchers conclude:

The results of this study suggest that a person’s fear of death often diminishes as a direct result of ELDVs, and what arises is a new insight into mortality. The emotional impact is so frequently positive, comforting, and paradoxically life affirming; the individual is physically dying, but their emotional and spiritual identity remains present as manifested by dreams/visions. In this way, ELDVs do not deny death, but in fact, transcend the dying experience, and present a therapeutic opportunity for clinicians to assist patients and their families in the transition from life to death, thereby providing comfort and closure.

But the researchers tell us that despite the commonness and value of such experiences, patients, families, and clinicians report being reluctant to openly discuss end of life dreams and visions for fear of ridicule and doubts concerning medical legitimacy. This is the downside of our hyper scientific approach to health care. Apart from the constraints of time that plague medical practice, young physicians I have worked with report that although dealing with spiritual/existential matters like end of life dreams and visions seems enormously valuable for both patients and physicians, they don't feel  they have developed the skills and depth of understanding that is required.

Years ago, when I taught medical students at the Howard University clinic in Washington, DC, many of our patients came from the rural South. I was impressed with how often they reported visions of a dead family member. As we listened to these experiences, it was clear that the patients were not hallucinating or experiencing psychosis. The exchanges they reported - like the dreams of the patients near death - were meaningful to them, and to us. And towards the end of his life, when I was visiting my three-times widowed father in Florida, he told me that he was expecting a "visit" from his own father, who came to him in dreams every year or two, in a way that gave comfort and joy.

The study I've summarized is potentially very influential. By making such personal experiences the focus of scientific study they bring what might be seen as solely the spiritual matters for pastors to deal with or psychopathology to be treated by psychiatrists within the orbit of what clinicians can listen to, work with, and learn from.

Mindfulness, Clinical Outcomes, and Patient Safety

Two months ago, when I wrote a post about using the walking we clinicians do in the course of the working day as opportunities for  meditation, I wondered if it was a harebrained idea or a piece of personal eccentricity. But when I came upon "Use Hand Cleaning to Promote Mindfulness in Clinic" published in BMJ earlier this month, I decided there's something to it.

The author is Heather Gilmartin, a nurse fellow in the Colorado VA system. She makes the excellent suggestion that hand washing, a recurrent act of patient care and self care, can be used as a moment of meditation. Here's the practical summary Ms. Gilmartin presents:

A moment of mindfulness

Focus your attention on your thoughts and emotions. Stay present and accept whatever arises, just as it is, without reacting.

Set an intention—be it listening with intent, choosing your words mindfully, or acting with compassion in your next encounter.

Smile to acknowledge this act of kindness to yourself and to your patient.

Alcohol based hand rub

Pause, take a breath, and notice the sound and feel of hand rub being delivered to your palm.
Be present in the moment and experience the sensation of rubbing the foam/gel into your wrists, hands, and fingers until the product evaporates and leaves you clean.

Soap and water

Pause, take a breath, notice that you are turning on the faucet, and regard the feeling of water flowing from your wrists to your fingers.
Be present in the moment and experience the sensation of rubbing soap into your wrists, hands, and fingers, and then washing it all down the drain.

The VA system disseminates innovations well. I anticipate the potential for an epidemic of meditative moments arising from Ms. Gilmartin's modest but well articulated proposal!

Via her article I read an empirical study of the simple idea of using recurrent components of our days as opportunities for "mini-meditative-moments." College students were instructed to wash dishes in their usual manner or to do the ordinarily mindless chore in a mindful manner. The group that meditated as they scrubbed showed increased positive emotion and decreased "nervousness." (The article is at:
"Washing Dishes to Wash the Dishes: Brief Instruction in an Informal Mindfulness Practice.")

Reading the two articles emboldens me to out myself for another practice I've built into my day. I'm vigilant about brushing my teeth twice a day. If tooth brushing takes one minute, in a year it adds up to 12 hours. If it takes two minutes, it's a full day. That's a lot of time to devote to an uninspiring chore. I've taken to applying what Ms. Gilmartin recommends for hand washing to those moments of tooth brushing. It's an N of 1 experiment, but I believe it makes a contribution to overall well being.

I believe that most participants in the US health "system" would agree that the "system" is a mess. There's a massive outpouring of proposals for fixing the broken "system." We need to seek mega-solutions. But micro-improvements, such as what Ms. Gilmartin proposes in her BMJ article, are steps all of us in health care can and should take as part of the larger movement of creating an ever-more ethical environment of care.

How to Deal with Controversy over Physician Assisted Death

We in the U.S. are not skilled at resolving controversy. We're vulnerable to demonizing those who hold different views on issues that matter a lot to us. Polarizations like "pro life" vs "pro choice" harden into rigid convictions. Physician assisted death (PAD - sometimes referred to as "physician assisted suicide") could fall into the same intractable trap. The American Association of Hospice and Palliative Medicine (AAHPM) teaches us how to approach the issue in a morally mature manner.

