Revenge of the Fifth

This is a reposting of the fourth of a previous series on alcoholism and addiction.

 
MercuryIt seemed like such a great idea at the time…

His name is Darin. Of course, that’s not his real name, but he is a casual friend of mine. A bright young man, possessed of good looks, a warm smile, and a soft-spoken demeanor. Darin is brilliant with computers–not merely competent, as many are, but a true geek, tear-’em-down-and-rebuild-’em smart, fearless in the depths of sockets and motherboards, Windows registries and Unix terminals. A true success story, you might say, bright future, make some girl very happy. But Darin was toolin’ down the freeway of goin’ nowhere fast.

You see, Darin had a little problem: a fondness for the grape and the snort which always seemed to get the best of him. Not that he didn’t try: he was in and out of AA rooms more often than a pastor’s wife at church socials, always returning beaten and remorseful, determined to do better this time. “This time” rarely lasted more than a few weeks or months.

Darin was quiet, but a man of passion. He was always in love. Intoxicated with the flush of a new romance, that rush of euphoria so real yet so maddingly transient. Each new girl was “the one”, but nights of passionate, drug-enhanced sex soon proved impotent to overcome the waning charm of Miss Demeanor, the rumpled sheets, and the rumblings of his restless soul. Before long he was again cruising for some other codependent wench, herself seeking a sodden soul to save. Like an ugly tie wrapped up pretty under the Christmas tree, Darin’s package looked good at first glance, but he quickly proved to be a daddy’s nightmare: “no phone, no food, no rent”, as the song goes. Soon he was once again welcome only in his mother’s house, with whom he could do no wrong.

Unfortunately, the same could not be said of Darin: someone did him dirty, stiffing him out of a good deal of cash, and forgiveness was not one of his many charms. The details are murky: a computer built or repaired, promises made but unkept. There was much lighthearted chatter at the coffee houses–was it Darin’s fault, or his nemesis? No matter–like a quiet bubbling cauldron in a witch’s lair, Darin was cooking up his favorite dish: a rip-roaring resentment. Not visible on the outside, of course, but raging like a Jerry Springer slugfest in the conference rooms of his mind. It was the perfect mixed drink: a perceived injustice blended with that unique obsessiveness which addicts possess seemingly in endless measure.

It is not clear when the brainstorm struck–an idea so brilliant, so flawless, that it would right all injustices and settle all disputes: Darin would break into his detractor’s home and steal back the computer which tortured him so. No mere larceny, mind you, but the picture-perfect crime, a liberation to rival Paris in ’45. Carefully timed when the enemy was not at home, staged so not even Sherlock Holmes would presume that Darin might be the perpetrator. Sweet revenge, sweetly executed.

Like tightly-written computer code, Darin’s nimble mind set the parameters, checked the variables, and executed commands in a tight loop whose efficiency and speed wasted no cycles. The Day of Vengeance arrived, with only one small ingredient missing: courage. But Darin had that algorithm factored as well: a fifth of Vodka erased all fears, drowning all doubts. By stealth of night, with watches synchronized and bottle drained, the window glass parted to usher him to glory. The mission was underway.

No one knows whether anyone heard the shattering of glass, but despite his stealth the disruption somehow caught the notice of neighbors. When the police arrived, the cause of the disturbance became evident: there was Darin, passed out on the floor, beside the untouched computer he coveted. Fate had struck a cruel blow–his celebratory blackout had arrived on the wings of Mercury rather than with the spoils of Mars. He awakened to handcuffs and an open-ended reservation at the Gray Bar Hotel.

All good stories–even true ones–should have a moral, but Darin’s story eludes easy lessons. He was taken by that peculiar insanity which alcoholics possess in abundance, even while sober. When Darin hatched his master plan, he was not drinking, but engaged in one of his countless attempts to clean up. For the alcoholic, the danger lies not in the bottle, but in the brain. The sane among us make mistakes, to be sure: wisdom comes from experience, and experience often comes from lack of wisdom. But facing the inevitable consequences of bad choices, we generally rearrange our lives and priorities to ensure that such a travesty does not happen again. Not so the alcoholic. Obsessively repeating behavior long ago proven destructive, he nevertheless pursues the optimism of denial which says the next time will be different. This baffling disconnect from reality cascades from farce to tragedy, as the alcoholic perceives no problems other than those bastards who are out to get him.

There is much resistance to the idea that alcoholism and addiction are a disease. Much of this comes from conservatives, and those of religious conviction, whose proper emphasis on personal responsibility and moral rectitude sees in the alcoholic only reckless hedonism and wanton irresponsibility. These qualities the addict has in spades, but less obvious is the driving obsessive compulsion, the thought disorder which is their engine. The medical evidence for the disease model of alcoholism and addiction is deep and wide, as I have detailed in part elsewhere (see also this and this for more on the topic). The liberals have this one right: the alcoholic is a victim of his or her genetics, and the addition of a mind-altering drug–which one is probably moot–starts a swirling whirlpool whose vortex holds only misery, destruction and death. Not many survive its power.

Yet defining deviance from normal as disease also has its risks: the proliferation of social disorders redefined as diseases seems endless, and points to the abrogation of all responsibility for one’s actions. It can become laughable at times. Several years ago, I saw a patient, a healthy, athletic women in her 40’s, who was covered under Medicare. Medicare covers the elderly, but also those with chronic renal failure and the disabled, so I inquired as to the nature of her disability. I was informed she had “hyperactivity disorder.” Attention deficit hyperactivity disorder (ADHD)? No, just hyperactivity disorder–she was restless. A black belt in Karate, she travelled around the country constantly, competing in tournaments and teaching seminars. She was disabled, in short, because she couldn’t sit still. No “cripple” jokes around her, no siree, unless you wanted your skull crushed by a foot you’ll never see coming.

