The Call

Still trying to stay one step ahead of the snapping alligators, so here’s another older post, hopefully worth your time — Dr. Bob

 
cancer

Damn!, I hate these calls…

Lying on my desk, clipped to a yellow manila binder, is a single sheet of paper. Its pleasant color format and sampled photomicrograph belie the gravity of its content:

Adenocarcinoma, Gleason grade 9, involving 60% of the specimen.

How do you deliver a death sentence?

Your first impression of Charlie is his sheer mass: 50 years young, healthy as a horse, built like a tank, a former football player turned popular coach at a local high school. He arrived at my office after seeing his family physician for an acute illness, with fever, chills, and problems urinating. His doctor had diagnosed a urinary tract infection, placed him on an antibiotic, and drew a PSA–a screening test for prostate cancer. It was markedly elevated: over 100, with normal being less than 4. I grumbled to myself as I reviewed his chart: Those damned primary care docs shouldn’t draw PSAs when patients have prostate infections — it just muddies the waters.

PSA (prostate specific antigen) is a test which measures a protein in the blood stream released by prostate tissue. It has greatly improved early detection of prostate cancer in the 20 years it has been in widespread use — but it is not, strictly speaking, a cancer test. It is noisy — often abnormal in other conditions, including benign prostate enlargement (BPH), inflammation, and prostate infection. It is virtually always elevated in the presence of an acute prostate infection — often markedly so — and can take months to return to normal. The high PSA alarms the patient, however, who is told he may have cancer. But most do not — and Charlie looked like a classic case of infection.

His history was typical, and his response to antibiotics appropriate, so this seemed at first glance like so many other similar cases I had seen. His prostate exam was alarming, however: rock-hard and irregular, unlike the typical soft, boggy texture of an infected gland. Experience and training kicked in, and I knew exactly what we were dealing with: a relatively uncommon form of prostate infection called granulomatous prostatitis. I had seen dozens of cases — always alarming on first exam, with very high PSA values — and always responding to long-term antibiotics. Charlie was started on a one-month course of high-powered, high-priced bug exterminator, and came back for follow-up after its completion.

He was feeling better, and his PSA had dropped markedly, to 45. His prostate exam also seemed improved, but still quite abnormal. I remained quite confident in my diagnosis — after all, cancer doesn’t get better on antibiotics — but was unwilling to wait much longer to know for sure. I scheduled a prostate biopsy, reassuring him after its completion of my optimism that the results would show only infection.

The report was a blow to the gut. I sat silently, staring at it, in stunned disbelief.

In the age of PSA screening, most prostate cancers are detected at an early, curable stage — although their slow-growing nature makes treatment less important in very elderly patients. The chances for cure at diagnosis are determined by an estimate of the size and aggressiveness of the tumor. Size is determined by exam, ultrasound findings, and total PSA values; aggressiveness by the Gleason score — a value indicator (between 2 and 10) of the aggressive appearance of the cancer cells under the microscope. Higher is not better: Gleason scores of 9 and 10 indicate rapidly growing cancers which tend to spread early and are difficult — if not impossible — to cure. Charlie had drawn a pair of deuces in a high-stakes poker game: large volume, high-Gleason score cancer. The statistics were dismal: he would likely be dead of cancer in 5 years, regardless of treatment. And as cancer deaths go, this one’s not pretty: pain is a huge management problem in many, as the cancer infests and erodes the spine and long bones, breaking even the strongest of men. One learns to hate this disease before very many such cases have been seen.

And now I had to call him with his biopsy results.

The actual call will be brief: I will inform him that, unfortunately, the biopsy has shown cancer, that additional tests will be needed to determine its extent and the best way to manage it, and arrange for a follow-up visit in the office. The real bad news will be transmitted then, face-to-face, with more than enough information for its gravity to sink in. To do this — without robbing hope — will require more inner strength than is readily at hand.

But for now, I simply need to tell him he has cancer.

The word cancer encapsulates the deepest fears and anxieties of man, embodying in one small word pain, suffering, loss of control, hopelessness, dependency, death, the fragility of our dreams and hopes, and our uncertainty about the hereafter. To inform a patient that he has cancer is to shatter the illusion, the daily denial that death may yet be outmaneuvered, forestalled, kept on hold for some future date of our own determining. It is an illusion which dies hard — surprisingly so, as we alone among all creation are cognizant of its inevitability and certainty.