With regard to whether it is ethically acceptable for a physician in a state that allows physician assisted death (currently Oregon, Washington, Montana, Vermont and California) to prescribe a potentially lethal medication for a terminally ill patient that the patient can use if he chooses, the AAHPM believes, as I do, that "sincere, compassionate, morally conscientious individuals stand on either side of [the] debate." That's the opposite of demonization. This crucial recognition leads the Association to take what it calls "a position of 'studied neutrality' on the subject of whether PAD should be legally regulated or prohibited."

Physicians who support PAD will be disappointed that the Association does not endorse it. Physicians who oppose PAD will be disappointed that the Association does not oppose it. What the Association chose to do was to tell its members and society itself how patients can best be cared for if and when PAD is legal. Here's the essence of their view, quoted - with slight modification - from the AAHPM policy statement:

• The permissibility of PAD is dependent upon access to excellent palliative care. No patient should be indirectly coerced to hasten his death because he lacks the best possible medical and palliative care.
• Requests for PAD emanate from a patient with full decision-making capacity.
• All reasonable alternatives to PAD have been considered and implemented if acceptable to the patient.
• The request is voluntary. Safeguards should focus in particular on protection of vulnerable groups including the elderly, frail, poor, or physically and/or mentally handicapped. Coercive influences from family or financial pressure from payors cannot be allowed to play any role.
• The practitioner is willing to participate in  PAD, never being pressured to act against his own conscience if asked to assist a patient in dying.
• The most essential response to the request for PAD...is to attempt to clearly understand the request, to intensify palliative care treatments with the intent to relieve suffering, and to search with the patient for mutually acceptable approaches without violating any party's fundamental values.

The AAHPM has provided admirable ethical and clinical guidance. "Studied neutrality" reflects moral wisdom, not wishy-washy waffling. AAHPM is doing what a professional association does at its best - offering clear guidance to members, the medical profession as a whole, and to wider society.

How Long Should We Live?

Spending Thanksgiving with my two sons/daughters-in-law and five grandchildren made me more aware than usual about the generations, the passage of time, and mortality. Those musings led me to look at a post I'd written for the (now discontinued) Over 65 blog. I'm republishing that post followed by some further reflections:

Why I Hope Not to Die at 75
Posted on Friday, September 26th, 2014 at 8:00 am.By James Sabin
I feel uniquely qualified to comment on Zeke Emanuel’s much-discussed article “Why I Hope to Die at 75.” I’m smack in the middle of the year he hopes will be his last. In addition, many years ago I wrote a book about health care organizational ethics with him (and Steven Pearson). I loved working with Zeke and admire the creative work he’s done on medical ethics and health policy.

Zeke says, correctly, that with limited exceptions, as we pass beyond 75 we typically lose physical and mental capacities, with the result, in his view, that “by 75, creativity, originality, and productivity are pretty much gone for the vast, vast majority of us, resulting in diminished productivity.” Although Zeke recognizes that we “accommodate [to] our physical and mental limitations” by diminishing our expectations and “restrict[ing] activities and projects, to ensure we can fulfill them,” at 57, he is horrified by the vision of diminution.

In Zeke’s view, to be remembered “framed not by our vivacity but by our frailty is the ultimate tragedy.” If a patient said this to me, I’d respond, “We can understand that losing vivacity and becoming frail is sad, but how can we understand why being remembered that way is ‘the ultimate tragedy’ for you?” Over the years, with patients who didn’t want to live beyond a particular age, we virtually always found highly personal fears underlying their picture of what the age meant.

We 75ers know from experience that Zeke has the facts right. I’ve experienced most of the changes he attributes to the age. But as is the case even for people who experience vastly more severe challenges than diminished aerobic capacity and declining productivity, most of us ferret out opportunities to contribute to the world and derive satisfaction. Many posts on Over 65 speak to this effort.

Zeke’s facts may be right, but what about the values he espouses? If Zeke were 17 his article would read as the exuberant outpourings of a brilliant adolescent. But he’s not 17 – he’s one of the leading bioethicists and policy experts in the world. As a result, rather than being understood for what he’s doing – presenting an unflattering view of himself in order to provoke thought in others, the Twitterati see him as telling others what values they should adopt. Even more foolishly, some claim that his highly idiosyncratic perspective, which I believe he will ultimately come to see as misguided, proves the truth of the “death panel” lie.

Many readers of Over 65 will agree with Zeke’s critique of American culture as too focused on the duration of life and too inattentive to the purposes of our lives. He calls this cultural type the “American Immortal.” But very few are likely to emulate his prediction that even if he is in excellent health at 75 he will decline all medical interventions except for relief of pain. No flu shots. No antibiotics for pneumonia.