The concern about labeling alcoholism, or any other behavioral disorder, as a disease is the tendency to tolerate and rationalize the resulting behavior, to use the “disease” label as an excuse for selfish, self-centered behavior destructive to one’s self, society, and those around you. The issue is not disease or no disease, but rather what drives the behavior and what can be done to change it.

The paradox about 12-step programs–which have the only reliable track record for successful recovery from addiction–is that they emphasize the disease as the problem, and honesty, integrity, and personal responsibility as the solution. They do not excuse the behavior while admitting the disease, and this blend of honesty and humility, acceptance and tough love, works like nothing else. It is, as recovering alcoholics are quick to point out, a spiritual program: the Catch-22 of a body which craves alcohol without limit and a mind which denies the resulting problems cannot be solved any other means.

But as any recovering alcoholic will tell you, the problem is not the booze; it is not even the obsessive, irrational mindset which drives the drinking. Both these problems are symptoms of an underlying decay, one of spiritual dimensions, characterized at its core by extreme self-centeredness. The pursuit of happiness by feeding this monster creates not the promised joy but rather pain and emptiness. Alcohol hides that pain for a while, until the monster, growing ever stronger by its constant feeding, kills its host spiritually, emotionally, and often physically.

But addiction is hardly alone as a symptom of this dark core. The list of destructive behaviors arising from its belly is endless: obesity, sexual promiscuity, compulsive overwork, materialism, computer obsession, gambling, the pursuit of beauty over character, the lust for money and power. Some may be biologically-driven; some learned behaviors or dysfunctional coping. All seek to fill a hole with no bottom, providing the wrong salve for the pain, and more of the same when the salve makes the wound fester.

And what of Darin? In many ways he is fortunate: his life is on hold, and forced reflection and change are his for the taking–should he choose to grasp them. The price is high; it might have been much higher. Yet his choice–and ours–is the same: feed the monster, or turn life over to One whose burden is light, who alone can fill that deep inner void.

Three Men on a Friday

CalvaryThree men on a Friday, condemned to die. Ensnared by Roman justice, convicted, and sentenced to a lingering death of profound cruelty and excruciating agony.

The Romans knew how to do it right: execution designed to utterly humiliate its victims, and maximize their suffering–a public spectacle and object lesson to others about the foolishness of defying Roman authority. First used by the Persians in the time of Alexander the Great, and adopted by Rome from Carthage, crucifixion was so horrible and debasing a fate that it was not permitted for citizens of Rome. Victims hung for days, their corpses consumed by carrion.

Our knowledge of these three men is incomplete. Two are described in ancient texts as thieves, the other a preacher run afoul of religious leaders, delivered to the Romans under pretense of imperial threat. There should have been nothing unusual about this event: the Romans crucified criminals often, sometimes hundreds at a time. Yet these men, in this spectacle, were different: on these crosses hung all of mankind.

Two thieves and a preacher — an odd picture indeed. And even more peculiar: the most hated was the preacher. Taunted, insulted, ridiculed, reviled. A miracle worker, he, a man who supposedly healed the sick and raised the dead, yet now hung naked in humiliation and agony, unable to extricate himself from his dire circumstance. Even those convicted with him–themselves dying in unbearable pain and mortification — join the fray. Insulting the rabbi, demanding he set himself–and naturally, themselves as well–free. They know his reputation, yet selfish to the end, desire only their own deliverance.

But one thief is slowly transformed, in frailty considering his fate and the foolishness of demanding release when his punishment is just. And he marvels at the man hung nearby — why? Why does this preacher, unjustly executed, not proclaim innocence nor demand justice or vengeance? Why does he–amazingly–ask God to forgive those who have so cruelly and unjustly punished him? Why, in the extraordinary agony only crucifixion can bring, does he seem to have peace, acceptance, perhaps even joy?

His revulsion at the baying crowd, at the arrogance of his fellow convict reviling this man of character and grace, bursts forth in rebuke at him who ridicules: “This man has done no wrong!” Turning to the preacher, he makes a simple, yet humble, request: to be remembered. Only that. No deliverance from agony, no sparing of death, no wealth, prosperity, or glory, no miracles–only to be remembered.

The reply reverberates throughout history: “This day you shall be with me in Paradise.” A promise of hope, a promise of relationship, a promise of forgiveness, a promise of comfort, joy, healing, peace.

Three men on a cross. In these three men are all who have lived: two are guilty, one innocent. Two are justly executed, one unjustly. All three have chosen their fate: one thief to revile, ridicule, hate, blaspheme; one criminal to trust, to seek consideration and mercy from one greater; one man to submit to brutal and humiliating torture and death, willingly, for no crime committed — or for all crimes committed, everywhere and for all time. Yet only one promise given–to the one who, though guilty, trusted and turned.

Who was this man in the middle, this preacher? A charlatan, perhaps – but an impostor abandons his schemes when such consequences appear. Delusional, deceived zealot, or presumptuous fool? Such grace in agonal death is inconceivable were he any such man. What power did he have to make such a promise? What proof that the promise was delivered?

An empty grave. A promise delivered by a cavern abandoned, a stone rolled away. A gruesome death transformed into a life of hope, meaning and purpose for those who also trust.

A Life Not Long

Last week, President Obama removed virtually all restrictions on fetal stem cell research, claiming a triumph of science over “ideology.” The hope, of course, is that science may find new ways to prolong and improve our lives, now that the shackles of moral restraint, humility, and ethics have been removed. It seemed fitting, therefore, to repost this older essay, pondering whether the “victories” which science now has in store for us will be indeed Pyrrhic.

 
sunset

A link from Glenn Reynolds hooked into something I’ve been ruminating on in recent days: the endless pursuit of longer life.

Here’s the question I’ve been pondering: is it an absolute good to be continually striving for a longer life span? Such a question may seem a bit odd coming from a physician, whose mission it is to restore and maintain health and prolong life. But the article which Glenn linked to, describing the striking changes in health and longevity of our present age, seemingly presents this achievement as an absolute good, and thereby left me a tad uneasy — perhaps because I find myself increasingly ambivalent about this unceasing pursuit of longer life.

