The Descent

cliffsIt haunted him, without mercy.

Strong, athletic, handsome, and personable, he seemed at life’s outset to be unfairly advantaged. His friends were many; a ladies man, by reputation, the life of every party, the love of every woman who gazed on him.

He was, by nature, a generous and gentle soul, a gift he received from his parents, humble and devout. He himself found religion attractive, and attended synagogue regularly with them. He had little use for the priests and the lawyers––he found them legalistic, arrogant, and judgmental––but embodied in his faith he discovered a formula for living: obey the law of God, and your life will be healthy and prosperous. Did not the Proverbs promise, “By humility and fear of the Lord are riches, and honor, and length of days”? He would do his part, and God His, and all would be well in life.

The climb had been arduous. Stronger and more agile than his friends, he had reached the top of the cliffs before them. His best friend, struggling behind him, lost his footing, and he reached back to save him from falling. His friend was saved — and his own life changed forever.

When he came to, he felt no pain — in fact, no sensation whatsoever. He heard the shouts and the dislodged rocks of his friends scrambling down the cliff; he tried to get up, but could not. He had survived the fall — and lived to wish he had not.

Weeks and months passed, with no improvement; his paralyzed body remained lifeless, though his mind, now a tortured prisoner, remained fully alive. Most of his friends drifted away, their discomfort in his presence so palpable that their absence was more relief than regret. The Four remained, though he saw no reason for them to do so, other than guilt, or some pathetic sense of charity to the crippled. His limbs withered and shriveled, twisted like the branches of those ancient trees on the cliffs. Racked by fevers, festering pressure sores, and wallowing in the excrement he could no longer control, he no longer had a life, but only a slow, agonizing, and hopeless descent toward death.

The Four visited him daily, alone, in pairs, and on occasion collectively. They cleaned him, tended his wounds, and tried to encourage him in his deepening depression, to no avail. As shriveled and twisted as his body had become, his soul became far more foul and fetid in its unquenched and raging bitterness. Self-pity, self-loathing, and a hopeless despondency descended upon him, crushing and torturing his spirit in a personal living hell. His friends prayed, read Scripture, and feigned faith in some deliverance of spirit, if not body; this only increased his cynicism and the sputtering rage he spewed toward God. How could a good God allow such an evil fate? Had he not kept his part of the bargain, only to be betrayed by a deity he had once trusted? Why did his friends torment him with this utter nonsense?

Then there was the humiliation he suffered at the hands of healers, who prayed and pranced and called down Heaven’s power to heal him; he had too little faith, they accused, when their futile foolishness failed. In this, they were most surely correct. Then, the day his friends dragged him to the Temple, to the priests, as Moses had prescribed. His bondage arose from hidden sin, they said: his own, or his parents. What sin was this, he challenged? The sin of saving a friend’s life? His parents had more righteousness in their little fingers than these prattling and pretentious fools — where was their repentance? The self-righteous religious cast him out of the Temple, and the long journey home was silent, and awkward, and hopeless.

The crowds were immense, if the stories be true — this charlatan must have some slick magic up his sleeve, and there was no shortage of gullible fools in the world to follow along. His angry protests were to no avail — must he go through this humiliation once again? — as the Four lifted him onto the cart and began the dusty and agonizing ride to ridicule. See the Master? Not even close — they could barely see the house for the mob. The Four muscled their way through the grumbling crowd, and ignoring the shouting owner, climbing a fig tree by the house. Before he could protest yet again, they lifted him onto the roof, nearly dropping him in the process — what a fitting and ironic end to his pathetic life that would be! Now what? They began to claw at the straw and tiles; curses arose from below as mud and straw and shards of clay tumbled onto upturned faces. Then they lowered him into the darkness.

