Budo 101: Conclusion.

*Warning: This story describes an offensive event, and so language and situations may be offensive to some and are not intended for young children.

Part I is here. Part II is here.

Budo 101, Continued:

Jack was left sitting in his chair, staring at the principle’s desk, trying not to make eye contact. So that was her dad? No wonder she went berserk. Shit! That’s a dude who means business!
Mr. Merckle, sat in silence for about thirty seconds. Then he looked up at Jack. “Go back out in the office and wait for your parent to get here. Ms. Hagg has your suspension letter.”
Ashley and her dad were still out there. Dan was talking with Ms. Hagg, who was smiling at him like a middle-aged fan girl. “Yeah, I think I probably did enjoy that a little too much, but you know, it’s just wrong, and something needs to be done. I’m not sure what, but Sharon and I are going to think about it.”
Ashley noticed Jack and looked away from him. Whatever, bitch. It was just a joke. Just wait until I see Deek again, Jack thought. I’m going to... But he knew he was going to do nothing. He was going to play it off as no big deal and go right back to being Deek’s minion just like he always did.
Dan turned and saw him. Oh shit! Jack slouched into his chair and whipped out his phone.
“Ashley, here are the keys, I’m parked out by Evergreen Street. I’ll be along in a minute.”
“Okay, dad. I’ve got to grab my stuff from my locker.”
“Okay, baby.”
Dan walked over and sat down in a chair one seat over from Jack.
When he didn’t say anything, Jack glanced up at him. He was just sitting there, scratching his five-o-clock shadow, staring at him with a musing expression.
“Look,” Jack said, “If you’re going to give me the speech about ‘stay away from my daughter or else,’ save it. I swear I’m not interested in her at all. It was just a stupid joke.”
“Oh I know,” Dan said. “I know it was a joke, and I believe that it wasn’t your idea.”
“My buddy dared me. He wouldn’t let up until I did it.”
“Sounds like a great friend,” Dan said with unconcealed irony.
Screw you, man, Jack thought. What do you know about high school? Back when you went it was a one-roomed schoolhouse probably.
“So are you tired of it?” Dan asked.
“Tired of what?”
“Being a punk.”
Jack stuffed his hands into his jacket pockets. “I’m not a punk.” Why was this guy even talking to him?
“Well, I don’t know what else to call you. I don’t think you’re a bad kid, and I sure as hell know you’re not a good man, because a good man knows when to tell his ‘friend’ to go to hell. A good man doesn’t grope teenage girls. You’re not bad, you’re just a punk. I know. I was a punk when I was your age.”
“Gah!” Jack rolled his eyes. “What do you want from me? I’m just a kid! I won’t do it again, okay, can you just leave me alone?”
“Oh believe me, I know you won’t do it again. Everyone in this school knows that you have wandering hands, and you got beat by a girl.”
“She didn’t beat me,” Jack yelled. He stood up and punched the wall. Dan’s expression did not even flicker. “She got lucky, she surprised me, and I don’t hit girls.”
“I know that. Dude, I know she wouldn’t beat you in a fair fight, and she knows it too. She fought like I taught her to, just hard enough and long enough to get away without getting decisively engaged. She did the right thing. You could too, you know.”
Dan stood up. Up close and personal Jack saw that he was not quite as tall as he looked from a distance, he just stood like he towered over everyone, so people thought he did.
“I want to give you this,” Dan handed him a business card. On one side was the name, “Five Senseis’ Shotokan Karate” and an address. On the other side was a picture of a fist covered by an open hand and the words, “Admit one for Budo 101.”
“What is it?”
“It’s an invitation.”
“To your karate school?”
“Well it technically isn’t my dojo. My friend Tanner Sensei owns it, I just help teach some evenings and weekends.”
“So you want me to learn karate?”
“No, this is a special class. Budo 101 is a special six-month program that I developed with Tanner Sensei, for teenage guys such as yourself. It is invitation only, or judge’s order.”
“Judge’s order?”
“We have an arrangement with the county courthouse. It is an option for first time juvenile offenders who are given probation.”
“Do I look like a fucking juvie?” he threw the card on the ground.
Dan very mildly crouched down, without taking his eyes off of Jack, and picked it up. “No, you’re not a juvie. And I want to keep it that way. Only about half of our students are juvies, the rest are referred by school counselors, parents, pastors, that sort of thing. I think you would benefit by it, so I am inviting you, but you don’t have to if you don’t want to.” He handed the card back.
Jack thought about not taking it, but something about the older man’s straightforward demeanor made him stretch out his hand. Dan was not yelling at him or cussing him out. He didn’t even seem mad anymore. Jack looked the card over again. “How much does it cost?”
“It’s free.”
“Yeah right.”
“No, seriously. I am a dentist and my wife is a child psychologist. We don’t need the money. But free does not mean that it is cheap. It is invitation only, but it takes a serious commitment. You show up six nights a week for six months. If you miss a night you apologize to the entire class and make it up on Saturday. If you miss two, you are done.”
Jack scoffed. “And if I come? You’ll teach me, what? How to fight?”
“Among other things, yes. You will learn how to treat people with respect, for starters, how to be somewhere on time, and in the right uniform. How to let a boss know if something comes up and you can’t make it. You will push yourself mentally and physically. If you make it to the end you will learn how to relate to women in a way that is based on real life and not on porn videos. You’ll learn how to pick friends, how to stand up to your friends, and yes, a basic level of how to defend yourself or others against physical attack.”
“Basic level?”
Dan smiled and shook his head. “If you make it all the way through, you get a green belt in Shotokan karate and are eligible to join the intermediate class if you want, but there is no obligation. Some stay, and some kids who get through Budo 101 are glad to be done with us.”
“So green belt is...”
“It usually takes students a year and a half to two years as a white belt to earn their green belt, but that’s because most only come once or twice a week.”
Jack was silent. This was crazy. This guy had just called him a sexual predator and now he was offering to teach him freakin’ karate. “What’s in it for you.”
Dan shrugged. “Well, I’d tell you not a damn thing, but you wouldn’t believe me. Think it over. When you get tired of being pushed around by your ‘friends’ and taking it out on teenage girls who have been trained not to stand up for themselves, give us a call or drop by. The class is continuous, so you can start at any time.”
He offered his hand, slender but veined and muscular.
Jack didn’t take it.
“Well, you have a nice day, then,” Dan said. He walked out of the office.
Jack sat down and put the card in his pocket.
He looked at the clock, which barely read 3:30 P.M.
I hate my life, he thought.

