Spirituality and Health
A lecture given in the Professional Competencies program of the Michael G. DeGroote School of Medicine, McMaster University
Good Morning to all gathered here and there and everywhere! A special shout out to your colleagues tuning in by video conference from Waterloo Regional Campus (Wave if you can see and hear me!) and Niagara Regional Campus (Hello to Niagara!)
Today’s session, like many of your experiences in medicine, begins with a germ, although in this case, it’s the germ of an idea and the idea is this:
That while medicine is a science, it is also an art and there is much to be learned between the lines of your medical texts and journals; much that can never be fully known despite the revelations of research and an ongoing body of evidence.
For this reason, your fellow students in this and in previous years developed (with help from their Pro Comp advisors) sessions that link together the experiences of patients and the deep reflections of you, their future doctors. Today’s session is envisioned as a continuation of your previous session entitled “Listening to Stories of Chronic Illness” and just some of the possibilities for small group sharing are on your Med Portal.
There is also a great role-playing exercise you may want to try called “Words That Help;” or you may want to share your personal reflective portfolio entry on listening to the patient’s perspective with your group, or discuss what arose for you in comparing the ancient and the modern versions of the Hippocratic Oath.
Above all, these sessions (as always at McMaster, who pioneered Small Group learning in Medical school, now called “The Harvard Model” but we know better!) are predicated on the idea that as representative human beings, each with families, experiences and stories of your own, you already have much to teach and much to learn from among and within yourselves and each other. Your fellow students, patients and your own self-knowledge are great teachers!
My own desire to talk with you today has arisen simply from my own experience of the medical profession as a minister walking with many people through all the times of their lives. I have also been on the other side of the bed in my own life on a number of occasions, most notably with a neck broken at C4 when I was about 30 and a long battle with infertility about 10 years later.
You will probably know that statistically I should be dead or a quadriplegiac, so I am happy to be standing here before you speaking with you today. I have long felt that if there is any way I or anyone in my profession could help the next generation of MAC medical students be even better, we should at least try. This is my effort to do that.
Mostly what I have for you today are stories. Dr. James Orbinski, one of a group of incredible McMaster trained doctors I believe inspired by Vic Neufeldt in the mid to late 1980s and early 1990s (among them Ontario’s Minister of Health Eric Hoskins, War Child founder Samantha Nutt, Richard Heinzl, founder of the North American chapter of MSF – and many others.)
James Orbinski was the international president for MSF Medecins Sans Frontieres/Doctors Without Borders and was the person who accepted the Nobel Peace Prize and delivered the Nobel Lecture on behalf of MSF in 1999 in Oslo, Norway.
He says in his book “An Imperfect Offering: Humanitarian Action for the Twenty-First Century” “Stories, we all have stories. Nature does not tell stories, we do. We find ourselves in them, make ourselves in them, choose ourselves in them. If we are the stories we tell ourselves, we had better choose them well. This book is a series of stories. I ask again and again “How am I to be, how are we to be in relation to the suffering of others?” It is a question that has preoccupied me for much of my life.”
If you, like Dr. Orbinski, have chosen to make medicine your “field of dreams,” his question will likely preoccupy you as well and will be lived out in relation to the stories of your lives and the lives of patients yet to come.
Just two weeks ago, you were invited into the stories of patients themselves and were asked to reflect upon their stories. And so in keeping with that theme, a lot of the stories I will share today are from my own life and observations. That way I am only betraying my own confidences when I share them with you!
My story intersects with your field at the beginning of my training and continues to this day. When you make the decision to go into the ministry, many denominations require you to do one unit of hospital chaplaincy. This is a three month educational unit where you are learning, yet also very much responsible for patient care or spiritual care, along the way. I loved my time as a hospital chaplain so much that I opted for 6 times the requirement that is, about a year and a half of continuous units as a hospital chaplain – and very nearly chose this type of ministry over congregational life.
Some may wonder why, because hospital chaplaincy puts you in the centre of peoples’ lives at probably, their worst moments. Perhaps most of you are going into medicine because of a desire to help, to heal, to make better. Many of us go into ministry for the same reasons; but I can assure you, no-one beeps the chaplain at 4 in the morning because they want to have a pleasant conversation about religion or how to live a better life! They call the chaplain because someone is dying or has died. After you in the medical field have done all you can, it’s over to us.
I was fortunate in my time as a hospital chaplain that I had a mentor who believed that since ministers are called to be present in every part of people’s lives that we should experience the greatest fullness of life possible in a hospital setting.