He saw their eyes first: seated above the crowd, dressed in fine linen robes, their phylacteries glittering with fiery jewels, their eyes blazing with hatred and contempt seemingly from the very depths of Sheol. Then, turning, he saw at last the healer’s eyes: strong, kind, penetrating to the depths of his spirit. To see them was to gaze into eternity, and see its joy. He felt utterly naked — but not ashamed.

He smiled: “Son, your sins are forgiven.”

There was no challenge this time — he knew the sins of which the healer spoke: bitterness, unforgiveness, cynicism, ingratitude, the hatred of God, of life, the despair over lost promise and shattered hopes. There befell then a lightness, an extraordinary peace, the lifting of a burden far heavier than that his friends had borne in bringing him here. A smile crossed his face, for the first time in many years: could this be joy?

Amazed at his inner awakening, he failed to hear the gasps, to notice the stunned silence of the once-noisy crowd. There was only the angry, strident whispers, hushed at first, then ever more intense, like the growl of a ravenous predator: Blasphemy. Blasphemy! BLASPHEMY!

He looked back at the healer: there was no fear, no anger; naught but an enormous strength, his eyes afire with the conviction of truth. “That you may know that the Son of Man has the power on earth to forgive sins…” He looked directly into his eyes: “Arise, pick up your mat, and walk.” It was far more invitation than command.

It lasted but an instant, but seemed an eternity. Great warmth seared through his withered flesh. Tendons tight as iron loosened and stretched; his shriveled muscles softened and fleshed out; his papyrus-thin skin pinked and plumped into a vibrant glow. He sat up — before realizing he could not do so. Swinging his legs free, he stood — he stood!! — bent over, and rolled up his mat.

The crowd gasped, and cried, and praised God; he heard none of it, not even the joyful shouts of his friends on the roof. As he bounded out the door, every hand reached out to touch him, as if he, the healed, had the power of the healer. As the sounds of the crowds faded into the distance, he touched his newborn limbs, still stunned in disbelief about what had just happened.

There was much work to do; relationships to repair, amends to make, and the endless telling of his story to the amazement of all who would listen. He followed the Master throughout Galilee wherever he preached. Sitting among the thousands, he nevertheless saw Jesus look directly at him each time, and smile. It seemed as though the Master had even more joy at the healing of his crippled heart than he himself did — and his own was indescribable.

Many months after his healing, he wandered again into the desert, alone. The storm clouds were gathering: the hatred he had seen in the eyes of the religious leaders was ever more intense, and he sensed something dark and foreboding ahead in his Master’s mission. His own journey led him back to the cliffs, where his life had changed forever. His eyes gazed upward at their great height, then slowly descended to the rocks of brokenness below. He recalled his Master’s words, spoken so prophetically: “Greater love than this no man has, than to lay down his life for his friends.”

And finally, at long last, he understood.

The Sword of Grace

Third in an ongoing series on grace in Christianity:

  1. On Purpose
  2. Justification, Sanctification, & Grace

 
We struggled through some intimidating “God-words” — justification and sanctification — in my previous post, and in the process I lost both of my regular readers, leaving but a few wandering insomniacs whose Ambien prescription had just run short. For those now drifting back, whose eyes are just now unglazing, I touched on something of how Christianity works — or doesn’t, for many who have tread its well-worn path.

If nothing else, I hope for those who endured that irreverent review, that there arose at least a glimpse of the uniqueness of the Christian faith. Christianity is not merely another framework of moral codes by which to live. It is not comprised solely of the teachings of a charismatic leader, urging compliance to please or placate God or promulgating some hidden wisdom. It asserts at its very heart an outrageous claim: that those who relinquish their right to self-centered autonomy by submitting to God through the specific and exclusive portal of Christ will become judicially guiltless before their Creator. It further claims — perhaps even more outrageously — by this act to re-create the person so submitting, in a manner so thorough and profound that the individual can no longer be thought of as the same person who existed prior to that moment of choice and submission.