Budo 101: Part II*

*Warning: This story describes an offensive event, and so language and situations may be offensive to some and are not intended for young children.

Part I is here.

Budo 101, Continued:

Mr. Merckle looked up from his computer with a ponderous sigh, his face red before he even said a word. His lower chin wobbled as he pushed himself back as far into his chair as he would go. “What is it now?”

“Fighting in the hall,” Mr. Sink, the English teacher, delivered up his captives.

Mr. Merckle sighed again and shook his head, causing fluid waves in the loose flesh under his jaw. Jack watched the ripples with amusement. How hard would he have to shake his head to get a ripple to go all the way around his neck and come back on the other side?

“Names?”

“John Snyder and Ashley Tildford.”

Mr. Merckle made a note. “You both understand that we don’t tolerate fighting in this school?”

“I wasn’t fight...”

“He grabbed...”

“Quiet, both of you!” The principle had a way of booming his voice and leaning his head forward with little eyes glaring out over cherry red cheeks. It worked every time, and had been known to stop cafeteria food fights dead in their tracks.  The two teenagers in the tiny office were no match for it. Even Mr. Sink jumped.

Jack subsided into his resentful thoughts.

“I am too busy to deal with you two at the moment. Ms. Hagg will telephone your parents and we will discuss what is to be done with you later. In the meantime, both of you will sit out in the office and Ms. Hagg will keep an eye on you until your parents get her. You may work on homework if you like. Dave, let Ms. Hagg know on your way out, would you?”

He thrust himself forward to his computer again. Clearly they were dismissed.

Damn it, Jack thought. They’re calling dad.

He didn’t think his dad would care too much about him fighting at school, but he would never hear the end of getting beaten by a girl. Well shit, how was he supposed to know she was into freakin’ karate or kung fu or whatever? And she didn’t beat him, he just wasn’t expecting it. She just surprised him that’s all.