We were sent to those two portals of human existence – the delivery room and the morgue. I have observed several open heart surgeries (including one at Toronto General where the patient woke up mid-surgery – but that’s another story) and watched while pathologists dissected the diseased organs of patients I had just sat with over lunch.
I have cared for medical and surgical floors, oncology, obstetrics, gynecology, geriatrics, mental health units; I was for over a year assigned the multi-organ transplant unit at Toronto General, the Pain Clinic, blood cancers and hematology, bone marrow transplants and so much more and of course, when we were on call, we served the whole of the University Health Network as it’s now called, two hospitals, the cancer and the Rehabilitation Centre. We cared for patients, staff, health care professionals, families and even each other on rough days.
The places I’ve just described may sound like a road map of your travels so far and to come. I share it just to say that I’ve spent some time in your world and of course, beyond those early years, counselled, visited and accompanied many parishioners to those all those places and ultimately, unto death as well. Now when I stop in on a hospital to visit a family member or friend, as soon as I enter the hall, the smell of that industrial cleaner that hospitals the world over use hits my nose and I know where I am and where I’ve been.
So on a break one time early in my chaplaincy, I found myself in the medical library, looking up a condition that one of my patients was dealing with. I was still wearing my hospital badge and a med student caught sight of it and calmly asked me “What are you doing here?” “What do you mean?” I asked. “Well, this is the medical library” he said “and you’re a chaplain; that’s the religious department isn’t it? Don’t you guys hang out in the chapel or something?” “Well,” I said “For most of human history, we’ve actually been the same thing.” He looked a little dumbfounded and confused and went on his merry way.
However clever I thought I was being, in fact what I said was quite accurate. For most of the time that we human beings have been on the planet, we have not made a distinction between medicine that treats the body and religion or spirituality that endeavors to heal the soul.
Furthermore, we have not seen so sharp a division between the self and the community, nor between humanity and the world of nature. This dichotomous thinking is quite a recent phenomenon. As the theoretical physicist David Bohm points out – wholeness is actually humanity’s default position.
Modern notions of science and religion as disparate ways of understanding the universe, or post Cartesian mind/body dualism are quite recent arrivals in human understanding and classification. And furthermore, they are also geographically quite narrowly distributed around the world even in the present time; pretty much found just in Western medicine.
Although this is the medicine in which you will receive much of your training and perhaps practice for most of your career, I humbly invite you to keep in mind what I said to that medical student. For much of human history and still, in much of the world, the distinction between what constitutes care of the body and care of the soul has not been so easily made.
And even in our modern medical institutional paradigms, where we use language and practice and tradition to insulate us from the interconnectedness of the many realms we work in, the truth of their connectedness haunts us, chasing us down corridors and poking holes in our paradigms on a daily basis.
I had a patient once on my Transplant floor who called me to her room with as much exasperation in her voice as a person who was waiting for a double lung transplant could possibly muster. “Why won’t anyone call it for what it is?” she demanded to know. “I am waiting, no, I am hoping for someone to die so that I can live! The doctors say “Well, we’re waiting on pair of lungs.” They don’t grow on trees you know!”
She was having a full blown crisis because of her medical care-givers’ inability to name the spiritual reality of her situation, that her life was dependent on the death of another. She was right; they were not waiting for lungs; they were waiting for misfortune to occur and perhaps, in the best possible rendering of the story, something positive to possibly come out of it. A spiritual crisis indeed, not a physical one.
Embedded within this spiritual crisis is of course, a moral one as well, which two stories of organ transplantation illustrate. The stories of twin girls adopted from Vietnam both in need of a liver transplant and Ottawa Senator’s owner Eugene Melnyk, both of whom used social media and a public campaign to find donors. Donors were found; lives were saved (even beyond the famous twins and hockey team owner) but yours is the generation that will have to wrestle with the moral ramifications of how social media and medicine intersect in ways we can now probably only imagine!
And before we get any farther, I want to say a few words about one of the terms I’m using. I don’t want to get bogged down in definitions – and “spirituality” or “a spiritual life” are terms that certainly defy definition or explanation.
