The Engine of Shame – Pt II

This essay, the second of a two-part series, was originally posted in October 2005.
DRGWIn 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 – Pt II”

The Engine of Shame – Part I

This essay, the first of a two-part series, was originally posted in October 2005.

Steam locomotiveA 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 I”

Healing Faith

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.

The Path – I:

A journal of one fool’s journey, and the faith which found him.

It was, at the outset, about direction.

Direction demands trust.

At the outset, I had neither.

Faith came easily when young, with a naturalness almost peculiar in retrospect. Ours was a religious home, Roman Catholic, not by any means an oppressive one or coercive as are some, but one in which faith was real, taken seriously, practiced more than preached, rather a quiet but ever-present fact of life. I took to it easily, a shy, timid kid, more at home with books and fantasy than with games and friends. The inner life was lord–for the outer life was, if not utterly chaotic, surely neither healthy nor sane. My mother ruled the roost: daughter of an alcoholic father who abandoned his family when she was young, and an immigrant mother from Poland whose rage at her own abandonment (sent by ship alone to America at age 14, married at 16, abandoned by her drunken spouse after 3 daughters a few years later) was never resolved in any meaningful way. Grandma’s bitterness was never far from the surface, poisoning my parents’ lives in a host of ways–and she passed this dark inheritance to her daughter. Grandmother had moved in with them shortly after their marriage, and lived with us throughout their married life, outliving my father–to my mom’s deep and oft-expressed resentment. My dad was quiet, gentle, rather a passive man, a physician adored by his patients and loved by his staff, but rarely seen by his family–in part due to devotion to his profession, in part, I suspect, to spend as little time with his mother-in-law as possible. My mom, left to husband a mother she at once loved and detested, concocted thereby a semi-toxic brew of smothering love and unpredictable rage which made engagement with her either emasculating, or terrifying–or both. To hide was the safest path–and hide I did. I learned to live alone while living among others.

Our home was but a few blocks from our parish church–a magical walk, with aged oaks hung low, cool and verdant in the moist heat of summer, stark and graceful in winter snows. I found the church a place of refuge–not during Mass, when far too crowded–but in those quiet times when pews were empty, lights were low, soft echoes of footsteps on marble, shadows of votive lights darting on darkened walls and sainted statues. The flickering candles whispered of a quiet presence: a comfort, a peace I rarely if ever found elsewhere. I loved it there: God was close. It was the only place where I knew no fear.

But children grow, and become teenagers. The Jesuit prep school I attended–men only, a tedious commuter train trek from home (my love of the rails its only saving grace)–fed me robust education and rotten theology. It introduced to me an angry God, constantly seeking to catch you in your faults, punishing you for every misdemeanor, trivial and trite. For a timid, wounded kid, it was hell: a lonely, graceless, fearful place with few friends and no happiness. It was a glorious day when I left those dark halls, their lockers like cell blocks in juvenescent jail. Abandoned in tatters was a simple faith of earlier years, replaced with cynical disgust for the hypocrisy of self-righteous religion.

College was liberation–a liberation, like most, more enslaving than ennobling. Whiskey, weed, and women were the new watchwords–success forthcoming in but two of three, as my social ineptitude and painful interpersonal impotency made relations with the opposite sex futile at best, moot most often. But booze and bogies trumped babes in spades–tequila demands no small talk, rejection revels in rotgut wine. These chemical friends restored a measure of serenity, divine ecstasy in empty bottles, cannabis incense, and solemn hymns of Hendrix and the Dead. There were, by grace, sufficient periods of sanity and enough non-toxic neurons to survive with good academic achievements. Miracles do happen, indeed.

There is in life always a guiding theology–though you be atheist or agnostic, religious or indifferent–as was I. Mine in this period was remarkably feeble: a passing acknowledgment of some vast Being able to create a billion unique snowflakes, yet caring not one wit about some solo slob stumbling through life. So, I figured, I was on my own–and on my own wasn’t going well: my chosen major, chemistry, a crushing bore, and a career therein unimaginably awful; an aching loneliness for relationships never fulfilled; the dreaded demand to settle on a lifelong career with no inkling whatsoever of a course which might bring happiness or satisfaction. My draft lottery number–31–assured a rapidly evaporating school deferment would soon sweep me to new and untold adventures in the steamy jungles of ‘Nam. Panic is not too strong a term to describe my state of mind.