Of course, long life and good health have always been considered blessings, as indeed they are. But long life in particular seems to have become a goal unto itself — and from where I stand is most decidedly a mixed blessing.

Many of the most difficult health problems with which we battle, which drain our resources struggling to overcome, are largely a function of our longer life spans. Pick a problem: cancer, heart disease, dementia, crippling arthritis, stroke — all of these increase significantly with age, and can result in profound physical and mental disability. In many cases, we are living longer, but doing so restricted by physical or mental limitations which make such a longer life burdensome both to ourselves and to others. Is it a positive good to live to age 90, spending the last 10 or more years with dementia, not knowing who you are nor recognizing your own friends or family? Is it a positive good to be kept alive by aggressive medical therapy for heart failure or emphysema, yet barely able to function physically? Is it worthwhile undergoing highly toxic chemotherapy or disfiguring surgery to cure cancer, thereby sparing a life then severely impaired by the treatment which saved that life?

These questions, in some way, cut to the very heart of what it means to be human. Is our humanity enriched simply by living longer? Does longer life automatically imply more happiness–or are we simply adding years of pain, disability, unhappiness, burden? The breathlessness with which authors often speak of greater longevity, or the cure or solution to these intractable health problems, seems to imply a naive optimism, both from the standpoint of likely outcomes, and from the assumption that a vastly longer life will be a vastly better life. Ignored in such rosy projections are key elements of the human condition — those of moral fiber and spiritual health, those of character and spirit. For we who live longer in such an idyllic world may not live better: we may indeed live far worse. Should we somehow master these illnesses which cripple us in our old age, and thereby live beyond our years, will we then encounter new, even more frightening illnesses and disabilities? And what of the spirit? Will a man who lives longer thereby have a longer opportunity to do good, or rather to do evil? Will longevity increase our wisdom, or augment our depravity? Will we, like Dorian Gray, awake to find our ageless beauty but a shell for our monstrous souls?

Such ruminations bring to mind a friend, a good man who died young. Matt was a physician, a tall, lanky lad with sharp bony features and deep, intense eyes. He was possessed of a brilliant mind, a superb physician, but left his mark on life not solely through medicine nor merely by intellect. A convert to Christianity as a young adult, Matt embraced his new faith with a passion and province rarely seen. His medical practice became a mission field. His flame burned so brightly it was uncomfortable to draw near: he was as likely to diagnose your festering spiritual condition as your daunting medical illness — and had no compunction about drilling to the core of what he perceived to be the root of the problem. Such men make you uneasy, for they sweep away the veneer of polite correction and diplomatic encouragement which we physicians are trained to deliver. Like some gifted surgeon of the soul, he cast sharp shadows rather than soft blurs, brandishing his brilliant insight on your now-naked condition. The polished conventions of medicine were never his strength — a characteristic which endeared him not at all to many in his profession. But his patients — those who could endure his honesty and strength of character — were passionate in their devotion to him, personally and professionally. For he was a man of extraordinary compassion and generosity, seeing countless patients at no charge, giving generously of his time and finances far beyond the modest means earned from his always-struggling practice.

The call I received from another friend, a general surgeon, requesting an assist at his surgery, was an unsettling one: Matt had developed a growth in his left adrenal gland. His surgery went deftly, with much confidence that the lesion had been fully excised. The pathology proved otherwise: Matt had an extremely rare, highly aggressive form of adrenal cancer. Fewer than 100 cases had been reported worldwide, and there was no known successful treatment. Nevertheless, as much for his wife and two boys as for himself, he underwent highly toxic chemotherapy, which sapped his strength and left him enfeebled. In spite of this, the tumor grew rapidly, causing extreme pain and rapid deterioration, bulging like some loathsome demon seeking to burst forth from his frail body. I saw him regularly, although in retrospect not nearly often enough, and never heard him complain; his waning energies were spent with his family, and he never lost the intense flame of faith. Indeed, as his weakened body increasingly became no more than life support for his cancer, wasting him physically and leaving him pale and sallow, there grew in him a spirit so remarkable that one was drawn to him despite the natural repulsion of watching death’s demonic march.

Matt died at age 38, alert and joyful to the end. His funeral was a most remarkable event: at an age in life where most would be happy to have sufficient friends to bear one’s casket, his funeral service at a large church was filled to overflowing — thousands of friends, patients, and professional peers paying their respects in a ceremony far more celebration than mourning. There was an open time for testimony — and such a time it was, as one after another took to the lectern to speak through tears of how Matt had touched their lives; of services rendered, small and large, unknown before that day; of funny anecdotes and sad remembrances which left not one soul of that large crowd untouched or unmoved.

A journey such as his casts critical light on our mindless pursuit of life lived only to live long. In Matt’s short life he brought more good into the world, touched more people, changed more lives, than I could ever hope to do were I to live a century more. It boils down to purpose: mere years are no substitute for a life lived with passion, striving for some goal greater than self, with transcendent purpose multiplying and compounding each waking moment. This is a life well-lived, whether long or short, whether weakened or well.

Like all, I trust, I hope to live life long, and seek a journey lived in good health and sound mind. But even more — far more indeed — do I desire that those days yet remaining — be they long or short — be rich in purpose, wise in time spent, and graced by love.

The Crush of Covenant

Well, I finally did it: I quit.

Walked into the boss’s office, gave him a piece of my mind, tossed my resignation letter on the desk, and told him exactly what he do with his stinkin’ job. “Take this job and shove it”, as the country song goes.

Felt great. Been wantin’ to do this for a loooong time.

What led me to such a drastic, disgruntled display of ill-demeanor?

Here’s just a few vignettes from the past few days:

Monday 7 A.M: It’s Monday, my regular ER on call day. Full office scheduled. The ER calls — at exactly 7 A.M. Which means the weekend call guy, who goes off at 7:00, hasn’t answered his pages for the last 2 hours. Bastard. There’s a term for this: it’s called “dumping.”