What I do want to say is that your spiritual world view is not only a belief in God or the afterlife, it is also your “non-belief” or even being open to proof either way. Whether you are an agnostic or “born again,” a devout Muslim or a non-practicing Jew, a Buddhist, Pagan, Hindu, Sikh, a pantheist or follower of traditional aboriginal spirituality – you bring some set of beliefs or non-beliefs to your work as doctor and to who you are as a human being. Even the atheist has a notion of the God in which he or she does not believe, or, as the theologian Paul Tillich said to an atheist friend “Tell me about the God in which you do not believe. Chances are, I don’t believe in him either!”
I believe it is too simplistic to say “I am a scientist or an atheist, so I don’t have a spiritual world view” or as one of last year’s students said “My brain is nothing but ones and zeros.” Even that, he acknowledged, is a kind of spiritual world view. We ARE meaning-making creatures who, for whatever reason, have the need and desire to make meaning out of life, death, suffering and misfortune.
Oddly, it doesn’t work the other way – you don’t see people who won the lottery shaking their fist at the sky and saying “Why me, God, why me?” Somehow we don’t feel as deep a need to make spiritual sense of the good stuff!
So I want to disabuse you of the notion that this subject doesn’t affect you if you’re not a believer. Even if that’s true, depending on how you define it, 80% of Canadians say they believe in God. So your patients or the other health care providers or the families or your colleagues – will be trying to wrestle with that indefinable element even if you keep to “just the facts, Ma’am,” the ones and zeros.
And you can also never assume what God or world view or spiritual belief they hold within the circle of their experience. A benevolent God or a punishing God? A God in charge of everyone’s fate or one who suffers alongside the victims of misfortune? Beliefs are as diverse as there are religions but as unique as there are human beings. I liked to use the Buddhist “empty bowl” as a metaphor for my approach to ministry, but I think it works for medicine as well; take something with you, but empty out your own expectations to make room for what the patient puts there.
The modern version of the Hippocratic oath that you commit to here at MAC when you graduate (God willing – that’s my prayer for you!) puts it this way “I will remember that there is art to medicine as well as science, and that warmth, sympathy, and understanding may outweigh the surgeon’s knife or the chemist’s drug.”
So I want to challenge you to think about that art as well as the science you’re learning and to begin to consider some questions.
What would happen if, as medical students, you started from a place that assumed your responsibility for caring for your patients in real wholeness – heart, mind, body and soul? What if as a medical doctor you approached the people you are to care for with the idea that your care of them extends far beyond the health of their body? How might you act or not act with that model before you at all times?
The wonderful physiotherapist who helped me come back to the land of the living after my broken neck told me she took every single elective she could possibly take on her way to becoming the best physio she could possibly be; every extra science course, every practicum, ever cross–cultural teaching or learning, every alternate therapy or theory.
She said to me “If I want to be a healer, why would I turn down any kind of opportunity to learn something that people somewhere have found helpful at one time or another?” Why indeed? We do not have the answers to all things; our answers are provisional, which the history of science, medicine and most other human endeavors will prove. And the road to knowledge is paved with error, even or perhaps most especially in science and medicine. The physicist Niels Bohr said “An expert is one who has made all the mistakes which can be made, in a very narrow field.”
The question I want you to consider, embedded in some of the stories I’ll tell you today is “As a doctor and a healer – is there something more you can do – even when there is nothing more you can do?” To me, this question contains a wholeness, a wider world view, an inclusivity, a culturally nuanced approach – it embodies the spiritual dimension of health care.
One more thing before we get to the stories. I’d like to put in a word for humility. I wondered earlier if most of you are going into medicine because of a desire to help, to heal, to make better and I’m betting the answer is “Yes.” Someone told me last year – before the session began – that they “don’t really like all this “Pro-Comp” stuff – I just want to learn how to save lives!” Totally understandable.
But if you believe that you want to become a doctor in order to stave off illness, pain and death, then I would recommend that you quit now, before you do irreparable harm in your quest to achieve this totally unrealistic goal.
Former Dean of Medicine John Kelton who is a brilliant hematologist and researcher in internal medicine, candidly said (I am paraphrasing him now) that he got into research and administration because he really didn’t like telling parents that their children were going to die.
You will not only save lives, you will lose them. And yes, there will inevitably be times when it is your fault. You will know failure, disappointment, humiliation and limitation and if you can persevere in spite of it all, you may become a good or even great doctor along the way. You will need your own “meaning-making” compass to guide you through such a perilous path.
Because of course, we would probably all like to die peacefully in our sleep at an advanced age after a healthy, long life. But the reality is this ending happens to only a few of us. Most of us will encounter illness, pain, disability, infirmity, mental or physical diminishment before we die and will be in need of a doctor at those times.