The decision was easy–if profoundly superficial: with my father a physician, and a brother headed as well down this path, medicine was the default choice–and offered an extended student deferment, and the faint hope of the approval of a remote father–a hope never to be realized.

Was there ever a more noble calling to the healing profession?

But the simple fact was that I had not one clue: no way of knowing if the choice was the right one; no means to judge my own suitability for such an undertaking; no tools, skills, or craft for assessing such a weighty decision; no sense of calling or direction. I was a blind pig praying acorns weren’t afflictions, stumbling forward with blind faith in pure dumb luck.

And thus, as if guided by some mighty unseen hand, I chose a course of life which would by turns transform that very life, in ways I could neither anticipate, nor plan, nor hope for, nor even dream possible. That journey, and the faith thus engendered, I hope to share in some yet unwritten and undiscovered entries in this path’s journal.

A Life Not Long


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.

Euthanasia Investigation in New Orleans:
Medical Personel Charged

syringeFor those who may have read my earlier posts (here, here, and here) about the possibility of euthanasia at a hospital in New Orleans in the aftermath of Hurricae Katrina, you may be interested in the following report on the conclusion of an investigation by the Louisiana Attorney General, just reported by CNN:

NEW ORLEANS, Louisiana (CNN) — In the desperate days after hurricane Katrina struck, a doctor and two nurses at a flooded New Orleans hospital allegedly killed four patients by giving them a lethal drug cocktail, Louisiana’s top law enforcement official said Tuesday.

“We’re talking about people that pretended that maybe they were God,” Attorney General Charles C. Foti Jr. said, announcing second-degree murder charges against Dr. Anna Pou, Lori L. Budo and Cheri Landry.

“This is not euthanasia. It’s homicide,” Foti said.

The charges stem from the post-Katrina deaths of some patients at New Orleans Memorial Medical Center.

An affidavit said tests determined that a lethal amount of morphine was administered on September 1 to four patients ages 62, 66, 89 and 90. Hurricane Katrina swamped the city on August 29.

According to the court document, the morphine was paired with midazolam hydrochloride, known by its brand name Versed. Both drugs are central nervous system depressants. Taken together, Foti said, they become “a lethal cocktail that guarantees that you die.”

The doctor and nurses were taken into custody late Monday, following a 10-month investigation that continues. Each was charged with four counts of being a principal to second-degree murder and released on $100,000 bond.

The original reports showed up in a British tabloid not known for its reliability, and this sourcing, as well as some of the details therein, led to widespread scepticism about their reliability. However, interviews with physicians and health care workers at Memorial Hospital raised troubling questions as well, and a formal investigation was launched. The investigation was delayed by the reluctance of the involved hospital personal to testify, as well as the difficulty of obtaining autopsy evidence on the badly decomposed bodies after the fact.

What struck me the most, at the time I first posted it, was the vehemence of some commenters about how ridiculous this report was. One suspects there will be no humble pie eaten by those who sarcastically castigated me for posting on such obviously fictitious urban legends.

But sometimes the truth can be more frightening than fiction.

UPDATE: Here’s some earlier media links filling in some detals of the investigation as it unfolded (I’ll keep this updated as more becomes available):

The Maze – Part 8
Is There an Exit? – II

This is a part of an ongoing series on medical coding, billing, and reimbursement.

Previous posts are here:


In my previous post, I suggested that there may be simpler, more effective ways to manage reimbursement in health care. Clearly, the current system is broken. Health care costs have been spiraling despite aggressive attempts by insurance carriers to control them, using coercive methods of regulation and market dominance, and neither managed-care nor burgeoning federal regulation has succeeded in bringing them under control. These measures have only succeeded in vastly increasing the complexity and resources required to provide health care. Physicians are under growing pressures of both time and energy to meet the extraordinary paperwork load and time requirements to master and comply with this excessive regulatory environment.