Yet if these claims are true, if this transformation be as radical and profound as its teachings and proponents assert, why then are those who lay hold of this conviction seemingly so little different from others who have not undergone this metamorphosis? If Christians are utterly transformed in the depth of their beings, why do they struggle and fail so often to be outwardly transformed as they should inevitably be by such a tectonic shift of the soul?

I was afraid you were going to ask that.

And I would be presumptuous and foolish to pretend that I have simple answers; I do not. What I do have is experience — the experience of many years of walking the Christian life, with stunning successes which proved all too fleeting, and disastrous failures which made a mockery of the high calling and lofty precepts of the convictions I hold dear. And I have shared this journey and experiences with many others, both past and present, whose path while wildly different in particulars is indistinguishable at its core.

What exactly is the nature of this transformation, this re-creation, which lays claim to a man in such mysterious manner? It is perhaps best described by what it is not.

It is not simply a change in thinking, a new perspective, a different set of opinions or a new worldview. If anything, the mind is the last bastion of resistance to its influence, and often the greatest enemy of the very change needed to transform the whole of one’s being.

It is not simply an emotional experience. Although emotions may be powerfully affected, emotions often serve to inhibit or distract from true progress, and are notoriously unreliable guides to its course.

It is not simply a change of the will, a setting of a new direction and discipline to achieve new goals and improve one’s life. The will, indeed, must be conquered, shackled, broken like a wild stallion to suit the purposes of this new Master. The will becomes but servant — rebellious, recalcitrant, resistant, remorseless, fighting its new overlord at every turn.

It is not simply a change of heart — although the heart lies closest to the seat of change, and senses its arrival before all else.

It is perhaps best described as a genesis; an arid fountainhead bursting forth with fresh spring water; an ancient stygian chamber shot through with dazzling shafts of light; a Phoenix arising from the ashes of the heart. There is a primordial recess in the soul of man, a silent sarcophagus unheralded and unseen, which springs to life like the burst of new flora at winter’s demise, when this dawn first breaks.

Thus is the experience of this new creation — but it is far more than mere renewal. It is as well — unexpectedly, surprisingly — a force of sedition with an unassailable foothold in a hostile land, seeking to undermine and overturn the tyranny of self with the sword of grace.

We are now at war. “I have come, not to bring peace, but the sword.”

Its effects are immediate, and often profound. There is a new vision, a grasp of things formerly hidden, a new light disclosing much which was cloaked in darkness, a profound and unbounded joy of discovery, and purpose, and optimism. We glory in the glint of sunlight reflecting off the helmets of our soldiers, marching in perfect unison, their colorful regalia stirring our hearts with visions of triumphant victory.

The reality is soon discovered to be starkly different. The cratered carnage of the battlefield, littered with the detritus of battles fought bravely but foolishly, sobers the spirit and saps the strength. The victory we hoped to be swift and painless now seems pyhrric if not pointless. Yet the failures are themselves at the point of the sword — they are, paradoxically, the means to triumph.

When a man becomes new in his spirit, he has engaged the very power of God in an irrevocable union whose outcome will be the full restoration of the purpose and relationship intended — by design — between the Creator and His creation. But the love which such a relationship demands must be utterly free, and hence the will and actions of man must be left unfettered and without coercion. This will, long subsumed to the service of self, must ultimately be turned to harmonious submission to the will of God, which desires, in freedom, the full integration of the new man into the wholeness and purpose of God’s design.

Though the inner change brought about by submission to God and our judicial pardon is profound, the mind and the will are steeped in a toxic brew of lifelong slavery to self. We have years of destructively pursuing that which seems right to us — of deceiving ourselves and others about our true thoughts and motives; of addictions and obsessions and hardened habits which have served to mitigate the pain and emptiness which our ego-enlargement have ultimately wrought. We lie to cover the shame; we react in anger, and resentment, and rage to cover the fears: fears of exposure and moral nakedness; fears of rejection; fears of failure; fears of existential insignificance. The sex, the booze, the pursuit of money and prestige, the materialism — all are exploited in search of integration and meaning, all leading only to more emptiness, more pain, more meaninglessness — and more of the same behaviors, over and over, endlessly.