And anyway, what was her problem? It was just a joke. It was just a little boob grab. He knew guys like Deek who did that all the time. Walk down the halls, grab an ass, feel a girl up. Those chicks always giggled and maybe shoved back a little, in a playful way. They didn’t go berserk and turn into vengeful teenage warrior goddesses.

Ashley, that was what Mr. Sink had called her. She was curled up in a chair on the far side of the office, as far away from him as she could get, almost with her back to him. A cell phone chimed some synthesized classical music, and she fished a flip phone out of her butt pocket.

She did have a nice ass, Jack thought.

A fast, shrill buzz sounded on the other end of the line.

“Hey Mom.”

Buzz buzz buzz.

“No, I’m okay. I know. No. I’ll see you tonight. No, Mom, I’m okay.” She gave a short, nervous laugh. “I beat the snot out of him.”

“Bitch!” Jack muttered, “You just got lucky. I wasn’t trying to fight cause I don’t hit girls.”

She ignored him.

“I know. I’m fine. Love you too. See you tonight. Bye.”

She snapped the phone shut and put it away, turning even further away from him. He pulled out his phone and started playing “Angry Birds.”

Five minutes later he heard a Bruce Lee kung-fu yell coming from her pocket. It was her cellphone again. She answered, “Hey Dad,” without checking the number.

This buzz was deeper and slower. The girl hugged herself and sank even more deeply into her chair. Jack, for his part, lounged even more emphatically, stretching himself further out into the office. Phone calls from two parents? What a momma’s girl!

“Yeah. I’m okay,” but she sniffed back a tear.

The phone buzzed a question.

“He...” she swallowed. “He grabbed me.”

Buzz.

“Around my chest.”

Silence.

“But it’s okay, Dad.”

Emphatic buzzing.

“No, I know, but I got him good. Then the jerk tried to come after me again. I hip tossed him really hard.”

Buzz Buzz.

“Me too.” Her voice got lower and quieter. “I wish you were here, Dad. I need a hug.”

The buzz was deep and soothing. Jack found himself wishing he could hear what it was saying, in spite of himself.

“Really?” Ashley said. He could hear the smile in her voice. “When? Okay. I will see you when you get here. Thanks, Dad. Love you too.” She closed the phone with a smile.

About an hour later a tall man in his mid-forties walked into the office. Jack didn’t like the look of him. He was wearing khakis, button up shirt and tie, but he didn’t look like someone you messed with. He looked like he was over six feet tall, with wide shoulders and long arms. His hands were slender, but looked strong. He carried himself like an athlete with upright head, alert eyes, moving from his hips like the guys on the wrestling team. Not the kind of guy Jack really wanted to have pissed off at him.

But Mr. Tildford did not even look at him or at Ms. Hagg. He walked straight towards Ashley’s chair like a man on a mission. She didn’t hear him coming until he was almost there, but when she turned and saw him she leapt up and jumped into his arms in a flying hug. He caught her and hugged her back, holding her face against his chest and smoothing her hair. “Hey Ash,” he said. “It’s okay. I’m here.”

How long were they going to hug, Jack thought. Was she crying? What a baby! He rolled his eyes and looked away with burning cheeks.

“You okay?” Mr. Tildford said.

“Yeah, I’m fine.” She nodded and brushed her hair back behind her ear.

“What are we waiting for?”

“Mr. Merckle said we had to sit here until he was ready to deal with us.”

“Oh, really? The message I got was you were suspended.”

“What!?!?” Her jaw dropped and she clasped her hands to her cheeks. “Suspended? I didn’t do anything. He didn’t even give me a chance to explain.”

Jack sighed and dropped his head in his hands. Suspended. Now his dad was really going to blow a gasket.

“Right. Well, I think we should have a talk with him, shall we.” Mr. Tildford stepped over to Ms. Hagg’s desk. “Could you let Mr. Merckle know that Dan Tildford is here to see him.”

“Certainly Mr. Tildford.” She relayed the message into her phone.

“Send him in,” boomed back, cracked and staticky but clearly audible.

“You may go in, right through that door, Sir,” Ms. Hagg pointed with her pen.

“Thank you. Come on Ashley.”