In arriving at some potential solutions to this growing crisis, I have attempted to go back to core principles based on an understanding of human nature and motivation, striving for three major goals: simplicity, transparency, and accountability. I am under no illusion that such changes in our massive, complex, and politically-charged system will be easy to implement. Nevertheless, it is time to begin rethinking our entire system, before its problems become so burdensome that the quality of our health care delivery deteriorates drastically. Whether the political and social will exist to make such drastic changes is, of course, a very open question.

We are currently expending a huge amount of resources simply sustaining the current system, which are therefore not available for the actual provision of health care. Hence we have health care costs taking an increasingly large percentage of the federal budget; health insurance premiums eroding employee earnings and employer profits; and decreasing access of patients to physicians due to financially unsustainable entitlement programs which no longer cover even the cost of providing care. The rapid-fire nature of our information-based society, with media and Internet, has tended to create an endless series of daily crises, many of which prove to be nonexistent over time. Meanwhile, under the radar, the health-care morass continues to grow into a gargantuan issue, with little fresh thinking, and little media attention given the magnitude of the problem and its potential to impact all of our lives.

I hope to put forward here a few simple ideas. I make no claim to any expertise in the area of health care policy, other than nearly 30 years of day-to-day patient care, with the resulting cumulative experience in a system which is rapidly becoming unworkable. Our health care system is extraordinarily complex, and I am not naive enough to believe that such simple ideas will solve every problem which its complexity and scope presents. Nevertheless, I believe that by applying core principles, rather than continuing on present flawed assumptions, the potential for genuinely profound changes in our health care delivery system is substantial.

Here are some proposals for reforming the health-care system.

♦ Pay physicians by time: In virtually every profession and avocation, including law, accounting, consulting, and most trades, the primary measure of one’s efforts is the time spent performing the task at which you are trained and skilled. The hourly rate will, of course, vary widely based on your profession, training, and expertise; but, by and large, the time you spend on a task is well-correlated with its economic value.

The exception to this, as I have pointed out in lurid detail in previous posts, is the health-care profession. We have evolved an extraordinarily complex system of service codes, diagnosis codes, and business rules and regulations which have become so convoluted and contradictory that virtually no one can master them. We hire additional employees, requiring specialized training, in an attempt to delegate much of these efforts, with only marginal success, as the rules are both constantly changing, and vary widely from one insurance carrier to another, one federal health-care program to the next. As a result, much effort and many resources are expended in simply getting properly and fairly reimbursed for one’s services and expertise. A physician who must expend substantial time and energy, and squander substantial business overhead, managing such a system is obviously no longer solely focused on the provision of his primary skill, the practice of medicine.

Paying physicians solely by time spent would, I believe, drastically alter this equation, and significantly change motivation and incentives to be more in line with what both physicians and patients seek. If you examine any study on patient’s complaints about the health-care system, you’ll find at the top of nearly every list of complaints two issues: physicians do not spend enough time with their patients, and patients have to wait too long to see the doctor. Of course, some of these complaints arise from physician personality problems or practice management issues–but in no small part, they arise from the perverse incentives and necessities generated by our current system. Since physicians are paid per unit service, it is in their best interest financially–and increasingly a financial necessity–to see as many patients as possible in order to generate sufficient revenue to sustain their increasingly costly medical practices. The high overhead thus required by extra employees and employee benefits, dictation costs, the overall rise in medical practice expenses and malpractice premiums, require that physicians often see as many patients as possible–thus resulting in over-scheduling and rushed visits.

Imagine how transformative it might be to simply pay the physician based on the time he spends with the patient. The incentives are suddenly flipped: the physician is now motivated to spend more time with you, since time is money. There’s no need to cram a high volume of services into one’s day to make ends meet, since you will be paid simply based on the time you have spent with patients–whether they be few or many. Practice overhead would drop drastically, as the need for highly-trained medical billers would disappear. Time is a very simple parameter to measure, and easily understood by both patients, physicians, and staff, reducing much of the confusion which now exists with our existing service code-based structure.