If that view holds for the next 18 years, which I doubt will happen, I hope that when Zeke declines a flu shot or an antibiotic for a treatable infection his physician will be guided by “Four Models of the physician-patient relationship,” an article Zeke wrote in 1992 with his then-wife Linda. Here’s how they described the “deliberative model”:

“The aim of the physician-patient interaction [under the deliberative model] is to help the patient determine and choose the best health-related values that can be realized in the clinical situation . . . The physician’s objectives include suggesting why certain health-related values are more worthy and should be aspired to . . .” (emphasis added)

The values Zeke anticipates applying are not “the best health-related values” for a healthy 75 year old. It is not “worthy” to invite healthy life to end sooner than need be out of fear that we will be remembered as a frail elder, not as a vigorous youngster. That would be neurosis, not wisdom.

I mentioned above that I had the privilege of working on a project and writing a book with Zeke. I understood him to be a warm-hearted person and a gifted teacher who evinced respect and affection for a wide range of humanity quite independently of whether they were “creative” and “productive.” I believe the article he is being roundly attacked for is actually a gift. Zeke wants us to think seriously about what we value in life. By presenting views that many have found repugnant, and that I see as understandable but wrong, he’s achieving his purpose of provoking thought and discussion.

Zeke gives himself an out in the final paragraph of his long (5,000 words) article: “I retain the right to change my mind and offer a vigorous and reasoned defense of living as long as possible.” (I trust by that he means “as long as possible” in a state in which he can appreciate life and respond to others in a meaningful way.) I’m prepared to bet that when Zeke turns 75 he will no longer regard youthful vigor and stunning productivity as the only values worth living for. If I’m alive, I’ll look forward to his contributions to Over 65 when he hits that birthday in 18 years!

This morning the New York Times carried an article on "Mothering my Dying Friend." The author - Catherine Newman - presents a powerful picture of what it was like to care for her best friend who was dying of ovarian cancer at 47. It's an excellent piece. If you want to read about the experience of (a) caring or (b) dying, follow the link.

I focused on (b). To me, Zeke Emanuel's wish to die at 75 in order to avoid the waning of intellectual and physical energy, seems more like a younger man's phobia about vulnerability than wise thinking about life. But I agree with Zeke that it's important for us to think about how we want to handle aging, illness and death before trouble hits the fan.

I know from many conversations with friends in their 70s and 80s that a majority wish for a more rapid demise than Catherine Newman's friend experienced. Physician assisted suicide is the most talked about approach to hastening death, but VSED, ("voluntary stopping eating and drinking") is a more common practice. When we're close to the end of our lives, we typically experience less hunger and thirst. While some clinicians and facilities are reluctant to honor a patient's decision to stop eating and drinking, there's a strong emerging trend in law and ethics to honor VSED when chosen by competent adults, as evidenced by the strong recommendation made in a recent review of literature on the topic:

...we think that the issue of suicide, euthanasia and hastened death should not be regarded as a last resort option. They have to be discussed early with the affected persons and not in the last days of life. If options of prematurely ending one’s life are known beforehand, VSED is an expression of autonomy and control, and therefore a sign of the patient’s competence. 

Thinking about mortality over this holiday weekend led me to add a codicil to my advance directive. In an aging society, clinicians, health care organizations, and the wider public, need to reflect of values and policies. I'll be writing more about the topic in the future.

Priests and Physicians who betray their trust

If you’re a moviegoer, don’t miss Spotlight, which opened earlier this month. It tells the story of the Boston Globe investigative team that broke the story about sexual abuse of children by priests. For Bostonian’s it’s a must-see. But it’s such a well-acted, well-directed film that even those with no interest in Boston or priestly behavior should find it engaging.

Sexual abuse of children is and should be a crime, whoever perpetrates it. But the story of priests who betray their calling sheds light on the most-read topic on this blog: doctor-patient sex. The further back in time we go, the more overlap we see between medicine and religion. Jesus, Muhammad and Buddha all healed sickness as well as sin. In every religion priesthood is a calling. The priest is literally called by God. I think of health care as a secular calling to which practitioners may be “called” by fidelity to our common humanity.

Spotlight shows how, priests, like physicians (especially psychiatrists), are the object of transference, that can endow them with enormous power in the eyes of their congregants/patients. When that transferential power is combined with recurrent private contact – whether in the church or the consulting room – we have the potential for great benefit or great betrayal. For too-many priests, the combination of sexual temptation in the presence of parishioners who idealized them was a devil’s brew.

For Catholic priests, celibacy adds an additional risk factor. Dylan Thomas nailed the challenge the young priest must contend with:

The force that through the green fuse drives the flower

Drives my green age: that blasts the roots of trees

Is my destroyer.