Perhaps the cruelest wish a man might be granted — were there some bottled genie passing out such favors — is knowledge of his own future. Yet, in some small measure, that power has been granted to me, and others of my profession. Not in any specific manner, of course — not of days or years, details or circumstances — but in knowledge deep enough to see the broad strokes: shadowy figures through rippled glass, of pain, and loss, and shattered dreams, of desperate grasping at the frail straws of fading hope, as the drumbeat of mortality pounds ever louder toward its dark crescendo.

Patients receive the call in different ways. Most accept it with seeming stoicism, and little expressed emotion — yet it is not hard to imagine — and sometimes to sense — the tight grasp of fear that grabs the throat and grips the heart. When wives are listening, the fear is more immediate, more palpable, as voices tremble with panic despite every effort to control it. A million questions will arise — but almost never on the initial call. On rare occasion, there is a casual indifference to the news — prompting reflection on what strength of spirit — or dense denial — such men possess.

I often wonder how I would receive the call. As a Christian, I am confident of a life hereafter, eternal, spent in the presence of Him who loves me. Some call that arrogance, or self-righteous; it is not. God alone knows better than I the darkness of my heart, the depravity that makes me uniquely unsuited to be in the presence of the Holy One but for one moment, much less eternity. But I have been adopted — an unworthy child by an unspeakably loving and merciful Father, who only asks submission to His tender guidance and direction, and transforms a lost fool into something useful, something cherished, someone with purposes aligned — though poorly so — with His own.

But the call of death — so confidently faced from the comfortable vantage of good health and cheap grace — will strike fear into my heart when it arrives, for far smaller challenges have brought dread in larger measure. There will be the fear of the ordeal, the journey of suffering, the loss of things now treasured but instantly made worthless. There will be the pain of watching the loss of those close to me, struggling to make sense of a relationship, undervalued while unthreatened, yet now more precious while counting down inexorably to its end. I know – -by the tutor of past and bitter experience — that faith will sustain me and mine through it all. But one cannot know what that day will be like — nor should we wish to ever know.

But for Charlie, the battle will now be enjoined — the weapons and wherewithal of modern medicine in all-out war against its implacable foe. Perhaps by some miracle or unexpected grace he will be given a reprieve, a window to revalue and reassess life’s course, its priorities, its purpose. For even when we are cured, we are healed to face death again: Lazarus, once risen, will revisit the stony crypt. Yet the Voice which called him forth calls us also, beckoning toward a painful light from the cold terrors of death.

How difficult to be the herald of another’s mortality — it is a burden no man should have to bear. Some will deliver it through the steely detachment hammered hard by years of training; some avoid it altogether where possible, through choice of profession or abdication of responsibility. But for those who must speak this hard truth, may there be grace and wisdom, empathy and compassion.

May it be also for me.

A Life Not Long

Another older post, as my friends at the IRS seem to be demanding an extra dose of torture this year.

 
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.

Katrina Euthanasia Update

Lost in the dustbin of inconvenient memories, left behind in the light-speed pace of internet information mania is the story of the deaths of patients at Memorial Hospital in New Orleans in the wake of Hurricane Katrina. A physician and two nurses were arrested after the Louisiana District Attorney charged them with murder, accusing them of having injected a lethal cocktail to terminate frail patients who had no hope of rescue from the hell-hole the hospital had become.

The arrests were widely decried in the medical community — most of whom clearly had read none of the rather compelling and chilling testimony of other physicians and nurses who were present at the hospital. The case quickly became mired in charges of political grandstanding by the DA, who was considering running for governor and using the publicity around the case to raise money for his campaign. It subsequently went to a grand jury, which has used deliberate — some would say glacial — speed in investigating the case.

CNN today reports an update on the grand jury proceedings, where two of the involved nurses have been offered immunity to testify against the physician accused, Dr. Anna Pou.

The CNN update mentions this previously-unknown side story:

Craig Nelson, a New Orleans lawyer who is convinced his mother was killed by a lethal dose of morphine, has taken steps to file a civil lawsuit.