Jack watched them go in and lounged as far back as he could in his chair.  His butt was hanging off the seat and his legs were stretched out into the aisle. Back to the Angry Birds, then. He didn’t expect his dad to be around any time soon. He didn’t get off shift until 4:00.

About ten minutes later, Ms. Hagg got a call. She looked up and called Jack’s name. “Please go into Mr. Merckle’s office. He wants to talk to you.”

What did they want with him? Jack slouched to his feet.

“Mr. Snyder, come in, sit down.” Mr. Merckle pointed him to a chair. “Mr. Tildford thinks you should be here for this. Now, continue Mr. Tildford.”

“Call me Dan.”

“Dan.”

“All I’m saying is, I really think you should listen to what these two have to say before suspending them.”

The principle shook his head and smiled condescendingly. “Dan, do you know how many troubled students come through this office on a weekly basis? Do you know how much time it would take for me to listen to every single one? Our policies are very clear, fighting is not tolerated. The penalty is suspension. I really am not interested in what they have to say. They will be given a letter explaining the policy and terms of the penalty.”

“So you are not interested in, say, who started it?”

Mr. Merckle sat up stiffly and frowned. I guess he’s not used to being argued with, Jack thought. “Excuse me, but I don’t think it matters who started it.”

“Oh excuse me, but yes it absolutely does.” Dan scooted his chair forward a couple of inches closer to the desk. “If my daughter is attacking random people and abusing her karate skills then I need to know so I can ground her and remove her from karate class. If, on the other hand, she is defending herself or someone else from bullying or sexual harassment...”

“Really, Mr. Tildford...”

“As I said, if she is defending herself or someone else as I have taught her to do, then we are going on a father-daughter date this weekend, wherever she wants.”

Jack almost snorted but silenced it. It wasn’t that he was afraid of Dan, but he didn’t feel like drawing attention to himself.

“Mr. Tildford,” the principle shifted and glanced at the clock on the wall. “I understand that teenagers can sometimes be insecure about some peer interactions in school. We have school counselors who are trained to assess and intervene in situations like that. However, we do not believe in using violence to solve our problems.”

“Who is ‘We?’” Dan looked irritated. He was leaning back in his chair with his hands folded in front of him, tapping his index fingers together, and the muscle in his jaw was bulging.

Why the hell do I need to be here to listen to this, Jack thought.

“Pardon?”

“Who is ‘we?’” Dan repeated. “You said ‘we’ don’t believe in violence. Do you mean the people in this room? Or maybe us as a society? Or are you just using the royal we?”

“Mr. Tildford! If you are not going to discuss this in a reasonable fashion I will have to ask you to leave. My time is extremely valuable.” He was using his food-fight stopping voice.

“So is mine,” Dan shot back, not the least bit phased, “I had to reschedule two patients this afternoon to be here and you will damn sure do us the courtesy of listening to both sides of this story before you pass judgment on my daughter.”

Jack raised his eyebrows and allowed himself a little smirk of satisfaction. It was good to see someone put the principle in his place for once.

Mr. Merckle swallowed a shocked expression. “All right, fine. What do you two have to say for yourself?”

Dan looked at Jack. “Go ahead, son. What happened?”

I’m not your freakin’ son, Jack thought. “It was just a joke!”

“What did you do?”

“Nothing. I just, like, touched her a little.”

“How did you touch my daughter?”

Jack shut his mouth. Something in the tall man’s eyes made him extremely reluctant to answer that question.

“Ashley?”

“He grabbed my... breasts. From behind.” Her face was scarlet.

“Is that true?” Dan turned a clenched jaw towards Jack.

“It was just a joke. She didn’t have to freak out about it.”

“No? And why didn’t she have to freak out about it?”

“Shit, that stuff happens all the time. Everybody does it.”

“Who is everybody?” The questions came at him almost before he could finish his replies.

“All the guys. It’s just, like, I don’t know, flirting.”

“Hell no, it is not flirting! Do you know what that’s called in the workplace? Or anywhere else in the real world outside this school? That’s called sexual assault, and it’s a crime. It results in fines, jail time and potentially being labeled a sexual predator for the rest of your life.”

“Come on!” Jack’s voice cracked. He suddenly remembered horror stories he had heard about guys getting put on watch lists for silly things like peeping in windows and stuff. Sweat was breaking out all over his back. “Come on, I’m not a predator! It was a dare. I didn’t even want to. A friend made me do it.”