Still others may draw the card for an even more difficult death; accidental or deliberate harm, whether by self or others, deaths due to war or acts of terror; the untimely deaths of good people before their time or the inexplicable deaths of innocent children whose lives are snuffed out almost before they have begun. And there you will be at the centre of the story, an usher in the theatre of life, expected to help people find their way and know where you’re going in the dark at one and the same time.
I still remember the story that one of my pastoral counselling profs told of his first experience as the priest walking into a home after someone had just died. He said he can never describe the abject terror he felt as a young, newly ordained priest, hearing the words “Thank God, Father John is here. He’ll know what to do.”
Perhaps many of you can identify with this feeling and perhaps for others, that moment is still most surely ahead. You will pause after entering the hospital room of a patient who is gravely ill or has just died, and you will hear “Thank goodness, Dr. Shoukri or Dr. Rao, is here.” “We can relax, Dr. Teshome or Dr. MacDonald or Dr. Li will take over now.”
There will be a beat of silence and all of a sudden, you’ll feel it before you see it – people in the room will turn their faces to you in anticipation, some who may be twice or three times your age – with an expectation of words of wisdom, explanation or understanding issuing from your mouth – and you will resist the urge to look behind yourself to see who is this expert to whom they are turning? And then you will realize – Oh, no, it’s me. I’m the one with the white coat” and you’ll probably feel like there’s been a mistake of some sort.
My wish for you, while you are figuring out how to not make their trust be misplaced, is that you will have more of the “Good Doctor” and even “Great Doctor” moments I am going to describe than the “Bad Doctor Moments.” You will have some of all three, and here’s a few stories of what they might look like.
One of the best was my sister Joan’s oncologist. Without telling you more of her story than she would want, my sister was diagnosed with a cancer that has a high cure rate if caught and treated early and a very poor survival rate if diagnosed later or untreated. Hers was found about in the middle, and that WAS as a result of malpractice, a bad doctor moment – a missed reporting of test results and subsequent selling of a practice without follow up. By the time the error was discovered, pre-cancerous cells had become frank carcinoma. But it probably still wouldn’t have been too late at for treatment at that point has she made that decision.
But my sister had a belief system that included some alternate therapies practiced the world over but which have not (yet) been shown to be efficacious in the practice of medicine. She also had some very powerful spiritual beliefs that made her believe in the possibility of miracles and divine intervention. This combination of beliefs dovetailed into her decision to initially refuse conventional western medical care – radiation and chemotherapy in her case.
As you can imagine, this was a very hard decision for us all to support, and in fact, none more so than her doctor, an extremely competent and compassionate Mac-trained doctor who, beyond all frustration and reason, had what he needed to help her and could not. But she was an adult of sound mind and his patient and when she made her decision, he was able to set aside his own need to save her and be fully present for her and to take care of his patient as she was. He showed her respect and kindness until the end.
After she died, I thanked him for the very difficult task he had undertaken and especially for the ability to treat her with respect and dignity even while disagreeing deeply as a physician with the choices she made. “Well, thank you” he said “That was a very hard time back then when she decided not to have treatment. There was a window of opportunity and it was only open a short time. I lost a lot of sleep over that. But ultimately I had to accept it.” That he could do that and still continue to treat her in ways that she found healing and helpful was amazing.
When there was nothing else he could do, there was something he still could do. It took incredible spiritual strength on both their parts to walk through that time as people, although one lost their life and the other lost a patient. This is caring for the whole of a person, heart, mind, body and spirit. This is the story of a great doctor, even though he didn’t save my sister’s life.
His colleague in palliative care was also a great doctor, as they so often are. He walked my sister through the stages of understanding what was happening in her body to acceptance of a path that would ultimately free her from much of her discomfort and pain. This took a long time and there were good and bad days until of course the bad outnumbered the good. He was able to give her the peaceful death she finally accepted was inevitable.
After she died, he came to her room and I believe he thought he was alone with her. He knelt at her bedside for a few moments and closed his eyes. I do not know whether he was paying his last respects or praying and it doesn’t really matter. He certainly did it for no-one else’s benefit and it was only chance that I saw him; my other sister and I had been staying overnight in the adjoining room and the door was barely ajar. I believe I witnessed his last act of caring for his patient, caring for her even after her life was over.