The patient: a 90-something man with Alzheimer’s dementia, from a nursing home. Not any nursing home, mind you: one specializing in the care of Alzheimer’s patients. Ads on the radio about how caring and compassionate they are — you’ve heard ’em. Creme’ d’ la creme, and all that. Chronic Foley (urinary) catheter for incontinence. Despite their fawning attention, he somehow managed to grab his Foley and pull it out — with the balloon inflated, of course. He’s bleeding. A lot. The caring, attentive staff at the home has also neglected routine catheter care, so it has basically eaten its way through his penis. He now pees (if he could) through a hole just over the scrotum.

The ER staff can’t get the catheter back in. Not just because the anatomy ain’t quite normal (the P.A. is still trying to insert the catheter into the end of the penis, and can’t figure out why it won’t go in) — but he’s agitated. Really agitated. 4 nurses and counting to hold him down, still throwing punches. (great left hook!). Clearly this isn’t going to work — he’ll need to go to surgery ASAP, so this can be done under anesthesia — putting in a more permanent bladder catheter through a small hole in the low abdomen. With a big-ass balloon he can’t pull out. Hopefully.

Monday 9 A.M.: Inform my office staff that most of my busy morning office has to be rescheduled, the rest will have to wait. They are not happy. The patients rescheduled will not be happy – most have waited over 6 weeks for their appointment, and probably another 6 for their new one. C’est la vie. They will likely think my “medical emergency” means I’m on the 1st tee with my golfing buddies. Whatever. The more urgent ones will get squeezed into another day, already overbooked. Then they can be even more unhappy because the doctor is running late, and “Their appointment was at 10:00 A.M., dammit, and their time is valuable.”

Monday 1 P.M.: Back from surgery, the few longsuffering and surly patients from the morning clinic seen and (somewhat) assuaged. Short conference with my billing specialist, a soft-spoken pit bull with lipstick who daily does battle with the forces of evil and corruption (a.k.a., insurance carriers and Medicare), and wins an amazing number of battles. But not today.

Mr. Jones, you see, had a prostate problem. So he needed a fairly simple test to check for obstruction, called a uroflow, to evaluate whether his prostate was causing blockage. Charges for this procedure? About $325.

Sounds like a lot of money to pee in a jug. But it’s a very special jug. The equipment which measures and records his urinary efforts cost over 6 figures (it has a number of other highly specialized functions as well, lest you think it’s too extravagant for such a lowly task). The specialized catheters used to measure pressures for the more sophisticated tests cost well over $100 each — and are single-use disposables. Setup, cleanup, patient instruction and assistance by my back-office nurse, about 20 minutes of her salary, benefits, health insurance, 401(k) contributions. Overhead to keep the office open (rent, supplies, maintenance, malpractice insurance, licenses, etc., etc.), about $200 an hour. Oh, and my interpretation of the test and conclusions about how best to treat the patient is included in the fee.

What the insurance usually pays for the procedure: about $125.

What Mr.Jones’ insurance company paid: $0.

The reason? Mr. Jones’ policy doesn’t cover in-office surgery. “But peeing in a jug isn’t surgery!”, you protest. As did I. But the CPT service code has been incorrectly categorized as surgery by our friends at the AMA, in their massive annual tome used by insurers and federal payors to determine payments for medical services.

So I sat down and wrote a detailed appeal letter, explaining in a clear, courteous, and detailed manner that peeing in a jug is not surgery. Dictated, proof-read, sent off. My time? About 20 minutes. My reimbursement for that time? $0 (Called your attorney lately and chatted for 20 minutes, for free? Didn’t think so).

One month later, the response arrived: Appeal denied. The letter explained how the medical situation had been carefully reviewed: first, by their highly-trained Resource and Review Nurse; then by a panel of esteemed physicians and other health care providers; and finally, because of the seriousness of the matter, by their Medical Director (whose 7-figure income reflects the gravity and burden of such decisions). The verdict?

Peeing in a jug is surgery.

Of course, it is never prudent to take the last shred of hope from the hopeless, so they politely inform me that I may submit a Level II appeal — which requires pleading to the AMA that the categorization of peeing in a jug as surgery, in their massive annual CPT coding tome, is an error. And, of course, they will be more than happy to reconsider the matter once the AMA has agreed, and changed their rules.

Oh, and have a wonderful day! We cannot tell you how much we appreciate your outstanding care for our insured clients!

Monday, 1:10 P.M:: Billing conference, part II. Mr. Smith, another nursing home patient, had blood in the urine. Came to our office for a cystoscopy, a visual inspection of the bladder. Found he had a small bladder cancer, and was scheduled for surgery in a few weeks. Went back to the nursing home until then.

In the past, billing for such a procedure was simple: submit the claim to Medicare, get paid (about 40% of my billed fee, about 10-20% less than my overhead to perform the procedure) by Medicare a few weeks later.

Then Medicare changed the rules. Since Mr. Smith is in a nursing home, the nursing home must now bill for my cystoscopy, get paid by them — and then pay me, if and when they get around to it. But, of course, they have no motivation to do so — since I have no recourse against them if they fail to bill it, or bill it incompetently and get denied, or refuse to pay me.

So the executive summary: I get nada for Mr. Smith’s procedure.

The unintended consequence of this little change in Medicare regulations? Urologists and other specialists now refuse to do procedures in the office on nursing home patients, since they don’t get paid. The procedures either don’t get done — or the patient has to be admitted to the hospital when his bleeding gets bad enough, where his cystoscopy will be performed at a cost to Medicare of, oh, about 500-fold what it would have been if I did it in the office.