Nelson had an autopsy performed on the body of his mother, Elaine Nelson. The 90-year-old Jefferson Parish resident died inside Memorial Medical Center during the aftermath of the hurricane. Nelson said her death is not part of the murder investigation because his mother was elderly, frail and sick.

She was a patient of LifeCare, a long-term care facility run inside Memorial Medical Center’s seventh floor. Nelson said his sister was helping to care for his mother during Katrina, but was asked to leave. It was after his sister was evacuated that he was told his mother had died.

Test results conducted by a private lab hired by the lawyer indicate high levels of morphine in Elaine Nelson’s liver, muscle tissue and brain, Nelson said. He said his mother should have had no morphine in her system, since none had been prescribed to her in the week and a half before she died.

My prior discussion of this event may be found here, along with a substantial list of links for more information.

Healing Faith

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A reader named Katherine recently e-mailed me. She had lost her husband, a man some years older than she, to multiple myeloma and Alzheimer’s disease. She is a Christian, and is struggling to make sense of his death, and the difficult questions of why God allows suffering. She writes, after giving me some details of his life, death, and fine character, and asks:

Why does God allow such terrible illnesses to such a kind person? I know there is really no answer as I know all about Job. The thing I am really afraid is that I prayed for his healing, and it did not happen. When I became a Christian back in the 80’s, the health and prosperity gospel was big at the time, and I guess it really influenced me more than I care to admit as I now know it is false. Even though I know it is false, I have become obsessed that God did not answer my prayer because of not being able to get rid of all the sin in my life (as if this were possible to do). One of the teachings of that movement was that if your prayer for healing went unanswered it was either because of lack of faith or sin in your life. I kept thinking that I don’t always put God first in my life, and that I spent more time reading secular magazines than reading my Bible and listening to more secular music than Christian music. These were my “main” sins, at least in my mind and thinking. Can you shed some light on this for me? I would be very appreciative.

The problem of suffering and evil is an ageless one. It poses a particular challenge for Judaism and Christianity, because of the seemingly insoluble tension between a world filled with suffering and evil, and the belief in a God who is good and all-powerful. Solutions to this dilemma, both adequate and inadequate, abound. It is the desperate hope of the atheist that this logical incompatibility proves beyond question the nonexistence of God. Others, less willing to ditch a Divine order, have concluded that God is good, but impotent; or that God is detached and uncaring, or capricious, or moody, or sadistic — and therefore not good.

It must be said plainly that answers to this paradox are neither simple nor entirely satisfactory. The dilemma as it stands may be solved in a global and satisfactory way — as has been done by both Judaism and Christianity — but invariably the lofty principles seem to break down at the moment when a solution is most needed: in the time of crisis when we ourselves experienced the depths, hopelessness, and irrationality of suffering in our own lives. CS Lewis, whose tightly reasoned treatise The Problem of Pain provides an extraordinarily deep and thorough discussion of this dilemna–later in life nearly repudiates his faith and sound theology after the death of his wife, a process painfully detailed in his diaries, A Grief Observed. It is indeed unsettling to watch Lewis discard all of his carefully reasoned and theological understandings of pain and suffering in the brutal crucible of unbearable pain and loss. Nonetheless, he ultimately comes to terms with the paradox, and undergoes an embracing of this profound dilemma far deeper than the intellectual by means of his own trial of fire.

At the heart of this difficult issue lies the human heart. God undertook a vast and dangerous experiment when creating man: He wanted, not merely another animal — of which there were countless — but an animal capable of something He alone understood: love. He gave this exalted animal vast intellect — but this was not sufficient to engender love. He gave His creation powerful emotions, the capacity for both creation and destruction, which He alone had possessed — but this also was not sufficient. For love — the utter, uninhibited emptying of self for another — required that most dangerous license of all: free will. This being thus created, designed with the capacity to love, must of necessity be utterly free to choose — for choice is the very heart, the very essence of love.

It was, by all measures, an experiment gone wildly awry. Having given this creature the extraordinary capabilities required to love fully — intellect, emotion, passion, empathy, the ability to feel intense pleasure and pain both physically and spiritually — he set this creature free to love, first of all Him, and then others of its kind. And the first choice of this pinnacle of creation was the decision to turn away: to replace the intended objects of love with the sterile altar of self. Thus was unleashed the monstrous liability of a truly free creature: the ability to hate, to cause pain, to kill, to destroy.