Before our transformation, we are in a sense of one mind: this is the only life we know, the only tools we have at hand. Our inner and outer selves are on the same page, though the story is going nowhere and the final chapter looks bleak.

After our inner selves are transformed, however, the old contrivances no longer find consonance within; they find, instead, dis-ease. Our spirits are forging forward on a separate journey, and there is increasing tension between a mind and a will committed to failed, destructive solutions and an inner being seeking truth and wholeness.

We react to the inner discord our old life engenders with the tools we know best: we try, using knowledge, and effort, and will power, and discipline, to change the thoughts and actions we now know to be destructive. And we succeed — at first.

Sort of.

The behavior changes, but the thoughts and desires linger. The appearance improves, but the inner demons remain — if anything, they grow stronger, as each failure is a new victory for an old life. The struggle is draining and painful, disheartening and exhausting, as old habits persist and even prosper. With each failure, renewed commitment; with each relapse, new resolve. With each sortie, stalemate. Again. And again. And again.

And this, surprisingly, is exactly as it should be.

The mind and the will, unaided by grace, have no power to conquer the forces which bind them. They must be broken. There can be no resurrection of the dead until the dead be shown incapable of resurrection.

At some point in this long and fruitless journey, a juncture is reached. The wheels are coming off the car, and we’ve tired of pushing the pedal ever harder. It is a moment of choice: to resign ourselves to our old life, embrace our failure, and drown out the quiet pleadings of that inner voice; or submit, yet again, broken, falling headlong into the arms of grace, which alone can conquer that which is vastly larger than our feeble wills and darkened minds can overcome.

The sword of grace has slayed yet another stronghold of the old life. Another small parcel of the tyranny of self has been repurchased. We have been given what we could not gain by our own efforts, regardless how determined.

Cheer up. There are many more such battles ahead.

How then do we appropriate this liberating grace, this victory through surrender? There is no formula, for formulas are the haven of fools. But there are answers. The answers, I have found, are always simple — and never easy.

But that, my friends, is a topic for another day.

The Engine of Shame – Part 2

In my previous post on guilt and shame, I discussed their nature and differences, their impact on personal and social life, and their instrumentality in much of our individual unhappiness and communal dysfunction. If indeed shame is the common thread of the human condition–fraught as it is with pain, suffering, and evil–it must be mastered and overcome if we are to bring a measure of joy to life and peace to our spirits and our social interactions.

Shame is the most private of personal emotions, thriving in the dark, secluded lairs of our souls. It is the secret never told, the fears never revealed, the dread of exposure and abandonment, our harshest judge and most merciless prosecutor. Yet like the Wizard of Oz, the man behind the curtain is far less intimidating than his booming voice in our subconscious mind.

The power of shame is the secret; its antidote, transparency and grace. Shame thrives in the dark recesses of the mind, where its accusations are amplified by repetition without external reference. Shame becomes self-verifying, as each new negative thought or emotion reinforces the theme that we are rejected and without worth. It is only by allowing the light of openness, trust, and honesty that this vicious cycle may be broken.
 
Continue reading “The Engine of Shame – Part 2”

The Engine of Shame – Part 1

A wise friend–a man who helped me emerge from a period of considerable difficulty in my life–once taught me a simple lesson. In less than a minute, he handed me a gift which I have spent years only beginning to understand, integrating it into my life with agonizing slowness. It is a lesson which intellect cannot grasp or resolve, which faith only begins to illuminate–a simple principle which I believe lies close to the root of the human condition.

My friend taught me a simple distinction: the difference between guilt and shame.