Medicare, of course, will be ecstatic: their payments for office procedures will plummet, after their careful review of regulations helped trim “wasteful and unnecessary medical spending” from their budget. The jump in costs for hospital procedures which results from this shell game are, of course, because of greedy health care providers, fraud and abuse, and more wasteful medical spending — and come out of a different pocket, so’ll they’ll never make the connection. The politicians are sure to trim those frivolous expenses as well, by carefully reviewing the regulations and implementing more “fraud and abuse” abuse, as they seek high quality, affordable health care coverage for all.

Tuesday, 1: P.M: Mr. Smith’s nurse from the Alzheimer’s Home calls, and says he has some blood in the urine from his new bladder catheter (which is expected). “How much?” “Dark pink, no clots.” “Have you irrigated it?” “Yes, and we’re sending him back to the hospital.” “Is the catheter draining well?” “Yes, but we’re going to send him back.” “Is he stable, blood pressure OK, any pain, blood count OK?” “Yes, do you want him to go by ambulance or do we call 911?” “He doesn’t need to go back to the hospital.” “Well, he’s going anyway. We can’t handle this.” Yeah, I guess that’s why they call it a nursing facility. God forbid you should deliver, you know, nursing care.

14 hours later he returns to the nursing home after an ER visit, perfectly stable medically, just as he was when he left the nursing home. About an $8-10,000 medical junket, because a nurse couldn’t, or wouldn’t, handle basic nursing care.

Wednesday 9:00 A.M.: Mr. Johnson is waiting when the office opens. His is a sad story: prostate cancer, had successful surgery to remove it, and is cured. Developed scar tissue afterward and couldn’t pee. Opened it up and he couldn’t not pee — bad incontinence. Had a prosthetic device placed, an artificial urinary sphincter, nine months ago. Worked beautifully, Mr. Johnson is happy. 8 months later, leaking again: Mr. Johnson is not happy.

Took him to surgery yesterday to repair it. A tiny leak had developed, and the pressure on the sphincter cuffs was lost — an uncommon but known problem with these devices. Replaced the components, hooked it up, tested it thoroughly, worked great. The device has a control valve located in the scrotal area to open the cuffs when you need to pee, which was one of the components replaced. It has a locking button, which holds the cuffs open, as things are too swollen and tender for the patient to use it for a while. Locked the cuffs open, tested it again several times, everything’s perfect.

He goes home, and can’t urinate. Somehow the lock released on its own — which isn’t supposed to happen. Goes to the ER, where they try to put a catheter in, rather indelicately, and left it in — which greatly increases the risk his sphincter prosthesis will get infected, and have to be removed. And he needs to go back to surgery, since it is far too painful to try to lock the cuffs open now, and he will need a temporary bladder drain through the skin until the swelling goes down.

Mr. Johnson is not happy. I am not happy.

Not to be too whiny, but the responsibility of this profession at times can be crushing. At the risk of seeming hyperbolic, you really do, to a greater or lesser degree, take patient’s lives in your hands when you assume their care. Not just the life-and-death stuff, although that’s sometimes part of it too. No, it’s the rest of their lives which come under your responsibility. It’s the drug to treat a serious disease, which causes serious side effects or unintended adverse effects on their other diseases. It’s the surgery to cure cancer which can have painful, disruptive, frustrating complications, even when the cancer is cured — and even when the surgery is competently and expertly performed. You are, in the end, responsible. When the side effects happen, you are responsible. When the patient fails to follow treatment advice, or has unrealistic expectations despite your best efforts to temper them, you are responsible. When the pharmacist sends the wrong drug; when the nurse fails to notice an important problem; when the technician doesn’t properly clean and sterilize the instrument; when the prosthesis fails to operate as designed: you are responsible.

Perhaps in some alternate universe, where Gucci-loafered lawyers with fat cigars parse guilt in mahogany-gilded chambers, the responsibility would be meted out in scrupulous fairness to all involved. But as a physician, where our relationship with the patient is one of covenant, not contract, those responsibilities become ours, because we commit to the patient’s best interest, no matter what, while orchestrating the complexities and complications of this enormous technological beast we call 21st century medicine. This gleaming beast can accomplish enormous good — or ghastly harm. And much of the behemoth we seek to command is not under our control — yet we remain responsible nevertheless. So we lash, kick, prod, and goad the monster, trying to reign in the mind-numbing complexity and tie up the endless loose ends, as the monster snarls back and snaps at your head or pummels you with its tail. And never forget your own frailty: perfection is unattainable despite your most obsessive, strenuous efforts. The country doc with his black bag could do little good and cause little harm; small errors today, even unrecognized, can multiply and spiral into disaster at frightening speed. This fact alone crushes many a doctor with its gravity, as witnessed by the high rates of physician burnout, suicide, divorce, and drug and alcohol problems.

The feeling is like a punch in the gut, only worse. I am not happy. I am depressed, and angry, and fearful, and discouraged — and convinced that with my level of competence I should be flipping burgers at McDonalds. Self-condemnation is a narcotic, savored and craved by perfectionists: noxious in flavor, but oddly salutary in the self-pitying comfort of its dark and fetid euphoria.

It does not pass easily.

Wednesday, Noon: Mr. Smith, with the Alzheimer’s, is back in the ER, and they are calling me. No preliminary call to me this time from his nursing home — they just sent him back. His 4-by-4 inch gauze dressing around his new bladder catheter is bloody — about a silver-dollar sized area. The ER doc sees and evaluates him: still demented, still medically stable as a rock, blood count unchanged. The ER doc changes his dressing, and sends him back to the nursing home. So, here we are, some $20-25,000 spent on this poor man, because his nurses are inept, lazy, incompetent, and can’t change a g*d-damned dressing. No one at the nursing home will have their pay docked because of this travesty; no one will be fired or fined. Medicare will pay its fractional part of the costs, oblivious to the incompetence which triggered it. The hospital will eat the difference.

And life in the circus of 21st century medicine will go on.

And so, enough is enough: the camel’s back has snapped. I quit. It’s not the first time, by any means; likely won’t be the last. My boss is very understanding, and he’s been through this all before. That’s one of the skills you need when you’re a self-employed, solo physician.