What part of her then was he physician to? He could have “pronounced” her but he gave that job to another, unrelated doctor and stayed true to his role as protector and guardian of her dignity, her humanity, her body and soul. Now that’s a good doctor moment, in fact a great doctor moment and a great doctor. He also gave me the gift of the beginning of my healing from a most horrendous loss of a very beloved sister.
OK, enough of the good doctor stories; I’m sure it’s too intimidating for you at this stage. It must be time for a bad doctor story. Here’s one I can tell on my own. At the age of 41, after three years of marriage spent hoping I would get pregnant followed by a series of miscarriages, I found myself in a fertility doctor’s office, grieving and mystified by my body’s seeming inability to do the one thing that my mother had been warning me for 25 years would happen to me if I even looked sideways at a boy! All our tests looked great and I had gotten pregnant on my own twice in the past 6 months and I didn’t really understand what was happening. I knew that fertility declined with age but I didn’t really know why, so I asked the question and this is what my doctor said “God doesn’t want people your age to have children.”
Wow, or as Jon Stewart used to say “What? WHAT???” 15 years later (I have 2 beautiful daughters adopted from China – just so you know there’s a happy ending – I guess the Chinese government wanted me to be a mother, even if God didn’t – at least according to the doctor!) I can still feel the sting of those words. “God doesn’t want people your age to have children.”
I know what he was trying to do – explain biological egg age and probability and perhaps give me reasonable expectations – but the words he chose, out of his own religious paradigm, cut me to the quick. I left his office in tears, surely not a healing encounter in anyone`s definition of the word.
Even as an Ordained Minister, my belief in God is not the belief of a being who is in charge of every daily occurrence, who thinks cancer in children is an opportunity for their parents’ spiritual growth, that God`s purpose can be discerned in the Holocaust or Rwanda, Syria or Darfur, or that every person on the plane that disappeared into the ocean or the mountainside must have had their “number come up” at the same time – the babies, the grandmas, the teenager, the good and the bad.
I don’t believe, for example, even though she was younger than I, that God wanted Hitler’s mother to be a mum but not me. I don’t really think that just because they’re the optimal age according to caveman life expectancy that the teen moms on TV are more favoured by God than I to become mothers. While I was going through years of infertility and baby loss, I remember hearing Rebecca Eckler, author of the book “Knocked Up” interviewed on the radio and when asked what inspired her to become a mother, she said “Open Bar.” That was a little hard to take.
So I know, I think we all know, that babies are born for all sorts of good and not so good reasons and certainly not always to the best parents. I didn’t, I don’t actually believe that what he said was in any way true. My rational brain rejects that notion, but yet it still hit me in a very vulnerable place spiritually and emotionally; in the existential angst `Why?’ place – the shaking-your-fist-at-the-sky kind of place many of your patients will visit when confronted with an accident, an awful diagnosis, an inexplicable death.
It upset me enough that I mentioned it when I went back in for my next appointment a week later. He was contrite and tried to explain and when our visit was over, asked if he could pray with me. Being a minister, I guess he thought that was a good bet. What could I say? I said “Yes.” And he closed his eyes, put his hands on mine and prayed this prayer “Dear God, please if it be your will, give this woman a child. And if it not be your will, help her come to peace with your decision.”
Again, it was “God’s will” whether or not I had a child, His decision whether or not the fertility treatment worked? The doctor didn’t seem to understand that his prayer had just done the same thing as his comment the week before! His belief in an all-powerful deity in control of every sparrow that falls, while perhaps comforting to him, had become an instrument of deep wounding to me. Needless to say, I left his office and never went back. I never tried any further to make him see how his religion, his spiritual world view, even with this minister, had interfered very deeply with his compassionate practice of medicine.
I saw a funny bumper sticker once that said “Your karma ran over my dogma” and I wanted to tell him that in this case, it was the reverse; his “dogma” ran over my “karma!” His religious beliefs came between him and being a good doctor to me. He may be a good doctor; in fact, he is a good doctor and I believe a good person, but that was a bad doctor moment for him and for me. My goal in this talk is to help, in even the smallest way, you avoid those Bad Doctor Moments or BDMs.
The first thing you need to know is you can NEVER assume that you know what a person’s beliefs are, even if you think you know what religion they are! And whatever your own belief system, use it to make sense of your life and to inspire others by your example; use it for comfort when you fail, or faith when you are uncertain, but under no circumstances should you use it to explain away other people’s lives or illnesses or misfortunes or choices to them!