And I am dumb to tell the crooked rose

My youth is bent by the same wintry fever.

Spotlightdramatizes that while individual priests sinned, the system of the church protected them and neglected their victims by moving the offending priests from parish to parish. It required a diligent and courageous reportorial team to blow past the cover-up. Psychiatrists who betrayed their profession and exploited patients were not protected to the same extent, but it required the brave feminists who outed the offending physicians to stem the psychiatric abuse that was more prevalent in the 1960s and 1970s.

In an especially powerful moment, Spotlight shows a reporter speaking with Father Ronald Paquin. In a strangely dissociated manner, Father Paquin acknowledges that he “played around” with children, but never “raped” them and did not “gratify” himself, as if these claims exonerated him. Self-delusion is a powerful human capacity, and perpetrators frequently find ways to “justify” their actions. Last month Father Paquin, now 72, was released from prison. (For an earlier story, see here.)

It’s comforting to the rest of us to dismiss offending priests and physicians as bad apples. But that excuses us from our own responsibilities for governing the professions of priesthood and medicine. When the bystanders wanted to stone the woman taken in adultery, Jesus rebuked them: “He that is without sin among you, let him cast a stone at her.” Believers and atheists should agree that this was a true teaching.

Walking Meditation and Health Care Ethics

Health care can be frantic. Emergency rooms, intensive care units, and surgical suites are obviously high paced, but so is "ordinary" hospital and outpatient care. In my busy days of practice I sometimes had 18 appointments in 10 hours. It's not surprising that clinicians report high levels of tension.

Tension can sharpen our focus, but when it's sustained over time it can lead to irritability and distraction. These create hazards to patient safety and contribute to burnout. That kind of tension is bad.

Insofar as the conditions of practice can be modified to reduce tension, doing what's needed and possible should obviously be done. But clinical practice inevitably brings tension. For our own sake and for the sake of our patients, we need to develop ways to chill out. As the late Ken Schwartz wrote in "A Patient's Story," "...in a high-volume setting, the high-pressure atmosphere tends to stifle a caregiver’s inherent compassion and humanity." To be truly effective caretakers, we need to cherish our capacity for "compassion and humanity"!

For some, meditation is a tremendously valuable tool!

Unfortunately, meditation is often thought of as a touchy-feely matter of sitting in an uncomfortable lotus position and chanting mantras. That view confuses external practice with the internal objective. If meditation is taken to mean sitting in a quiet space for 20 minutes or more to carry out the practice, not many health professionals will make use of it.

That's where walking meditation comes in. In hospitals, doctors and nurses typically walk a few miles - in short bursts - during a shift. In my outpatient practice I often walked from my office to classrooms where I taught and to meetings at the nearby hospitals. I could even take a few paces in the office between appointments. I tried to use these interludes as opportunities for meditation.

There are excellent on line guides to walking meditation. (See here, here and here for examples.) But no approach fits everyone. I found that the excellent descriptions of how to focus on body sensation and the experience of walking didn't work for me. My mind kept wandering to matters I was fretting about. That got me riled up, not settled down.

I recently found a technique that works well for me. I like to look around as I walk. Here's what I learned to do:

1. Breathe in, and, at the same time focus my eyes on some aspect of the external world, as by saying "look at the trees," or "look at the clouds," or "look at the people."
2. As in all forms of meditation, the aim is to experience the trees, clouds, people passing by, or some other focus, not to think about them.
3. I found that for my obsessional nature, it helped to say numbers sequentially as I breathed out - one number for each cycle. That seems to help me stay with the experience rather than drifting off into ruminations. I also like to keep track of how long I can sustain the process before my mind gets filled with trivia.

I present my experience to make the point that it's kosher to develop an approach that works for us. Gurus can be helpful teachers, but the wise ones don't look for slavish followers. If walking meditation clicks for a person it can fit into the interstices of the day. Parents give children a "time out" for the child to regain some composure. Walking meditation has potential for potentially stressed out health professionals to create mini "time outs" for ourselves. When it works it serves us and our patients well! That's good ethics!

The Right Kind of Love Between Doctors and Patients

Yesterday I attended a remarkable educational session at the Brigham & Women's Hospital - "Love Stories: Deconstructing and Learning from Successful Doctor-Patient Relationships."

The stars of the session were Doris Bunte, who turned 80 this year, and Dr. Chuck Morris, her primary care physician. The large audience of medical students, residents, and staff, were transfixed by their description of their first appointment, the building of trust, and Dr. Morris's presence as a "guest of honor" at a large 80th birthday celebration.