He knows I’ll be back at my desk tomorrow, as if nothing happened. Ready to start it all over again.

* All names are, of course, fictional.

The Celebration of Hope


The lady on the morning “news”, in her warmest and faux-sincere voice, said it sweetly: “This is the season of hope and joy” — and moved on quickly to tug at the heartstrings with some touching story of the downtrodden redeemed, a perfect production for this “holiday” season.

I don’t really think she understands the things of which she speaks.

I often wonder, when watching the scrupulously secular stars of media utter such banalities: what, exactly, is the basis of your “hope”? Is it the optimism of wishful thinking, the notion that in our oh-so-progressive world, things will simply get better and better, hurtling at light-speed toward an inevitable utopia? Is it the hope of new politics, new icons of power to guide us out of the wilderness of war and hatred with an enlightenment found nowhere else? Or is it simply the Big Lie, repeated ad infinitum until it becomes Truth, designed to deaden terrifying voices of angst and uncertainty which screech like harpies just beneath a consciousness deadened by frenzy, acquisitional obsession, and the myriad addictions which numb our fears and deaden our souls.

Yet it is a season of hope — or more precisely, a season to celebrate a perpetual and profound hope, not the emotional hopiate mainlined by the hopeless, dragged out like some green plastic tree from a dusty closet to adorn a meaningless holiday, no longer called “Christmas.”

So what is this true hope, this enduring and transformational power which we celebrate this season, yet abide in throughout the year?

It is the hope of true harmony, God and Man in right relation, the only source for Peace on Earth.

It is the hope, beyond reason, of forgiveness of the unforgivable, of acceptance of the rejected, of healing of sick and mortally wounded souls.

It is the hope of conquest of the demons which drive us, enslaving us in what masquerades as freedom.

It is the hope of deep joy, not mere shallow happiness.

It is the hope of a purpose beyond self-satisfaction, of a meaning beyond random chance, of direction for the lost and aimless.

It is about God becoming small that Man may become great, in Him.

It is about sacrificial love, the emptying of self, the death of pretense and a life of humble dependence.

It is about a Child who became Man so that men might reclaim the wonder and joy of children.

It is about infinite love, abounding mercy, endless grace, transformational power.

It is about Christ: humble in birth, extraordinary in life, sacrificial in death, glorious in resurrection.

It is about our hope — the only true and certain hope — the hope of those who know, and serve, and rely on Him, and His gentle hands which lift us up, and cherish us, and carry us home.

It is about Christmas, when Light entered the world and changed it forevermore.

That is our hope, and nothing less.

Have a most blessed and Merry Christmas, and may the peace of God rest upon you and yours.

On Assisted Suicide


In a previous post on physician-assisted suicide, I had the following exchange with a commenter named Van:

Van:

I take it you are are against assisted-suicide?

Let me ask you this – how can we say we live in a free nation if we cannot do what we wish to our own bodies, as long as we do not impact the life, liberty and safety of others?

I have mixed feelings on the subject, but I really have a hard time with others telling me what to do with my body.

Dr. Bob:

Yes, very much against it.

You are, of course, perfectly free to end your own life, with or without such legislation. A handgun and a single bullet will do the job very nicely — along with a hundred other ways.

The problem with this public policy is that you are asking your physician to kill you — and therefore it is no longer just about “what you do with your body”, but very much involves other people — the doctor, the families, and society as a whole.

The problem with this sort of “it \'s my body” radical self-autonomy is that it focuses solely on the self, while conveniently ignoring the enormous consequences of such legalization on others and society as a whole.

Van:

So your key issue is the doctor assisting in the suicide, thereby involving others?

Let \'s say you have a 90 year old individual with no family, suffering from cancer, who has no meaningful impact on others… If they take their own life, you are OK with it?

Just trying to understand where you are coming from.

Van’s question is a valid one, to be addressed shortly, but in digression one should note what often passes for arguing from principles in our current culture: the argument from the exceptional. When promoting or defending some contentious social or moral issue, we seem always to find the most extreme example imaginable and argue from this specific, then applying our conclusions to the general. Hence, for example, when arguing for government prescription health coverage, we must first find some old woman who has to eat cat food in order to pay for her prescriptions; when discussing gay adoption, we must find the idyllic gay couple, lifelong partners (or so we are told), ecstatically happy with nary a relational dispute, as parents; when arguing for assisted suicide, we must find the patient in unbearable pain with a loving husband passionate about ending her life “in dignity” by slipping her a deadly cocktail — or one who is dying utterly alone, with nary a friend or family member to share their suffering. That such argumentation almost invariably presents a false dichotomy is never considered; that far better alternatives might exist to solve the problem never pondered; that applying the suggestive solution based on emotion without consideration for its broad implications or ramifications might prove disastrous, is never seen as a possibility. We press for great social and policy changes with profound effects on culture and society using pop emotionalism and pulp fiction.

But I digress. So, to answer the question: I would not find suicide of such a sadly-abandoned individual justified, simply because no physician was involved. Suicide is the ultimate repudiation of life, of relationships, of hope, the product of the deep hopelessness and self-absorbed insanity of depression. My point was simply this: we all have free will. Each of us may choose, if we decide to do so, to end our own lives. There is a pernicious distortion of the idea of freedom which is a product of our radical individualism, to wit: I live in a free society, therefore by necessity I must be free to do whatsoever I please, and others must not only allow me to do so, but must bear the consequences of my actions, and must be actively engaged in enabling my behavior, because it is my right. Hence, I must be free to say anything I wish, without consequence, including criticism of my speech; I must be free to terminate my pregnancy, without guilt or restriction, though my unborn child pays the ultimate price; I must be free to end my life when I wish, and my physician must be required to deliver the lethal potion — or at least must be coerced into finding another doctor who will, if his “values” (defined as mere subjective opinions) don’t agree with mine.