If we are to be honest, much of the pain and suffering which comprise the evil of the world is due to nothing more than this: that man, having been given the ability to choose, chooses wrongly, and uses the gifts and abilities given for the purpose of love to instead elevate himself at the expense of others, often in ways stunningly malicious and utterly wicked. Look around you, at the world both near and far: pride, selfishness, greed, lust, rage, jealousy — all these things manifest themselves in our lives and those of others, causing great pain and endless suffering. The child abused; the wife abandoned; the drive-by shooting; the greedy CEO who bankrupts the company and rapes the stockholders; the serial killer and the rapist; genocide; wars of conquest; torture; senseless massacres: these are the actions of men and women putting self above others — and each of us does it, to a greater or lesser degree, though we minimize our own roles to justify our own actions. We all wish for a world where God would eliminate evil — but all assume that we ourselves would be the only ones left standing when His judgment is delivered. A world in which God eliminated evil would by necessity be emptied of all mankind.

Yet there also exists those evils which have been called, in days past, somewhat ironically, “acts of God” — those circumstances or events which cause pain and suffering, not directly engendered by human evil. Thus the child is born with a severe birth defect; hurricanes, earthquakes, and tornadoes cause death and destruction; chronic and devastating diseases fall upon those who seemingly deserve a far better fate. It is with this, this seemingly capricious evil, with which we struggle most earnestly, straining to understand, yet to no avail. Judaism and Christianity both imply that some such evil may be consequential, the result of punishment or predictable consequences for the malfeasance of man. A more robust theology is less accusatory and thereby more coarsely granular — maintaining that such evil has entered the world because of the fall of man. Under such design our divine divorce has corrupted not only behavior, but our very natures, and all of creation. Yet such theology is of little comfort to those who are the objects of such seemingly random evil; we demand to know of God, “Why?” — and in particular, “Why me?” Yet there is no answer forthcoming, and we are left assuming a God either powerless to stop such evil or unwilling to do so.

Yet the problem of a good God, an omnipotent God, and an evil world of His creation is not entirely insoluble. Much lies in our projection of human frailty onto the nature of the Divine, and the impreciseness of our definitions of good and omnipotent. When we say God is good, we tend to mean that God is “nice” — that he would never do anything to cause us pain or suffering. Yet even in our limited experience, we must acknowledge that pain and suffering, while not inherently good, may be a means to goodness. We choose to have surgery or chemotherapy, though painful and debilitating, that our cancer may be cured. The halls of Alcoholics Anonymous are filled with men and women who, having faced both personal and relational destruction, have used their former liabilities as a gateway to a new, more fulfilling life — one which could not have taken place apart from their harrowing journey through alcoholism. To a misbehaving child, the discipline of a loving father is not perceived as good, but such correction is essential for the development of personal integrity, social integration, and responsibility. Our inability to discern the potential for good in pain and suffering does not by necessity deny its presence; there are many who, when asked, will point to painful, difficult, and unbearable times in life which have brought about profound, often unexpected good in their lives, unforeseeable in the midst of their dark days. There surely is much suffering which defies our capacity to understand, even through we strive with every fiber of our being to find the goodness therein. But the fact that such inexplicable suffering exists, and that answers are often lacking, does not preclude the possibility that God is good, or that such suffering may ultimately lead to something greater and more noble than the pain endured.

In our egocentricity we often neglect to look for the benefit in our suffering which comes not to us, but rather to others. Caring for someone suffering unbearably provides an opportunity to the caretaker to experience selfless love, compassion, tenderness, patience and endurance — character traits sadly lacking in our selfish world, which routinely turns its back on suffering to pursue an untroubled life of self-fulfillment and self-gratification. It is not inherently evil to be called to give beyond our means and ability — as caring for someone suffering always demands — for in the exhaustion and inadequacy thus revealed, we may discover unknown inner strengths, and come to a richer, and more fulfilling dependence on God. We are, as CS Lewis so accurately described, “not merely imperfect creatures that need improvement: we are rebels that need lay down their arms” — and finding how shallow are our reserves of love, compassion, and strength, we may through this brokenness seek to acquire them, humbly, from their Source.