Here's how Ms. Bunte spoke about her relationship with Chuck Morris:

I feel something inviting in you that says you are understanding me; you appreciate what I am going through. You rise to the expectations I have for a physician. You are a partner with me in my illness, helping me look at all possible angles and decisions. I feel very blessed by how closely you watch me. I appreciate your candor even about missteps between us. I value our honesty with each other when things are not working well for me. I feel a warmth. We have a mutual understanding and have never reached anger. Any illness is frightening. I must trust the doctor, especially as a patient who is alone. It is a very important partnership. 

I was happy that the panelists used the word "love" to characterize an optimal doctor-patient relationship. That's certainly true to my own experience in practice. Even before Facebook degraded the concept of "friend," I felt that "love" better connoted the attitude of deep affection, cherishing, and strong wish for the well-being of the other, that doctors should feel for their patients in the context of long term caretaking relationships.

Early in my practice I learned a lesson I've never forgotten. I inherited as a patient a man almost twice my age (I was 35, he was in his 60s) who'd suffered from a serious psychiatric ailment throughout his adult life that had impeded his capacity for work and caused suffering for himself, his wife, and his children. By the time we met his condition was quiescent. I met with him and his wife every month or two, gave what counsel I could, and tinkered with his medications. But at heart I felt guilty - I liked him and his wife, and felt I was doing nothing for them.

My wife and I wrote off for tickets to an event. (This was in the pre-internet era.) I received a letter in response:

Dear Dr. Sabin:

There were no tickets left for this event, but when I saw who was asking, I managed to find two. You've been such a wonderful doctor for my parents that I wanted to do something for you.

Gratefully yours

XYZ

The incident still brings tears to my eyes. At the same time that I was feeling guilty about how little I was doing for my patient, he and his wife had conveyed to their adult child how grateful they were for my ministrations. My "technical" offerings were essentially nil, but the letter I received showed just how much the "soft" element - respecting and caring about my patient and his wife mattered to them.

In retrospect, I'd use the term "love" to characterize the bond between me and my patient, his wife, and even their adult child who I'd never met.

Over the years I've had many discussions with primary care and psychiatry residents about how we can establish clinical relationships that a) allow for the right kind of love, b) don't interfere with our capacity for objective analysis, and c) don't leave us overwhelmed when our patients do not do well. I knew these were longstanding questions in medicine. As a first year Harvard Medical student in 1960 I was in a tutorial led by Dr. William Castle, the eminent hematologist. Dr. Castle, who was 63, described the following dialogue from when he interned at the Massachusetts General Hospital in the early 1920s:

Teacher: Dr. Castle, if you had a patient with pneumonia, and you did ABCD, but the patient died, how would you feel? 

Dr. Castle: I would feel terrible! 

Teacher: Dr. Castle - if you persist in feeling that way, you will have to leave medicine. You would have done everything that we are able to do at this time. You will have to learn to govern your emotions! (reconstructed from my memory)

My current understanding is that there are two key factors in learning how to establish loving relationships within which we are adequately "insulated" so that we can think objectively and withstand the bad outcomes that inevitably occur.

First, role modeling. Dr. Castle was passing on to young medical students what his respected teacher had passed on to him 40 years earlier. Dr. Castle wasn't just a brilliant hematologist. He conveyed to us that he loved his patients. We loved him and wanted to be like him. I repeat his story to students 50 years after I heard it from him.

The second factor is practice. Perhaps establishing the right kind of relationship comes naturally to some. For me it didn't. Sometimes I let my emotions interfere with the needed objectivity. Other times I was too stand-offish. With guidance from teachers, colleagues, and patients, I believe I did better over the years.

I know from observing students that it's a learnable capacity. This was brought home to me years ago when a resident who erred in the direction of being too stand-offish at the start of his training, described a final visit with a patient who was in a nursing facility, close to death from AIDS . At the end of the visit his patient was too tired to sit up any longer but no staff was available to help. The resident picked up his frail and emaciated patient, carried him to his bed, and said a fond goodbye.

That's the right kind of love between the doctor and the patient!

From Faith to Atheism

What would you think was being talked about if you read the following:

"I got to come out...It used to terrify me, what people's reactions would be. But it's been so long now...I don't even care...I slept like a baby last night because I knew I wasn't going to have to live a lie any more..."

This isn't a young gay or lesbian person coming out to the family - it's Teresa MacBain, a Methodist pastor, telling NPR about "confessing " to her congregation that she has lost her faith and is now an atheist.

I interpreted the NPR interview and an article in today's New York Times in light of my Rosh Hashanah post about religion and medicine. Teresa MacBain stopped believing in God, but terribly missed the community solidarity, shared values, and supportive rituals that being part of a congregation provided. While she no longer believed in the divinity of Jesus, she had not lost faith in what she calls “the philosophy of Christ.” She averred that leaving religion did not mean she had left morality - she still adheres to the Ten Commandments, the Golden Rule and other moral teachings common to many world religions.(See this article in Religion News to learn more about how she gave up her theology but retained her moral perspective.)