I have asked myself many times how it could have been different, how even a religious person who believed as he did could have answered. Perhaps he could have said this: “There are possibly lots of causes, but no good reason. You will be a wonderful mother. What we can do is try to eliminate some of the most common causes and improve your chances in the others. If you want to become a mother, I believe that one day you will.” (whether by adoption, fostering or giving birth was not for him to say.)
Then he could have gone on to explain about all the potential causes and their treatment, leaving my hope and my dreams for the future intact and my sense of the relative balance of blessing and curse in my own life at least where it was before, no better, no worse.
Then he could have prayed all he wanted to the God “in charge” of whether or not I had a baby. But if he wanted to pray that kind of prayer for me, he could have prayed it on his own. It was the nature of the way his faith impacted his practice of medicine that turned him into a “wounding healer.”
It may seem like semantics, but words are often all we have. “Cause” is a word from a scientific paradigm – cause and effect – and “reason” comes from a spiritual one; it implies intent or justification. It helps to know the difference when patients ask you “Why?”
Are they asking what happened here or what does it mean? Your training as a doctor should inform your answer to the first question, but if we are honest, we must admit that our spiritual world view impacts how we answer the second one.
My hope is to help you become aware that what you believe about the “Why?” questions influences your practice of medicine whether you realize it or not. So it behooves you to think about it ahead of time and to be aware of your own beliefs and feelings. That way you are less likely to give your patients an unpleasant surprise like the one I received in that fertility clinic.
Just to be balanced, I’ll tell you a bad minister moment, although in fairness it was preceded by a bad doctor moment; an inexperienced doctor had given the family very bad news and then in a hurry, probably dealing with his own feelings of helplessness and horror, excused himself to get to a meeting. I call that the “Triple D – Diagnose, Dump and Disappear.” We know it’s our own discomfort we are running away from, yet we do it just the same.
So as Chaplain, I was summoned to be with the family who had just received this awful diagnosis for their beloved teenaged daughter. In our hospital chaplaincy unit we had been talking a lot about the techniques of “reflecting people’s feelings” and “mirroring” – in essence, showing that you understand by repeating people’s words back to them in a sympathetic way.
The mother was understandably devastated, crying and saying things like “It’s so awful, it’s not fair, I don’t understand, it makes no sense!” and in my inexperience, could only think of repeating her words back to her. “You’re so right, it IS awful, it makes no sense, it’s terrible” and suddenly the Mother sat up, wiped her tears from her eyes and said “NO, it makes sense to God, God knows what He is doing, there IS a reason, DON’T tell me there’s no reason, Don’t tell me God doesn’t know what he is doing; you are a minister!”
In that case, my efforts to NOT attach religious meaning to her daughter’s illness were just the wrong thing entirely. This is a person who would have totally benefitted from me saying – not “God is the cause of this” but perhaps “I believe you will get through this with God’s help.” Even the doctor could have said “This is hard news to hear. I’m here to answer as many questions as I can, but would you like to talk to a Chaplain or anyone else further about it? You don’t have to face it alone.”
Of course, the trick is knowing which patient needs which approach; when to refer out and when to try to use your own spiritual beliefs to help but not to harm. I believe above all you accomplish this by listening – listening, as I used to say to pastoral counseling students – with your “other ears” for what the patient is really saying and the question they are really asking. It can take a lifetime to get good at that.
You will be asked to play God, but Hippocrates tells you that is never the job. Even though life and death will pass through your hands, you must retain that inner humility that understands the limits of your power.
I remember only too well the first time I was confronted with the same conundrum – the minister’s version, while the doctor was faced with the classic medical moral dilemma.
A woman who was the matriarch of her family was dying of advanced gangrene. Her family was large and seemed to all be gathered together in the hospital. She was on life support and the family had been told that her prognosis was not good.
I should add that the family were not really in agreement about what should happen, either and they were (understandably) emotionally all over the map. Some wanted amputation to “save her life at all costs” and others “heroic measures” and others to “let her go.” Many were grieving, some angry, some silent.
Finally her eldest daughter spoke and she asked the doctor simply: “If we say ‘Yes’ are we killing her?” Then they turned to me and said “And is it a sin?” (ministers also are asked to play God or at least to speak for Him or Her from time to time!)
This is another one of those moments where it pays to have done your homework ahead of time because it’s not a question by which you want to be surprised or to answer without thinking. In truth the young resident and the young chaplaincy student both were surprised and probably both answered without thinking. Thankfully we both said “No” at exactly the same time!