Paying physicians by time is not without challenges, obviously. Unlike legal or accounting services, for example, there are significant differences in the types of services provided by physicians to patients. Physicians may be engaged primarily in interacting with their patients in an office setting; in a hospital or intensive care unit; in surgery; performing procedures. While one might hope for a fixed hourly rate, for example, established by negotiation with an insurance carrier (more on this later) or set by the physicians themselves, different hourly rates for different broad categories of services may prove necessary. While time is in general an excellent indicator of complexity of service, there are circumstances in which time alone does not entirely reflect accurately on skill or expertise. For example, an inexperienced surgeon will likely take significantly longer on a given surgery than one who has many years of experience, since acquired surgical skills make for greater efficiency. Ultimately this may be solved by a system where more experienced physicians, or those with demonstrated efficiency and competency, recoup a better hourly rate. This would be consistent with other professions, where reputation, experience and expertise in given areas command higher hourly pay.

Some areas of medicine are not amenable to a time-based payment system: laboratory work, for example, and certain minor procedures. These might be better suited for alternative means of payment based on units rather than time. But a major move away from paying for most medical services based on multi-level service codes is highly desirable.

Time-based reimbursement would, with a single stroke, eliminate our inscrutable system of procedural and diagnosis codes, which are all but impossible to master, and which suck up extraordinary resources. If implemented fully, it is virtually certain that overall costs for medical care would decrease, as physicians would be able to significantly reduce their overhead, and therefore charge less to make a comparable income. Expensive electronic medical record systems (now touted as the savior of our health-care system, which they most certainly will not be) would no longer be mandatory, except as a convenience for documentation. Their current function is primarily that of automating complex coding rules and thereby keeping physicians one step ahead of federal and insurance auditors. Time is an extremely easy quantity to audit, and documentation could be reduced to core essentials, rather than pages of needless detail written simply to satisfy federal guidelines and insurance carrier requirements. Time is also an extremely easy parameter for patients to grasp: the doctor who bills a one-hour visit, when he only saw you for 15 minutes, is easily reported for dishonesty, whereas under the current system it is impossible for patients to assess whether their service coding is appropriate for their visit or not.

Time-based reimbursement would also provide an immediate reduction in the need for large federal and insurance bureaucracies, which exist now primarily to assess, review, monitor, and expedite reimbursement in our current labyrinthine system. Don’t be surprised, however, if such proposals would be vigorously opposed, especially by the insurance industry, which uses the complexity of the current system to reap bodacious profits. Complexity is bad for our health and bad for our economics–but is highly profitable for certain segments of the health-care economy, who by sheer size, market dominance, and massive resources have learned how to turn garbage into gold.

And this brings us to the second component of payment reform, which is health-care insurance:

♦ Dismantle the dysfunctional relationship between health-care payers and health-care providers: This one is going to ruffle some feathers. The current private health-care insurance industry makes huge profits by acting as the middleman between the patient and provider. They use the complexity of the system to deny payments for legitimate medical services, to reduce reimbursement to physicians, while raising premiums purportedly justified by climbing health-care costs. The insurance industry as it now exists represents a huge bureaucratic black hole, which sucks in massive amounts of health-care dollars in administration and profits for the company and their CEOs. An obscene percentage of health care dollars is now spent feeding this beast; it’s time to slay the dragon.

Here’s how I would structure the insurance industry to restore some sanity: I would mandate that universal catastrophic coverage be required for all, with very large deductibles, perhaps $25,000. While I am not generally a fan of mandates, the current formidable percentage of uninsured represents a huge tax on those who do carry insurance. In Washington state, for example, I cannot drive a car without car insurance; I cannot get a mortgage on my house without homeowners insurance. The reason for these requirements is simple: if disaster strikes, and I am uninsured, someone else has to foot the bill. Universal, catastrophic coverage, being broadly-based, would be relatively inexpensive; those who are unable to afford it could be subsidized through state or federal programs, via a system far simpler than our current Medicare or Medicaid eligibility system. Of course, this would involve means testing–which is the only rational way of providing federal subsidies to the poor and elderly, but anathema to the socialists in our midst. Relatively few people would be financially devastated by a loss of $25,000 for a major illness (although it would certainly be a financial strain for many), and therefore catastrophic coverage would protect against such a financial disaster–which often results in bankruptcy.