Here's how MacBain described the loss of her religious community:

“For me, religion was everything, my entire world. All my friendships, connections, family,  all the places I went to deal with difficulties, to do good works, to find resources to raise kids — everything was contained within that environment. I miss that social connectivity, that network.”

Not surprisingly, like a divorced person who rapidly enters a new relationship, MacBain affiliated herself with new communities - such as the American Humanist Association and American Atheists. At a meeting she met Greg Epstein, the humanist chaplain at Harvard, who hired her to be a kind of apostle to help humanists/atheists around the country build a non-theistic form of congregational life. MacBain has left the church, but she's again in a role that is structurally much like the theistic pastoral role she occupied before the lost her faith.

Before I ended my beloved clinical practice five years ago I felt great anxiety. Even though the practice was only a portion of my work life, I felt that it was totally central to my identity. I described my fear in images like a becalmed sailboat or a car that was out of gas. In retrospect I see that it wasn't just ending my psychiatric practice that was triggering the anxiety - it was also fear of no longer being part of my equivalent of a religious congregation - the "congregation of medicine."

I chair the Harvard Pilgrim Health Care Ethics Advisory Group. Typically we have 25 - 35 participants. The group sits in a U and I sit and stand in the open segment of the U. From time to time when I'm calling the group together to start the meeting I have spontaneously and whimsically said "Dearly beloved..." I do have a feeling akin to love for the group and the process we follow. Sliding into language associated with religious practice reflects my underlying feeling that a group deliberating on the values that inform health care is first cousin to a religious congregation.

Insofar as shared religious beliefs provide the glue that unites a congregation in mutual support and a commitment to social justice I feel a kinship with it. But insofar as it claims a unique truth for its theology and condemns those who do not share its beliefs I see it as undermining the health of society.

[If you want to get a sense of Teresa MacBain's pastoral skills, put her name into YouTube and sample some of the videos of talks she's given since leaving the church.]

Religious Ethics and Medical Ethics

The Jewish New Year - Rosh Hashanah – starts this evening, and the New York Times featured a front page article on “Bar Mitzvahs Get a New Look to Build Faith.” The article touched a very personal nerve for me.

Both my parents and all of my grandparents were Jewish, but the family I grew up in was very non-observant. We didn’t belong to a synagogue and didn’t celebrate the Jewish holidays, other than a very perfunctory Seder at my father’s ailing mother’s home in Brooklyn. But at 11 or 12 I asked my parents to send me to Sunday School, an almost unheard of request for a child to make. As best I can recall, I wondered how the universe was created and what my purpose in life should be, and had the idea that religion might help me answer these questions.

They enrolled me in Temple Emanu-El, a large reform congregation that was founded in 1845. I quickly concluded that I’d made a mistake. In class we memorized prayers in a language I didn’t understand, studied holiday rituals, and learned about the history of the Jewish migration to the US. We didn’t touch the big questions I was interested in. When I said I wanted to quit my father asked me to stick it out for the sake of his mother, who was happy at the idea of my having some Jewish education, even if it ended in a confirmation ceremony and not a bar mitzvah.

It’s clear to me in retrospect that I was searching for a community that shared fundamental values and collaborated in actions based on those values. I didn’t find what I was looking for at Temple Emanu-el, but during the summer when I turned 16 (and in the two summers after that) I worked as a counselor at Felicia Madison, a camp that served poor children from New York City. When I got to college I was able to create a combined major in philosophy and psychology – a program that let me explore the kinds of questions I had in mind in asking to go to Sunday School. And I worked as a volunteer at a public mental hospital, which led to a career in psychiatry and medical ethics.

I believe that an anthropologist studying my affiliations would see the involvements with psychiatry and medical ethics as structurally similar to an involvement with religion. I consort with colleagues who share an outlook on the world, values, and a commitment to forms of action. There’s no theology, but it is a community of belief.

The New York Times article describes an initiative by 80 congregations to place more emphasis on values, community engagement, and social action, than on theology and ritual. The problem the congregations are trying to solve is family departure from the congregation as soon as the bar or bat mitzvah has been accomplished.

If I’m forced to define myself in terms of religion I identify myself as “a religiously-minded Jewish atheist.” In my clinical practice I found religious language natural to use – “that’s something to pray for,” “if it happens it will be a blessing,” “XYZ is your calling,” and more. When a patient with chronic schizophrenia asked me to remember him in my prayers I said I would, even though I don’t do anything a religiously observant person would call “prayer.” I felt that his request was for me to care deeply about him and his quest for well-being, and since I did, I felt it was truthful to say I would remember him in my prayers.