I think we together probably did no harm. But I have asked myself “What would the best physician’s response to such a question have been?” How might a great doctor handle that conversation in a way that both releases the patient unto death and begins the process of healing for the family left behind?
And of course, I have thought a lot about what the right minister’s response should have been. I am not sure I have the answers in either case, but here’s a try:
The doctor can tell them what they are doing is not prolonging her life but her death; you can tell them that they are not killing her, her illness is killing her and what they are doing is giving her a peaceful passage.
The minister can say “You love her and letting her go so that God can take her by her other hand is not a sin, it’s an act of love” and only hope that her parish priest backs you up.
You will be asked these kinds of questions; physicians are asked minister questions and sometimes ministers or chaplains are asked medical questions. The lines can be very blurry at times. It makes sense to think through what you want to say ahead of time, even knowing that you cannot imagine every scenario.
There is also nothing wrong with admitting (as Hippocrates says) ”I do not know” – not only the answer to a factual question, but what answer to give when you really don’t know what to say. Perhaps the doctor’s answer in that case is “I know where to find out” and the minister’s answer is “I will be with you in the questions.”
And of course, in perhaps one of the greatest conundrums of all for those in the business of healing – after the Supreme Court’s decision to strike down the law governing doctor-assisted suicide, you will be among the first physicians in Canada who will graduate with the possibility that you will be legally able to help a patient end his or her own life.
Whatever your own thoughts, feelings and beliefs about this, you will be the doctors who may be asked to perform this act. The time to reflect deeply on it is not when you are asked but long before, so that whatever path you decide to take, you may bring your best self to whatever conversation you end up having with your patient.
These are incredibly complex times to be a physician. It is said that the only constant in life is change and this is true in medicine and in medical education as well. Much of what was held fast as truth in the medical classes that recited our first Hippocratic Oath will have been rejected or disproved by the time you recite the second – and that process will only accelerate exponentially over time. I believe that deep knowledge of self is a compass that will steer you on that journey.
Who you are as a doctor matters deeply – for not only your skills and experience come into play, but your wounds and limitations, your history and culture, your beliefs and your values, too will impact your patients in a profound way as you walk with them through their lives and deaths. Your story – the story you are still writing – will intersect with their story in a way that at its worst is wounding and at its best, healing and life-changing.
Finally, I want to tell you a story of a doctor who didn’t even examine the patient and yet, I believe was as responsible for her care as those who were her doctors for years. Some time ago, my mother who lives in Ottawa, was diagnosed with Chronic Lymphocytic Leukemia. She was told in one of those “Triple D – Diagnose, Dump and Disappear” moments that she probably had 3 – 5, at most 7 years to live and that she should “get her affairs in order.”
Now those of you who know anything about CLL will know that it can have a very optimistic prognosis; in fact, new information has shown that certain strains of the disease seem to progress so slowly that the person can virtually live out a normal life. But we knew nothing of that when my mother was diagnosed and as year 5 came and went, then year 6 and year 7 approached, she because increasingly anxious.
Don’t ask me how, but somehow, I managed to weasel my way into a 15 minute appointment for her to see the head of leukemia research at Mount Sinai – a doctor whose leukemia research was on aggressive childhood leukemias and not the Chronic Lymphocytic kind my mother contracted. He was not referred by my mother’s doctor and was, I can assure you, an extremely busy man. But he listened to our story and said three things to my mother, three things that helped allay her fears and face the future with some hope and possibility in her heart.
He said “Well, if you have to get cancer, this is the one to get!” and proceeded to explain why all cancers are not created equal and how out of the unlucky pool of people who get cancer, she was actually at the top of the lucky list! It kind of took the wind out of her leukemia’s sails and made it sound like a kind of second rate “wannabe” cancer, not a real contender in the ferocious cancer category. He simply used his knowledge to inform.
He said “You may not die from this disease.” “Really?“ said my mother; “I thought it was terminal.” “Well,” he said “actually all of our lives are terminal and you do have a cancer that could take your life. But you’ve gotten it in your 50s and it’s such a slow-growing disease that you could die of a heart attack first!”
I remember my mother laughing out loud. “Well, that would be great” she said “I’m up for that! You’ve gotta die of something!” “Exactly” he said “but you may not have to die soon of this!” They laughed together and in that one kind of funny way of putting it, he gave her back the optimism and hope that the fear of her disease had stolen.