To cover this large deductible, secondary policies would be available, paid either by individuals or their employers. However these plans would not make payments to physicians; they would reimburse patients for their health care costs. The patients themselves would be the contact point for payment; they would be the ones who actually pay the physician’s bill. This was the original concept in health insurance, and it has many advantages.

First of all, there is simplicity: the patient pays the physician’s bill, submits the claim, and is reimbursed for all, or a portion, of their health-care expenses. The physician gets paid up front, which reduces his overhead, and allows him or her to charge lower fees; the patient knows exactly what his health-care costs are at the point of service. This provides accountability with the physician as well, who must explain to the patient why their fees are so high.

The patient and the insurance company then become direct, accountable business partners; when the insurance company refuses to pay their claim, it is the person paying the premium who knows about it immediately, who can then complain or seek redress directly with the insurance company. No more letters to patients about physicians providing “medically unnecessary” care; no more convoluted denials based on blackbox coding edits; no more long delays as the insurance company stalls payment, knowing that the physician’s practice is overwhelmed with countless other claims denials and may just write it off.

When the patient is denied reimbursement for their care, they will demand to know why, and if unsatisfied, will find another insurance carrier for their health-care coverage. Accountability and transparency are built into the system. Insurance companies would soon be out of the business of dictating which medical services are appropriate, and which are not–a role which has never been appropriate for a third-party insurer. Furthermore, this system would allow physicians flexibility to provide reduced fee or charity care for the needy, without the risk of becoming ensnared in federal fraud regulations or insurance contractual violations. Amazingly enough, if I choose to forgo a co-payment or deductible for a poor Medicare patient, I am guilty of fraud. That’s how perverse our current system has become. Want to accept a gift, or food, or a bottle of homemade wine for your services instead of cash? Fraud under the current system, but ennobling and satisfying for both patient and physician under this reform.

Lastly, in this system reform, I would

♦ Provide tax credits for physicians to see the poor. I have written about this previously. The number of uninsured individuals in our country is large and growing, and represents a genuine scandal for such a wealthy nation. The current Medicaid system is degrading for the individual who needs it, and is onerous and punitive for physicians who choose to accept their payments. For many–especially since the reform of the Medicaid system–such coverage is not even available as an option. Hence the uninsured pour into emergency rooms (where legally they cannot be turned away), where they receive expensive care without emphasis on prevention or adequate maintenance or follow-up.

The institution of tax credits–not deductions–would provide physicians with an immediate incentive to see the poor. It need not be on a dollar-for-dollar basis; there could also be a cap on this credit per year. In Washington state, over 50% of physicians no longer see Medicaid patients–not because they have a desire to deny care to these individuals, but because reimbursement rates are so low they no longer cover expenses, and because the system is punitive, bureaucratic, arbitrary, and complex. As a result, many Medicaid patients find it nearly impossible to find even primary care physicians who will see them, much less specialists. Medicare is not far behind in this shameful dereliction of responsibility. By providing tax credits to care for those who cannot afford insurance, physicians would have a direct financial incentive to see the poor, and the massive bureaucratic administration now managing Medicaid health-care payments would become obsolete overnight. The money saved by such bureaucratic reduction would go a long way toward subsidizing universal catastrophic coverage or meeting non-medical programs such as job training and housing.

There are, no doubt, many challenges with such a simplified approach to health care reimbursement: our health-care system is expensive, very complex, and many players have a vested interest in the system as it now stands. But for those of us on the front lines–physicians, other health-care providers, and patients–drastic changes must begin, lest our system implode under its own weight. The hurdles to change are far less conceptual and practical than political: one can only begin to imagine the heated rhetoric about greedy doctors, charges of abandoning the poor, and other verbal invectives which have become the currency of our dark political age. However, if we do not begin to move away from our current system, and demand that those whom we elect bring about such radical changes, we will have no one but ourselves to blame when the gleaming luxury liner of our health-care system runs aground on the jagged rocks of reality.

The Maze – Part 7
Is There an Exit? – I

This is a part of an ongoing series on medical coding, billing, and reimbursement.