While you no doubt think I am devolving into the linguistic morass of terminal psychobabble, I ask you to stick with me for a few moments. What you may discover is a key to understanding religion, terrorism, social ills such as crime and violence–and why the jerk in the next cubicle pushes your buttons so often.
Continue reading “The Engine of Shame – Part 1”

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.

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 issue 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 the “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 a 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 instance, then applying our conclusions from the specific to the general.

So, 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 is never pondered; that applying the suggested solution based on emotion without consideration for its broad implications or ramifications may well prove disastrous — such complications are never considered as possibilities. 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. 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 any 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 undermine traditional heterosexual marriage as normative in culture, thereby removing not merely legal but cultural restraints on all forms of sexual and relational heterodoxy. 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” — or, “women’s health care”– 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 social fabric.

Were some silver-suited alien from Alpha Centuri to visit our noble globe, he would no doubt 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 discretion? 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, our visitor would ask, 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 examine 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.”

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.

The Road to Grace: Honesty

Fifth in an ongoing series on grace in Christianity:

  1. On Purpose
  2. Justification, Sanctification, & Grace
  3. The Sword of Grace
  4. Getting to Grace
  5. The Road to Grace: Transparency

 
MaskHonesty.

Perhaps the rarest of all human virtues, treasured mostly in its absence, brought into focus most sharply in its antithesis.

If you ponder the subject for a moment, you may well find it surprising that we are anything but honest — that we do less than express exactly what we think, that we are anything but open and honest about our actions and motives. There are, after all, no dishonest dogs, no lying cats (though some might differ), no roguish raccoons or shady shellfish or mendacious mammals — save man.

So why, then, do we twist and torture the truth, crafting clever stories or deft deceits to cover our shortcomings and faults, smiling warmly while telling the most audacious prevarications concerning things both weighty and trivial? Why is this so often our default behavior?

What, exactly, are we trying to hide?

The answer lies in that dark angel of shame, that inner incubus engendered from a life spent divesting endless energy in the pursuit of the empty self. For dishonesty arises from evil, from the desire to hide that which must not be seen, from the need to present ourselves to others as something other than we are. Our ruptured relationship with God produces a perverse and unnatural self-sufficiency, driven by the desperate desire to fill the vast inner chasm thus resulting with a host of destructive desires, behaviors, and obsessions.

These fevered yet futile attempts to kill the existential emptiness and primal agony of life lived unnaturally, isolated from the life-source of God, prove highly toxic, causing yet greater distraction by their inevitable consequences. Designed to give, we strive endlessly to acquire; created to love, we engender hatred, exploiting others to fill our unquenchable needs, and detesting them when they prove unable to meet them. Our relationships become, not fertile beds of true intimacy, but vast webs of manipulation, abuse, resentment, and fear, as we suck the life out of others, seeking to satiate the insatiable void in our still-empty soul.

When we use the finite and futile to fill our edacity for the infinite, the invariable outcome of this manic miasma is a deepening conviction of our own guilt and growing awareness of our intrinsic unworthiness. Yet there remains a gossamer thread still tying us to the divine, an ancient truth near forgotten, a genesis of the God-life deep within, which says this can not, this must not, be true. And thus we craft another narrative of necessity, convincing ourselves and all around us that we are something which in fact we are not.

This pervasive dishonesty is the antithesis of transparency, and if we are to approach the ideal of being truly integrated — our inner self and outer appearances drawing toward unity — then we must come face to face with our own deceitfulness. This pilgrimage toward honesty must begin with the one with whom we are most deceitful: ourselves.

In our sophistry and sophistication this self-delusion is called by many names: rationalization; minimalization; justification; denial; projection. Though we often place such concepts solidly in the realm of science and psychology, they are in fact the attributes of a soul unwilling to face its inner abyss. They are, distilled down to their sordid essence, our unwillingness, our inability, to be rigorously, ruthlessly honest with ourselves.