He used humour and wisdom to grant perspective – a long view of her prospects, her life and her chances. He may not have identified it this way, but he took a profoundly spiritual approach to answering her questions and fears. He put them against the backdrop of the larger knowledge of our own mortality and said “It has this much power, but maybe not as much as you think.” It made a huge difference in her attitude toward everything from that moment on.
Finally, he said “Would you like to talk to one of my patients who has lived with it for a while?” He connected her to a lovely man who had been living with CLL for several years. She had coffee with him and he told her all about his symptoms and his treatments, how he felt after chemo and that his hair hadn’t fallen out, how much energy he had, that he bruised easily and had night sweats and so much more.
At the end of it, she felt prepared to face whatever might come and she had the name and contact information of someone who was ahead of her on the journey. The doctor had recognized the value of connection and community, of knowing you are not alone in facing something daunting – again, a profoundly spiritual attribute he demonstrated in his brief interaction with my mother.
Fifteen minutes, no examination, no blood work, amazing medicine. He used his knowledge, yes – to give her the facts, but more importantly, he used his wisdom to give her the spiritual gifts of perspective, connection, and ultimately hope.
My Mum was diagnosed in 1978 by the way. I know med students are good at math, but I’ll save you the trouble; that’s 37 years ago. She actually DID have a heart attack when she was about 75, and a bout with colon cancer, but they didn’t slow her down much either. She is a devoted and wonderful Nana to my girls and this summer we will celebrate her 90th birthday.
So there are a few stories to start you off on your journey into the world of medicine and the spirit. The doctor who was steadfast in the face of the spiritual choices his patient made – choices that may have caused or hastened her own death. The doctor who paid his respects or said his prayers in the presence of the lifeless body but still present soul of his patient, bringing comfort to her family of which he wasn’t even aware.
The time, ironically, when the doctor overstepped his role and let his religious belief get in the way of good medicine; and the time when the minister underplayed her part and let her fear of imposing religion onto a patient get in the way of good pastoral care. The times when all of us in the helping professions are invited to audition for God. And the story of 15 minutes with a doctor who didn’t even treat the patient but was her healer nevertheless.
“Stories” says James Orbinski, “we all have stories. Nature does not tell stories, we do. We find ourselves in them, make ourselves in them, choose ourselves in them. If we are the stories we tell ourselves, we had better choose them well.”
What stories will you tell, will your practice of medicine tell? How many good doctor, bad doctor or great doctor moments will you have? You are still writing that story.
I don’t know what to use for a model of a great physician, what Orbinski refers to as “The good we can be if we so choose;” somehow it seems to me it ought to be 4 or 5 dimensional, but I believe that humility must be at the core of all you do – because by its very nature, caring for fragile, mortal creatures is doomed to failure or at least only partial success, some of the time.
Around that core of humility wrap a firm layer of respect, for yourself as well as for those you treat.
Nurture your own faith but keep it in your inside pocket, next to your skin where you can feel its presence. Let it be evident to your patients by your works and not your words.
Hold a broader definition of what healing means and draw a wider circle to include not only the whole person but their relationships and connections.
Finally take a longer view of what you are there to do and the generally daunting nature of the task. Understand that it is a calling to the world.
Ask yourself “Is there something more you can do – even when there is nothing more you can do?”
The title of Orbanski’s book comes from a Leonard Cohen song called “Anthem” which goes like this:
“Ring the bells that still can ring.
Forget your perfect offering.
There is a crack in everything.
That’s how the light gets in.”
The Yeats poem “He wishes for the Cloths of Heaven” comes to mind…
“Had I the heavens’ embroidered cloths,
Enwrought with golden and silver light,
The blue and the dim and the dark cloths
Of night and light and the half-light,
I would spread the cloths under your feet:
But I, being poor, have only my dreams;
I have spread my dreams under your feet;
Tread softly because you tread on my dreams.”
In the world of medicine and faith, indeed in any human endeavor, we tread on their dreams, so tread softly. People put their hopes, their dreams, their fears and wounds, indeed their very lives into our hands. We owe it to them and to the best in ourselves to be careful and to tread very, very softly.
That place where hope and reality, where belief and truth intersect is the softest spot in the human psyche. It’s where the light gets in. Inside your doctor’s bag, keep an empty bowl and let the patient fill it with what they need. You may find it filled with spirit, grace and healing.
Thank you!