Many of the “rights” which are being promulgated and promoted by today’s secular culture are in reality straw men, fine-sounding proxies for demands and desires far less salutary than they sound. Thus, gay marriage is not about gays getting married (hence the lack of enthusiasm among gay rights advocates for civil unions which provide all the legal benefits of marriage), but is instead an effort to destroy traditional heterosexual marriage as normative in culture, thereby removing not merely legal but cultural restraints on all forms of sexual and relational deviancy. The high standard — heterosexual marriage, with its enormous advantages in the raising of children and establishment of societal self-restraint, morality, and relational stability — must be brought down to the lowest common denominator of any two (or more) people getting “married” — with the sole purpose of muting societal condemnation for self-gratifying, dysfunctional and heterodox partnerships. Unrestricted abortion, a.k.a. “freedom of choice”, is about the uncompromising (albeit delusional) demand for unconstrained sexual license without consequences — especially for women, but also for their sperm donors who want no responsibility for their casual hookups: dispose of the unplanned pregnancy, move on to your next “partner”, and you have achieved the perfect “zipless fuck.”

Likewise, physician-assisted suicide is not at all about “death with dignity”, but rather about actively enlisting the culture in support of radical individual autonomy. Not only must we exert full control over the time and manner of our death — which we have always been able to do, by simply killing ourselves — but we demand that society support, honor, and praise this decision, without the faintest whiff of criticism or condemnation. It is not sufficient that we be able to kill ourselves. Rather, it is necessary that we actively kill those societal sensibilities and strictures which condemn such a choice as morally misguided and potentially destructive to our human dignity and our social fabric.

Were some silver-suited alien from Alpha Centuri to visit our noble globe, he would find our passion for self-extinction puzzling, to say the least. What manner of sentient being seeks to facilitate its own demise, only to perpetuate the illusion that they control their own lives? Has their existence no purpose but to be ended at their own direction? Are their relationships so shallow that they choose death over life, has their suffering no meaning, will their precious time with life partners, friends, and offspring be traded for the dark comfort of a deadly cocktail? Who are these intelligent fools who hand over the power of death to their doctors, oblivious to the evil which dwells in the hearts of men, waiting to be empowered by cold rationalism, scientific professionalism, self-justification, and sterile repetition?

Yet were our starship sojourner to study the society which breeds such nihilism, he would, by turns, find his answer: we are, for all our technological advances and unbounded prosperity, a culture without meaning, a people without purpose. We have embraced unquestioningly the mantra of materialism: we have come from nothing, and to nothing shall return. Our relationships mean naught but what we may gain from them; our suffering gains us nothing but rage and resentment; our deaths are like our lives — without hope, without a future, joyless and empty. We desperately push the buttons and mix the potions which promise to make us happy and whole, yet find they only echo forlornly through our hollow souls, singing that siren song:

“I am my own master.”

Monday Links

Richard Neuhaus: An Election About the Nature of the Church:

American Babylon is our culture. It is not the culture of our choice, although, given the other cultures on offer, it may be the culture we would choose if we had a choice. It is certainly the culture in which we have been chosen and for which we have a measure of responsibility. The irrepressible human aspiration toward the transcendent, toward that which at the core of our being we know to be our destined home, takes many different forms. That aspiration is our religion, whether or not we call it by the name of a religion. The aspiration may be stifled or misplaced, but it cannot be denied; at least it cannot be denied for long. When, as Augustine teaches, our loves and loyalties are rightly ordered, we recognize that the only satisfactory alternative to Babylon is the City of God. At least this is how Christians see the matter.

Living in the now and the not yet, we know Christ now. We know him in the context of prophetic promise as the Messiah of Israel; we know him in the biblical narrative of his birth, life, teaching, miracles, suffering, death, resurrection, and promised return; we know him in his words spoken in the assembly of the Church that is his body; we know him in the Real Presence of his sacramental promise daily fulfilled; we know him in the encounter with the needs of others who are, in the words of Mother Teresa, “Christ in distressed disguise”; and we know him in the cultivation of his friendship --day by day and, as Saint Paul says, without ceasing --that is the life of prayer.

Christ is now, the New Jerusalem is not yet. But then one must quickly add that the distinction between the now and not yet is not a separation, and certainly not an absolute separation. The movement of theological liberalism launched in the nineteenth century was given to such a separation. Alfred Loisy, a later modernist who was finally excommunicated from the Catholic Church, put the matter succinctly, “Jesus came preaching the Kingdom and what arrived was the Church.” In the view of many, the disappointment was understandable. Jesus and the gospel of the Kingdom is thought, not without reason, to be ever so much more appealing than his presence in the distressed, and distressing, disguise of the people who are the Church. And yet, while the two can be distinguished, they cannot be separated.

Saul of Tarsus, soon to become Paul the apostle, learned this the hard way. On his way to Damascus to imprison the Christians, Christ appeared and asked, “Saul, Saul, why do you persecute me?” Saul might have objected that he was not persecuting Christ but only the disciples of Christ. He would learn --as with great difficulty Christians have been learning ever since --that Jesus cannot be separated from his people; that Christ, the head, cannot be separated from the Church, his body. To persecute the members of the body is to persecute Christ, the head of the body…

Meanwhile, and as members of the “contrast society” that the Church is to be, Christians exercise the courage of their convictions in trying to bring clear reason and moral truth to bear in the temporal order. This is the mission betrayed by Catholics and others who resort to embarrassingly contrived complexifications in order not to be seen as adherents of “single-issue politics” in a political season in which we are confronted by the starkest alternatives on the single issue that distinguishes the culture of life from the culture of death.