At the end of his life my father turned against all religions because he saw them as sources of hatred, slaughter and war. He was thinking of fundamentalist religion. In my view all “liberal religions” are comparably true and good, and all “fundamentalist religions” are comparably false and bad. As I examine the course of my adult life, it’s clear that the calling of medicine has been my version of liberal religion.

Suing your children in Singapore

In the post I wrote yesterday I referred to the tradition of filial piety in Singapore. When I was discussing that topic with a lawyer at the Centre for Biomedical Ethics he told me about Singapore's fascinating "Maintenance of Parents Act," which went into effect in 1996.

The law allows any Singapore resident, 60 years old and above, who is unable to maintain himself adequately, to claim maintenance from his or her children, either in a lump-sum payment, or in the form of monthly allowances. If the parent gives consent, relatives or caregivers may apply for court action on the parent's behalf. Cases (recently there have been about 100-150 per year) are heard by a special Tribunal that decides whether payment should be made and how much it should be, based on criteria including the parent's financial needs and the child's earning capacity and other financial obligations.  The maintenance claim may be dismissed if the children can prove that they were abused, neglected or abandoned by their parents when they were young. The law stipulates that only the basic amenities and physical needs of the applicant including shelter, food and clothing are required.  The maintenance is not linked to the parent’s previous standard of living.The applicants tend to be Chinese fathers, either widowed or divorced.
The law was proposed by Walter Woon, who was a member of the Singapore Parliament at the time and also professor of law at the National University of Singapore.I found his comments about the law very persuasive, and quote them here:

Some critics have said that applying to the court for maintenance from one's children is undignified. I wonder whether it is more dignified to apply for public assistance or to depend on the kindness of strangers. Or perhaps it would be more dignified to starve quietly and without fuss.

Cynics have dubbed this the 'Sue Your Son' law. They miss the point completely. It would be only in a very extreme case that any parent would take his children to court. The effect of the bill, if it becomes law, will be more subtle.

First, it will reaffirm the notion that each individual has a responsibility to look after his parents. It is not society's responsibility. Singapore is still conservative enough so that this idea is not objectionable to most people. The bill reinforces the traditional values of Christianity, Islam, Hinduism and Buddhism as well as Confucianism. It doesn't hurt a society now and then to be reminded of what its core values are.

Second and more important, it will make those who are inclined to shirk their responsibility think twice. As things stand, If a person asks family members or clergymen or the Ministry of Community Development to help him get financial support from his children, the most that they can do is to try to mediate. The trouble with mediation is that the mediators have no teeth. They can exhort, preach, persuade, cajole, plead and even beg. But when push comes to shove, there is currently no way that a son can be forced to support his parents.

But if there were a legal remedy, that would be a different matter. To be sued by one's parents would entail a massive loss of face. It would be a public disgrace. The hand of the conciliator would be immeasurably strengthened. It is far more likely that some sort of amicable settlement would be reached through private mediation if the recalcitrant son knows that the alternative is a public trial. So, one hopes that the fact that such a law exists will make it unnecessary for it to be invoked.

The critics who say that the proposed law does not promote filial piety are right. It has nothing to do with filial piety. It kicks in where filial piety fails. The law cannot legislate love between parents and children and husbands and wives. All the law can do is provide a safety net where morality proves insufficient.

I take a pragmatic view. The law I have proposed won't affect the people who already are supporting their parents, not only with money but, it is hoped, with love and respect. The only ones who need worry are those who aren't living up to their moral obligations. If the law helps even one poor person, I think the effort is worth it.

Many years ago, in what turned out to be the last year of my father's life, I persuaded him to move from Florida to Massachusetts, where I live. He was blind from macular degeneration and needed a supportive living environment - ultimately one with 24 hour nursing care available. I engaged a geriatric care manager to help me (his only child) scope out the options. She told me about maneuvers that would allow him to receive Medicaid support. In the spirit of Professor Woon, I did not want to do that. The care my father  needed was costly, but I could afford it, and it seemed obviously wrong to ask my fellow citizens to support him. If I had refused to pay for his support I hope Medicaid would have come after me, as Professor Woon wanted the Singapore authorities to be able to do.

Praying for health

When I learned last week that a friend, who is also a colleague I admire, is having major surgery today, I included this sentence in the note I sent him: "Although I don't literally "pray," the phrase "you will be in my prayers feels true - and you will be next Tuesday."

He wrote back: "Technically, I do not "pray" either. However, I find that I have a strong faith in universal purpose, the importance of helping others, and that one's contributions profoundly matter in some way."

By chance on the same day I sent my email, another colleague wrote to me this way about our shared interest and pleasure in Vermont, where I am now: "We are so blessed living in New England!"

What's going on with non-praying prayers, universal purpose, and blessedness?