Previous posts are here:

MazeWhat started off in concept as a few posts on some of the craziness in the medical billing and reimbursement arena has been turning into something of an opus magnum on the subject–yet surprisingly, even at that has not even touched upon all of the complexity or contradictions inherent in this maze of regulations, bureaucracy, and inefficiency which we call our health care system. Such systems–complex, increasingly unworkable and counter-productive–do not arise by design, but rather by a sort of perverse evolution, growing a brier here and a bramble there, creeping tentacles and spiraling vines sprouting to address difficult problems, but increasingly choking the life out of their intended benefactors, strangling both those in need of help and those committed to providing it.

A regular question in comments throughout this series has been, “What, then, are your solutions?” Fair enough question–it is far too easy to dissect and depreciate the medical system we have at once inherited and created: it is, in soldiers’ parlance, a “target-rich environment.” A house built on sand cannot stand — and the mansion of American medicine, still rich in grand gables and ornate glass, is sagging from a rotting foundation, swaybacked from footings set on unsteady soil. The termites eroding its timbers are many, rooted in men’s souls as much as in Senate halls. We demand the finest care for ourselves, sparing no expense to others. We demand perfection of those capable only of imperfection. We hide behind our terror of death, unspoken yet unrelenting, seeking false hope in technology and technique against that dark looming fortress which stands unbending against our extravagant but ultimately fruitless endeavors. We pass law upon law and regulation upon regulation, engorging a byzantine monster so immense it can no longer ambulate–yet still we feed the beast, hoping against hope it may someday become the chrysalis which will carry us to a better world. It will not, and can not, for it has not the wherewithal to do that which is most needed: its own dismantling.

The complexity of our current system is both the cause and the result of its dysfunctionality. We have created an environment of perverse motivation and punitive legalism. Patients are shielded from the true costs of their decisions by insurance rendered nearly free to them by their employers or the government. Physicians, seeing their medical decisions challenged and checkmated by capricious clerks and aggressive algorithms, work the complex system to outmaneuver its clear intent to squeeze more work from them for less pay, while their patients are denied the care they have recommended. Insurers, pressured by employers to cut spiralling premiums, make cold calculations from afar which infuriate physicians and injure patients. Attorneys play Monday-morning quarterback, second-guessing complex decisions years after the fact, before gullible juries with Jerry Springer ethics, reaping personal windfalls far exceeding the benefits of their wounded plaintiffs. And government, having opened the financial floodgates of health care entitlements, now seeks to stem the rising waters by sandbagging the banks rather than repairing the dam.

Each player in this dysfunctional drama plays their part, driven in no small part by incentives which drive up costs and increase inefficiency and complexity. Health insurance, while necessary to avoid financial disaster in a health crisis, serves also to buffer patients from the cost implications of their health care decisions. Costly and sometimes unnecessary tests, drugs, or treatments are demanded because “insurance pays for them”–and because media and internet hype inflate their usefulness while minimizing their risks and costs. End-of-life care is extraordinarily expensive in part because patients and families refuse to accept the inevitability of death. Physicians play along, fearing lawsuits if they do not–while themselves refusing to recognize their own impotence against death and the futility of their own technological railings against the darkness. Government, desperately trying to reign in rampaging health care costs, responds by increasing regulation and complexity while decreasing reimbursements–greatly escalating pressure on physicians to manipulate the complex rules for their patient’s welfare and their own financial survival–and compounding the risk that by doing so they will run afoul of its legal and ethical clutches.

To restore a measure of sanity to this system we must return to core principles and truths, long since lost in the maze of regulations and rules we have allowed our health care system to become. In attempting to arrive at a better way to deliver health care, it may be best to start first with doesn’t work–and why:

 ♦ Managed care: Managed care works–or at least it used to–as long as you defined its success as the reduction of health care costs. Managed care uses several models. Most involve the use of a gatekeeper–a primary care provider who is the übermeister of who, when, and where you as a patient get care. Need a specialist? No go, unless Herr Pförtner approves. Got to see that specialist (finally), who recommends you have an MRI or CT scan? Gotta get a piece of paper from the Gatemeister before you go. And in many arrangements, the primary care gatekeeper has strong financial incentives to Just Say No–or strong disincentives should he break down and say Yes. So for you to see that specialist, your family doctor has to: 1) do extra work, filling out and sending more paperwork and forms, and 2) lose money. Bet he or she finds some way to treat you without that visit or test. Even good, ethical doctors get beaten down by such a system.