Such a journey to the center of the soul cannot, indeed should not, be undertaken alone. The very strongholds we wish to conquer are such that they unite in their own defense: you will reason that you do not rationalize; you will deny your denial; project your fury at yourself onto others; minimalize your own responsibility for much which ails you. The mind is a dangerous neighborhood, best visited with another.

There is much to be learned from those who have undertaken this road to rigorous honesty through the crushing collapse of all of life’s props, brought about by the slavery of addiction and alcoholism. Driven to utter depredation and despondency by the scourge of a compulsion unbeatable and hopeless, they stagger into smoke-filled halls and church basements to seek what help they may from others of their kind. There they find kindred spirits — coarse in speech and common in appearance — yet victorious over the selfsame demons which shriek within their own dissipated minds.

They hear, for the first time, a startling truth:

Those who do not recover are people who cannot or will not completely give themselves to this simple program, usually men and women who are constitutionally incapable of being honest with themselves. There are such unfortunates. They are not at fault; they seem to have been born that way. They are naturally incapable of grasping and developing a manner of living which demands rigorous honesty. Their chances are less than average.

There are those, too, who suffer from grave emotional and mental disorders, but many of them do recover if they have the capacity to be honest.

Honesty: how peculiar, how unexpected, how self-evidently foolish as the solution to a deadly losing battle against booze. Yet those who triumph are those who become most willing to expose their darkest secrets, to face their shame, to lay it open before God, and share these hidden horrors which have enslaved them with another trusted friend.

Of course, you protest, you are not at all like those people, drunks and druggies, whose lack of moral character, hedonism, and enfeebled will must depend on such extreme and ridiculous measures to overcome their moral turpitude. You, on the other hand, a faithful Christian, have seen the light, and are walking the straight and narrow, secure in your own righteousness — err, the righteousness of Christ. The truth has set you free, after all — you know Christ.

Uh-huh.

And Christ knows you, and spoke about you often: something about “whitewashed tombs” comes to mind.

The path to honesty starts — startlingly — by getting honest, first and foremost, about ourselves. The dark heart of man knows no bounds — and the Christian is no exception, no matter how righteously we present ourselves to the outside world. Our hearts are filled with greed, lust, hatred, fear, pride, and extreme selfishness. Our one great advantage is this: when we are honest about our true nature, and act on that honesty, there is grace unlimited to overcome these inner demons.

So how then should we proceed?

We should, first of all, be systematic. Recovery programs use an approach which lists resentments, fears, and harms done to others — thereby covering a vast expanse of problems in human relationships which poison the soul — relationships so often devastated by the extraordinary self-centeredness so central to addiction. Other structured formats exist, based on lists of character defects, the principles of the Sermon on the Mount, the seven deadly sins, or other moral or spiritual principles. In a subsequent post I hope to expand on the recovery model, as well as provide a list of questions as a starting point to discovering core moral failings. The key here is not to achieve some legalistic righteousness, nor to engender guilt and self-pity, but rather to bring about conviction — that painful but healing knowledge of where we have failed, which is the commencement of a journey toward breaking the control of self-centered evil over our lives.

The second point is this: we do this to share with another. We should not strive to paint a rosy picture to impress, nor fill our story with a host of justifications, or endless whining about how life and its inhabitants have done us dirty. Surely they have in many instances — but we are responsible for our own attitudes and actions, regardless of the culpability of others. If we are rigorous and honest with ourselves, we will generally find we have brought much of life’s pain upon ourselves.

And lastly, we must pray. Unaided, our souls will drift and dodge, and find a million excuses for putting off this necessary work or justifying our ill motives and evil actions. Prayer empowers us to know, and in knowing, enables us to change. “I am the Truth and the Light” — both the ideal and the means to grasp and achieve it.

Everything inside you will rebel at this task, complete with procrastination, timidity, and our insane busyness whereby we avoid facing life’s painful truths and necessary reflections.

And of course, this self-examination isn’t really necessary, after all.

Unless, of course, you want to experience grace.