My love of religious language is not rooted in a theology. When I'm forced to explicate my religious position I define myself as "a religiously minded atheist." As an atheist, I don't participate in a congregation or community that calls itself religious. But here I was, on the same day, telling my friend that he would be in my prayers, hearing back from him about universal purpose, and hearing from another friend and colleague that we were blessed.

I do feel blessed to be part of a set of overlapping communities committed to health and health care - clinicians, researchers, and folks involved with health care ethics. An anthropologist studying us would say that these communities are like religious communities in (1) sharing values and (2) regularly talking about ("professing") those values while (3) maintaining recurrent, long term contact with each other. For me, and for folks like the two colleagues I exchanged messages with, these moral communities have the same valence that an organized religion can have for someone for whom the religion as a living experience, not a dutiful routine.

Referring to "prayer," "blessedness" and "universal purpose" uses terms that have been developed in the context of religious commitment and theological belief to affirm and reinforce the commitment that my friends/colleagues share. The religious terms carry a distinctive weight. They help to convey that health care can be a "vocation" and "calling," not a job.

I haven't been down on my knees today, but my friend is definitely in my prayers!

Wartime Heroism and Personal Ideals

I'm sorry I never met Dr. Tina Strobos, whose obituary I read in this morning's Boston Globe. But I have a new hero.

Dr. Strobos was a 19 year old medical student in Amsterdam when Nazi Germany invaded in May, 1940. When she and her fellow students refused to sign a loyalty oath to Adolf Hitler, the school was closed.

Dr. Strobos joined the Dutch underground, initially ferrying arms and supplies to resistance fighters. Then she turned to helping her Jewish friends and ultimately others to escape. She and her mother had a secret room constructed on the third floor of their Amsterdam home, just a short walk from the home that sheltered Ann Frank and her family. It became part of an underground railroad for escapees. During the war they helped save 100 Jews, for which, in 1989, the Yad Vashem Holocaust Museum in Jerusalem honored her and her late mother as "righteous among the nations."

 After the war Dr. Strobos came to the U.S. and studied child psychiatry. Despite extensive Google searching I haven't been able to learn much about her career. She appears to have run a treatment facility in Rye, N.Y. One listing said it was for people with chronic psychiatric ailments. Another site said she'd helped Katrina victims. I like to think that her work as a psychiatrist carried forward the same values she lived by during her years of wartime heroism.

I've thought a lot about the concept of health care as a "calling." For religious persons the call may come from their God. But what about agnostics and atheists? Dr. Strobos answered this way: "I never believed in God, but I believed in the sacredness of life." This outlook ran in her family. Her mother and maternal grandmother were also athiests, socialists, and activists. During World War I her grandmother had also hidden refugees! And all three of her children work in helping professions.

Dr. Strobos seems to have been a practical idealist. During the war, along with her work in the resistance, she also sought opportunities to continue her medical studies. "You have to be a little bit selfish and look after yourself; otherwise you just die inside, you burn out. There's just so much you can do for other people."

I'm proud to be part of the same psychiatric profession as Tina Strobos!

(For a moving video of Dr. Strobos receiving an award from the Holocaust and Human Rights Education Center in 2009, see here. For additional details on her life, see here, here, and here.)

Sister Margaret McBride Speaks Out

Fundamentalist certainty is an understandable, but dangerous, stance in a world that William James famously described as a "one great blooming, buzzing confusion." Believing that our "truths" are true for all, and that disagreement is iniquity, is simpler than dealing with the diverse views of seven billion fellow humans.

Last year Sister Margaret McBride was excommunicated for her role at St. Joseph's Hospital in Phoenix in allowing an abortion to be done to save a pregnant woman's life. In her first public comments since Bishop Olmsted pronounced her excommunication, she told the Arizona Republic (by email):

"My journey over the past year has led me in many directions, but ultimately to a new understanding of forgiveness and mercy...Whether we are talking about my situation, the state of the church or society in general, I believe that forgiveness and mercy are extremely important for each of us...

Our important mission to our community has not changed. This is an extraordinary place with people from every religious background doing the impossible every day. At the heart of St. Joseph's is still our commitment to caring for the poor and ill in our community. Each employee is an inspiration to me every day in carrying out the mission of the Sisters of Mercy," (McBride's religious order, which is active in education, health care and social service worldwide).

According to the article, "sources" report that Sister Margaret has "resolved" her excommunication by going to confession.

Here's my guess about what "resolved" means.

When I did my psychiatry training in Boston, we learned which priests were likely to absolve depressed patients for "sins" like masturbation and which were likely to reinforce what we saw as pathological guilt.

I hope that Sister Margaret has been absolved and recognized as a good Catholic by a wise priest!

(For previous posts on St. Joseph's Hospital and Sister Margaret McBride, see here, here, here, here, and here.)