Another variation on managed care makes the insurance carrier the gatekeeper, making decisions about what care you may have, under what conditions, by which doctors. If you like having your primary care physician giving a thumbs up or down on your tests and referrals, you’ll just love having this process run by insurance clerks, secret policies, and computer algorithms. Of course, the carriers constantly remind us they don’t practice medicine. They’re right, of course: no one would call making regular decisions about your access to referrals, tests, and medications purely for financial gain practicing medicine, no siree. Malpractice of medicine would be a better description.

Managed care saves money by restricting access to care–and hence it resulted, after its introduction, in a significant drop in health care costs. But patients got wise to the game, and became more demanding–and media stories about kids denied cancer treatment and women with breast cancer denied bone marrow transplants, made the managed care companies pariahs. And so, managed care was forced to become more flexible, allowing more specialty visits and looser restrictions on certain tests and procedures. The result? The savings melted away, and after several years of declining costs, premiums and costs for managed care are on the rise–at about the same rate as health care costs across the board.

 ♦ More regulations and harsher penalties for their violation: So here’s the plan: Medicare costing taxpayers tons of money, having covered all those eligible regardless of ability to afford care and opened the entitlement floodgates? Time to micromanage where all that money goes. Create highly complex rules about what services can be provided, under what circumstances, and then change them constantly based not on medical need or progress but simply to stem high cost areas. Make the rules so complex no one can understand them–then go after the bastards who are “cheating” the system by violating the rules. Well, fear works–up to a point. Most doctors will try to ignore the rules and simply code at lower service levels to minimize their risks and the time needed to master the maze; others will buckle down and try to master them. Then, when even this doesn’t work to stem costs, it’s time to lower reimbursement levels. Eventually, this brilliant plan–increasing the costs of providing care while paying less–will result in payments which fall below the costs of providing the care–and doctors either have to game the system to stay afloat, or stop seeing federally-insured patients. The end result: more “fraud”–and rapidly shrinking health care access for covered patients (the elderly, disabled and the poor). Brilliant theory, Einstein. Got any more like that?

 ♦ Paying for quality: This is one of the latest gimmicks the health care policy wonks have dreamed up, more commonly known as pay for performance. It’s based on the (highly disputable) notion that bad doctors are running up the cost of care by ordering unnecessary tests, recommending unneeded procedures and surgery, practicing costly medicine which lies outside the mainstream–renegades all, ransacking the health care treasury. The good guys in the white hats, on the other hand, walk carefully between the lines, following established standards of care, don’t cost the system nearly as much–and should be rewarded with better reimbursements.

Ten solid seconds of thought by anyone with an IQ over 50 should see problems with this idea. A superbly-trained physician saving the life of a desperately ill patient, on a ventilator in an ICU, will be spending a whole pile of money–whereas ol’ Doctor Feelgood, passing out antibiotics for your sniffles and pain pills like candy may not be spending many health care dollars at all. High quality — while not invariably more expensive–is often so. And what about those guidelines? Well, one problem is, by and large, they don’t exist — except in a few relatively straightforward areas of medicine. The reason, in no small part, is that quality medical care is a complex and constantly moving target: what was excellent care ten years ago may be marginal or even poor care today. Once you ossify guidelines into regulations governing payment, you run a great risk of freezing health care advancement. You will be paid for care meeting the guidelines–but not for better care, based on advances in medical knowledge and technology, which will tend to fall outside the guidelines. And any physician who thinks they’ll get paid more for following the guidelines needs a long session on Dr. Sanity’s couch: they will pay those physicians not meeting the guidelines a lot less, and the “good guys” better than them — but still less.

I could continue, but enough of bad ideas. More of the same is not the answer to our health care system. In my next post I hope to lay out a few ideas which are based, I believe, more solidly on reducing complexity and aligning our health care more solidly along the lines of simplicity, accountability, and transparency. Stay tuned, back soon.