“Do you think that will hold up in court in the real world,” Dan’s voice wasn’t loud, but it was hard as ice, and his eyes were blazing.

The principle broke in. “Mr. Tildford, aren’t you being a little severe? You cannot threaten this boy with being labeled as a sexual predator, ruining his life forever, because of a harmless prank.”

“Mr. Merckle, I am not planning on ruining anything or labeling anyone. We have no intention of seeking legal action. I am doing this kid a favor by reminding him that outside the narrow walls of this school, actions like that have consequences.” Dan was leaning forward, stabbing his finger into the top of the principle’s desk to emphasize his point.  “He had better wise up before that real world catches up with him.” He sat back again and turned to Ashley. “What happened, Ash?”

“He grabbed my breasts from behind. I elbowed him and knocked him back with a mae giri. I yelled, ‘back off creep,’ like you taught us. He tried to grab me again so I knocked him back again. But then he tried to grab me again with both hands, so I took him down and dropped a knee on him. Then I got away. That’s what you taught, right?”

“Yep,” Dan’s face seemed to smile in spite of him. “You did good.”

“Mr. Tildford, I repeat that this school cannot condone fighting. There are other ways of settling our conflicts.”

“No offense, Mr. Merckle, but that is the dumbest thing I ever heard. You just heard this boy confess to sexually assaulting a girl half his size, and not only that, but he boasted that this is a normal occurrence in this school. It ‘happens all the time.’”

The principle’s face was glowing red and a vein was pulsing on his forehead. “Don’t you think ‘sexual assault’ is a harsh description for a teenage prank?”

“Not at all. I think that is the technical legal description. I am a fourth degree black belt in Shotokan Karate, and I teach a self-defense course for women and minors every week. Placing your hands upon another person against their will is technically considered assault and battery, under law. Doing so for the purpose of sexual gratification is sexual assault. That is what he would be charged with if he did that in a military unit, or an office, or on the street somewhere.”

“This is not a military unit, an office, or the street. This is highschool...”

“A highschool that is failing royally in not preparing this boy for the real world.” He turned to Jack. “How old are you, son?”

“Fifteen,” Jack muttered, “And I’m not your freakin’ son.”

“I am sorry. Fifteen? You look older. I would have guessed 16 or 17,” Dan turned back to the principle. “In three years, he is going to be a legal majority and something like this will get him put in prison for a long, long time.” He stabbed his finger into the desk with every word, and then paused to let that thought sink in. “Not to mention it will ruin his life afterwards, being put on a sexual predator watch list. ‘Harmless pranks’ like this have a way of sticking with you.”

“Your opinion is duly noted,” Mr. Merckle snapped. “Did he do wrong? Yes. That does not justify the use of violence.”

“There we will have to agree to disagree. What you are telling me is that sexual harassment and abuse is rampant in this school, that the young girls here are powerless to protect themselves, and that the school faculty does absolutely nothing to protect them or put a stop to it.”

Mr. Merckle was silent.

“Can you understand why this is frustrating to me? As a father of a teenage daughter?”

“I understand that this is emotionally disturbing for you...” the principle began.

“Don’t give me that. Emotionally disturbing? Hell yeah it is emotionally disturbing!” He sighed and rested his chin in his hand, propped up on the arm of his chair. “I am not going to change your mind, am I? I think we’re done here. I’ve made my case and you have confirmed my opinion of this school. What is your decision?”

Jack was watching the exchange, almost holding his breath. And this dude was a black belt in karate? Shit! I hope I never piss him off. Wait, I already have. Way to go, me!

Mr. Merckle shrugged and held out his palms, helplessly. “The policies of this school. We cannot tolerate violence.”

“So you are suspending these two?”

“I have no alternative. I cannot make exceptions for one student that I will not make for another.”

Dan sighed. “For how long.”

“Our policy for first time offenders is three days.”

“Well, Ash, looks like you’ll just have to go help Tanner Sensei at the dojo for the next three days, after your homework is done, of course.”

“Bummer,” Ashley said, trying not to smile.