But surely an omnipotent God has the power to stop suffering — is He not either impotent or evil when failing to use such power to remove our suffering? The omnipotence of God, like His goodness, is but dimly perceived. For the power of God is in perfect harmony with the purpose of God, and is thus used to advance these purposes for the greater good. Thus, the good deed of creating man with free will — and thereby capable of love — by its very nature restrains the omnipotence of God to violate that free will. The evil of the world exists in large part, if not wholly, because this free will has been abused. Yet the abuse of free will must be permitted, that the proper use of free will — the laying down of arms, the surrender to the sovereignty of a wholly good God — may take place, freely and unfettered as required by love. God must tolerate the existence of suffering and evil, that all may have the freedom to choose the good — though many will refuse to do so. Yet he does not merely tolerate the presence of suffering, but provides for its very redemption: that suffering, though itself evil, may ultimately produce good. Thus pain, suffering, death, and evil need not triumph: they may provide the means that some may turn toward the good, or bring forth further good for themselves or others. This is redemption: to buy back that which is destructive, worthless, of no value, evil, and make it worthwhile, valuable, even priceless.

Christianity, throughout its history, has struggled with and largely resolved the problem of pain, within the confines of the mystery of God. Yet Christianity in its many doctrinal eddies has sometimes chosen the wrong path and the wrong answers to this challenge. Such errors generally fall into two broad categories: the concept of suffering as punishment or retribution from God, and the manipulation of God for man’s gratification. The first of these runs counter to the core doctrine of the cross: that God has chosen to provide in Christ a sacrificial lamb — that Christ, through his suffering, may bear the justice of God, so that we may see the mercy of God. Our suffering is not a punishment for sin, as such punishment negates the purpose of the cross. Correction, it may be; discipline, it often is; opportunity, it always is; punishment, it never is.

The countering position — that of God as divine opiate, ever present to kill our pain — is a variant of the faith which has become perniciously widespread, feeding on a culture of ease and self-gratification which creates God in its own image. Thus God becomes a font of wealth, of health, of prosperity, of a trouble-free materialistic lifestyle, a divine vending machine whose coinage is faith. Faith, however, in such a worldview is no longer a profound trust in a God who is beyond understanding and infinitely wise, but becomes instead a means of buying from God all which we demand. Hence, we may be wealthy, if we only have enough faith; we may be healed, if our faith is sufficient; we will not suffer if we will but strengthen and enlarge our faith. Our faith must be prefect, lest our pleas go unheard. The strength of faith matters more than its verity; we charge the gates of heaven with the bludgeon of self-will.

The perniciousness and destructiveness of this perversion of historical Christian faith lies in removing from the hands of God decisions of life and death, health and illness, wholeness and suffering, while burdening us with the hopeless demand that we steel our faith to impossible heights to coerce and manipulate the will of God. That such efforts are typically fruitless seems self-evident: God most surely is capable of healing — and does indeed do so at times — but most surely does so in accordance with his divine wisdom and will. Should His wisdom dictate that suffering, poverty, brokenness, even death and despair would better serve the purposes of drawing men to Himself, what measure of human obstinacy and recalcitrance will change this will? When such “faith” proves futile, it destroys trust in God, and not infrequently leads to utter loss of belief, a bitter agnosticism born in false expectations and misplaced hope. Hence, we demand of God that which we alone deem to be good, then blame Him when He pursues a greater good beyond our understanding. This is the struggle to which Kathleen is alluding, as she questions the goodness of God in failing to heal her husband, blaming her own “sins” for his untimely demise. To us, such a healing seems only good — in so far as it mitigates our pain and loss, as well as that of those we love — but like the surgeon’s knife, sometimes such pain must not be withheld that evil may be conquered by the good. Were he healed, and restored to full health, would he not then face death on yet another day? Our lives have both purpose and a proper time: we live for that purpose, and we die when that purpose is fulfilled. That those who are left behind cannot grasp that purpose — and appropriately suffer profound pain and loss at this separation — does not negate that purpose nor impede its culmination.