If the Brits get it, why don’t we? Is America really going to do this?:

Obama thinks world conflicts are basically the west \'s fault, and so it must right the injustices it has inflicted. That \'s why he believes in ‘soft power’ — diplomacy, aid, rectifying ‘grievances’ (thus legitimizing them, encouraging terror and promoting injustice) and resolving conflict by talking. As a result, he will take an axe to America \'s defenses at the very time when they need to be built up. He has said he will ‘cut investments in unproven missile defense systems’; he will ‘not weaponize space’; he will ‘slow our development of future combat systems’; and he will also ‘not develop nuclear weapons,’ pledging to seek ‘deep cuts’ in America \'s arsenal, thus unilaterally disabling its nuclear deterrent as Russia and China engage in massive military buildups…

Obama dismisses the threat from Islamism, shows zero grasp of the strategic threat to the region and the world from the encirclement of Israel by Iran, displays a similar failure to grasp the strategic importance of Iraq, thinks Israel is instead the source of Arab and Muslim aggression against the west, believes that a Palestinian state would promote world peace and considers that Israel – particularly through the ‘settlements’ – is the principal obstacle to that happy outcome. Accordingly, Obama has said he wants Israel to return to its 1967 borders – actually the strategically indefensible 1948 cease-fire line, known accordingly as the ‘Auschwitz borders’…

Daniel Pipes (Obama Would Fail Security Clearance) lists Obama \'s extensive connections to Islamists in general and the Nation of Islam in particular, and concludes with this astounding observation:

Obama’s multiple links to anti-Americans and subversives mean he would fail the standard security clearance process for Federal employees. Islamic aggression represents America \'s strategic enemy; Obama \'s many insalubrious connections raise grave doubts about his fitness to serve as America’s commander-in-chief.

Melanie Phillips stumps Richard Dawkins (or how Little Green Men are more believable than God):

I put to him that, since he is prepared to believe that the origin of all matter was an entirely spontaneous event, he therefore believes that something can be created out of nothing — and that since such a belief runs counter to the very scientific principles of verifiable evidence which he tells us should govern all our thinking, this is itself precisely the kind of irrationality, or ‘magic’, which he scorns. In reply he said that, although he agreed this was a problematic position, he did indeed believe that the first particle arose spontaneously from nothing, because the alternative explanation – God — was more incredible. Later, he amplified this by saying that physics was coming up with theories to show how matter could spontaneously be created from nothing. But as far as I can see – and as Anthony Flew elaborates – these theories cannot answer the crucial question of how the purpose-carrying codes which gave rise to self–reproduction in life-forms arose out of matter from which any sense of purpose was totally absent. So such a belief, whether adduced by physicists or anyone else, does not rest upon rational foundations.

Even more jaw-droppingly, Dawkins told me that, rather than believing in God, he was more receptive to the theory that life on earth had indeed been created by a governing intelligence – but one which had resided on another planet. Leave aside the question of where that extra-terrestrial intelligence had itself come from, is it not remarkable that the arch-apostle of reason finds the concept of God more unlikely as an explanation of the universe than the existence and plenipotentiary power of extra-terrestrial little green men?

John Robb on the global system shock: Observations:

One of the most interesting aspects of this global crisis is that it will impact all parts of the globe. This is arguably a first. In historical crises, wars or catastrophes, there is always a large external environment of relative normalcy. Our first real global event will directly impact all economic activity from Botswana to Albany. It’s even more interesting since the impact of this event is occurring simultaneously in all places at once.

This is a very bad thing.

Vanderleun: “What if we run out of jobs Americans won’t do?”: Armies of the Blight

Gagdad Bob tackles the problem of free will: Freedom, Authority, and the Absent-Presence of God:

…the Christian lives with “the paradox of almighty God reduced to a state of extreme powerlessness.” This is said to be “the most perfect revelation of the God of love.” It is quite radically different from the pagan or new age belief in a God who would leap down from the cross and, for a mere $1995.00, sell you the magical secrets of fulfilling your every desire at a weekend seminar in beautiful Sedona, Arizona! …
In short, “The idol of power has such a hold on some human minds that they prefer a God who is a mixture of good and evil, provided that he is powerful, to a God of love who governs only by intrinsic authority of the Divine — by truth, beauty, and goodness — i.e., they prefer a God who is actually almighty to the crucified God.”

Joe the Plumber & First Principles: Joe the Plumber, Part IV

Touchstone zeros in: Practical Atheism Revisited:

We are Christians, Catholic, Protestant, and Orthodox, denouncing the Democratic party as constitutionally anti-Christian…

One of the most common defenses for Democratic loyalties is to assert the moral equivalence of the two parties, to claim that their respective errors leave the Christian to vote for the one he thinks most Christian, or least unchristian. If the Democrats endorse abortion, sodomy, and the like, Republicans cut social programs for the poor. This is a plausible and attractive argument except for one thing. We know with certainty that abortion and sodomy are evil, but we do not know with any certainty whether any particular disbursement of funds for the poor is good or bad or mixed. Our faith directs us to give alms, quietly and generously, and to bless and care for the widows and the fatherless, but also tells that those who will not work shall not eat. Distinctions, often difficult ones, must be made in our policies between who should be marked as poor and who should not, and on how collective monies should be spent or not spent for their relief, the kind of distinctions that have historically marked differing party philosophies, and upon which Christians have historically had differences of opinion. A Christian may think the Democrats’ social and economic programs are superior to the Republicans’, but he knows that the Democrats’ moral policies are aggressively ungodly.

Think gay marriage is about gays getting married? Think again: What same-sex “marriage” has done to Massachusetts:

Homosexual “marriage” hangs over society like a hammer with the force of law. And it \'s only just begun.

It \'s pretty clear that the homosexual movement \'s obsession with marriage is not because large numbers of them actually want to marry each other. Research shows that homosexual relationships are fundamentally dysfunctional on many levels, and “marriage” as we know it isn \'t something they can achieve, or even desire. (In fact, over the last three months, the Sunday Boston Globe \'s marriage section hasn \'t had any photos of homosexual marriages. In the beginning it was full of them.) This is about putting the legal stamp of approval on homosexuality and imposing it with force throughout the various social and political institutions of a society that would never accept it otherwise. To the rest of America: You’ve been forewarned.