We live in a time when our expectations of health, of prosperity, of a pain-free life are increasingly met in the physical realm, while we progressively become sickly, impoverished, and empty in the realm of the spirit. Despite our longer lives, we live in dread of death; despite our greater health, we obsess about our ills; despite our comfortable lives, we ache from an aimlessness and purposelessness which eats at our souls and deadens our spirits. Though we have at our command the means to kill our pain–to a degree never before seen in the history of the world–yet we have bargained away our peace in pursuit of our pleasure. The problem of pain has never been an easy one; in our day, it has not been solved, but rather worsened, by our delusions of perpetual comfort and expectations of a trouble-free life. Until we come to terms with suffering, we will not have comfort; until we embrace our pain, we will never have peace.

A Life Not Long

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I’ve been working on several posts, which had been taking longer than expected — especially a post on euthanasia, which is beginning to look like another multi-part series. I hope to start getting some of these up in the near future.

In the meantime, 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 man 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.

Dancing With Death

Boat at sunsetThe war rages on. It is a battle with ancient roots, deeply embedded in religion, culture, and the tensions between rich and poor. It is a war of contrasts: high technology and primitive cultural weapons; knowledge versus ignorance; speed and urgency against the methodical slowness of an enemy who knows time is on his side.

It is a war in which enormous strides have been made, with countless victories large and small.

The enemy is death. The avenger is medicine. And the war is going very poorly indeed.

In many ways, the gains of modern medicine against death and disease are truly impressive: longer life expectancies; progress and cures against heart disease, cancer, and diabetes; surgical and procedural marvels hard to imagine even 15 or 20 years ago. Yet, it is these very advances which seem to lie at the heart of a growing problem. We are so engaged in the battle, so empowered by our growing capabilities, that we have lost sight of the bigger picture. While pushing back the adversary of death, we are ever so steadily being destroyed by the very battle itself.

Several recent experiences have driven this dichotomy home for me. Last week, I was asked to evaluate a man who had been hospitalized for a over a week. A nursing home resident in his late 80’s, his overall health was fair to poor at best, and he suffered from severe dementia. He was unable to communicate in any way, and could recognize no one — not even his wife of many years, who remained in possession of her full facilities. He was admitted to the hospital with a severe urinary tract infection with a highly resistant bacteria, and septic shock. When he arrived at the ER, the full extent of his dementia was not apparent to the physicians there, and his wife insisted that all measures be engaged to save him. Aggressive medical care was therefore initiated — intensive care unit, one-on-one nursing care, hemodynamic monitoring, drugs to support blood pressure, intravenous nutrition, and costly antibiotics. After nearly two weeks of such intensive therapy, the patient largely recovered from his life-threatening infection — returning to his baseline of profound dementia. Yet the underlying risk factors which led to it — his age, a chronic bladder catheter and bacteria-harboring stones, diabetes, — remained in place, lying in wait for another, inevitable opportunity, in a matter of weeks or months. The cost of his hospitalization was easily in 6 figures.

In another situation, an elderly women presented to the hospital with signs of a serious, life-threatening infection in her abdomen. A healthy widower, she lived independently with her sister prior to her illness. Emergency surgery was performed, and an abscessed kidney removed. Her medical condition deteriorated after surgery, with coma due to stroke and failure of her remaining kidney brought on by the infection.

The patient’s sister and living companion communicated the clear final wishes of the widower: a women of strong faith, she wished no extraordinary measures, such as ventilators or dialysis, to extend her life needlessly. She was comfortable with death, and not afraid. The staff prepared to allow her to die gracefully, comfortably, and in peace.

But such was not to be. There was no living will, and the sister did not have legal authority to make such decisions. But the widower’s daughter, a nurse living out-of-state with little recent contact with her mother, arrived in town demanding that aggressive measures be taken to save her. A nephrologist (kidney specialist) was called in. A superb physician, compassionate and dedicated, he had been successfully sued in a similar case after recommending that dialysis be withheld in a patient with a grim prognosis. This was a mistake he would not make twice: the widower was transferred to another hospital, placed on dialysis, and died 3 weeks — and a quarter of a million dollars — later, in an ICU. She never woke up.

The issues which these two cases bring up are numerous, complex, and defy easy answers. They touch upon the subjective measure of quality-of-life and what it is worth; the finite limit of economic health care resources; the relative responsibilities of physicians, patients, and their families in end-of-life decisions; the pressures placed on the health care system and its practitioners by after-the-fact second-guessing in an aggressive tort environment; and a host of others greater or lesser in weight and substance, up to and including the meaning of life itself.

All the players bear responsibility in this passion play. Physicians excel at grasping what they can accomplish, but are woefully inadequate for the task of deciding whether such things should be done. In the urgency of acute care, delay to consider the ramifications of a decision to treat may cost an opportunity to save a patient for whom such treatment is desirable; better always to err on the side of salvage. Pressured by family, potential litigation, or instinct, the path of least resistance is to follow your training and use your skills. And physicians themselves are uncomfortable with death, though inundated in its ubiquity.

Family members naturally resist the agonal separation of their loved ones, often harboring unrealistic hopes and expectations of recovery in the face of inevitable death. A curious dance of denial often ensues between physician and family, as each, unwilling to face the unpleasantness of the inevitable, avoids the topic at all costs. The physician hides behind intellect, speaking of blood counts, medications, and ventilators, or at best tiptoeing around the core issue with sterile terms like “prognosis.” Family members hesitate to ask questions whose answers they already know. Too rarely are the physician and family willing to place the subject squarely on the table, in all its ugliness and fearfulness. Decisions which need to be made are put off, unspoken and deferred. The clock ticks on, the meter is running, and only the outcome is not in doubt.

The tort system provides a ready outlet for the anguish and anger of death of a loved one. In such a period of intense emotional turmoil, the real or perceived indifference of physicians (often a mechanism of detachment by which doctors deal with the horrors of death and illness); the parade of unfamiliar medical faces as no-name consultants come and go during the final days; the compounding burden of crushing financial load from the extraordinary costs of intensive terminal medicine; the Monday-morning quarterbacking by the tort system of complex, often agonizingly difficult medical decisions in critically-ill patients: all present a toxic and intoxicating brew which impels the health care system forward to leave no avenue untravelled, no dollar unspent in prolonging life beyond its proper and respectful end.

This march of madness is not without resistors. Seizing on the high costs, the futility, and especially the lack of personal control fostered by impersonal, highly technical terminal care, the euthanasia movement is maneuvering into the gap. Cloaked in slogans of personal autonomy and “Death with Dignity”, active euthanasia proponents seek to replace the sterile prolongation of a now-meaningless life with the warm embrace of Death herself. Terrified by an out-of-control dying process, an end of a life which embodies all meaning, they seek to control death as their final act of significance. But Death will not be controlled, and those who dance with Death are seduced by her siren. Euthanasia starts with compassionate intent, but ends with termination of the useless. Man does not have the wisdom to control death; The Ringbearer is corrupted by its power.

Our discomfort with death is our confusion about life. Man is the only species cognizant of his coming demise — who then, in the ultimate paradox, lives his entire life pretending it will not happen. Our Western culture, enriched with a wealth of distractions, allows us to pass our living years without preparing for the inevitable. When the time arrives, we use all the weapons at our disposal — wealth, technology, information, law — to resist the dragon. We drive it back for a time — at enormous cost, personal, financial, physical and emotional. Death always wins — always.

I am not of course yearning for a return to the past, a passive resignation to the inevitable anabasis of disease and death. The benefits of medicine and the forestalling of death are precious and powerful gifts, which have greatly benefited many. But like all such great powers, they are useful for good or ill. When the defeat of death becomes an end in itself, detached from the meaningfulness of life lived, it has great destructive energy.

We must learn how to die. And to learn how to die, we must learn how to live — how to seek the transcendent, the power of love, and sacrifice, and giving which makes life rich and enduring. The selfish, the superficial, the transient all gratify for a time, but when this is all we possess, we grasp desperately to their threadbare fabric when beauty and health give way to weakness, fear and death. All great religions understand this: the meaning of life transcends life. In the Judeo-Christian view, life is an opportunity to draw ourselves and others closer to the light and goodness of God, with the promise of an even greater life and deeper relationship after death. Yet even for the agnostic or secular among us, service to others — personal and social — has the potential to endure long after us. None of us will be remembered for our desperate clinging to life in its waning days, but rather for the lives we touched, the world we made better when we lived.