“You have a nice day, Mr. Merckle,” Dan shot straight up to his feet and strode out the door, followed by his daughter. He stuck his head back in. “Oh, and one more thing. My brother in law is editor of the Summersville Dispatch. If I ever hear that my daughter was sexually harassed in this school again, you can bet he will be hearing about it. And that goes not just for my daughter but any other girl in this school. And you can also expect to hear about this at the next school board meeting. I suggest you come up with a plan to do something about it.” The office shook as he slammed the door.

Budo 101: Part I*

*Warning: This story describes an offensive event, and so language and situations may be offensive to some and are not intended for young children.

Budo 101

“What do you think of that one?”

Jack followed the upward lift of chin and eyebrows down the hall to an open locker on the other side. A group of girls was standing around it, chatting, while one of them seemed temporarily stalled in the act of putting something into the locker, or perhaps taking it out.

“Which one?”

Deek Davidson tossed his thick blond curls and gestured with his chin again. He was too important to be bothered to point. “The brunette in the red tank top.”

“Nice,” Jack agreed automatically. “I’d tap that.”

“You’d tap anything that spread its legs for you,” Deek bumped him off balance with a shoulder. “Don’t lie. You’d do any one of them if you got the chance. You’d do fat-ass Maria ‘Pig’linski if you could find the right fold.”

Jack tried hard not to turn red. He laughed derisively and retorted, “Oh if only you knew!” What else could he say? He couldn’t deny that he was still a virgin, or Deek would have demanded details, a name, place, date, time, etc. details that he would have been unable to supply.

“But seriously, what do you think about the brunette?”

“Meh, she’s cute enough,” he adopted a tolerant, superior attitude. Oh yeah, she was fine. She was okay, if that was the best you could do. If you weren’t a 15-year-old sex god like he was.

“Yeah? Which one would you do?”

Actually, he secretly knew the brunette in the red tank top was the cutest of the bunch, but he felt rebellious. Why should Deek be right all the time? Which one was the next cutest? Not the little blond who looked like she was barely out of a training bra, and not the Asian chick who looked like a dude. Black girls? Hell no.

“I’d go with blue t-shirt.”

“Bullshit!”

“I’d do her all night long.”

“She’s got no boobs!”

“She’s got great boobs. Nice little handfuls. And look at that ass!”

“She looks like a track chick, and those bitches be crazy.”

“She’s hot.” Okay, “hot” was stretching it. She was tall but petite, toned and athletic looking. He could see divisions in the muscles of her upper arms when she brushed a strand of hair away from her face. She wore jeans and a blue t-shirt, and her bra strap showed nicely through the back, but otherwise her outfit was not super revealing.

“Bullshit.” Deek snorted.

“Whatever, man.”

“Prove it.”

“What?”

“Prove it! Go up and talk to her. Better yet, go up and grab her ass.”

“That’s retarded.”

“Do it or you don’t have a hair on your balls. Pussy!”

“Come on, man. I gotta get to class.”

“Don’t try to chicken out! You said her boobs were nice little handfuls, right? Go right up behind her and grab them. Chicks like that. They pretend they don’t but they really do. Why else would they dress like that?”

“No, man, this is stupid. I’m not doing it.”

“Chicken! Buck-buck-ba-buck! Pussy!”

Each syllable hit him like a sledgehammer across the head, beating him into submission. As Deek continued, getting louder and louder, Jack could feel eyes around the crowded hall turning to look at him.

“Screw you, man,” he said. His body turned in a rush. Quickly now, he had to get it over with before he thought it through. Make it seem like an accident. Or a joke. Laugh and walk away....

He was right behind her. An agonizing pause. This was dumb, just forget the whole thing, but he heard a soft hiss behind him, “Pussy!”

He stepped forward, reached around her from both sides and grabbed.

A thrill of triumph shot through him. Nevermind that he had missed with his right hand, and had mostly a handful of ribs, he had done it. His heart was in his mouth, and he was seeing the world through a red haze of victory, while his pulse pounded in his temples like a marching band and a thousand cheerleaders.

“KIAI!!!!” The back of an elbow connected with his temple and he saw stars. Backing off with his head in his hands and a knot of deprecating excuses tangling his tongue, he saw the girl pivot to face him with her right knee raised to the level of her ear, it seemed. Then POW! Her sneaker shot straight out like a hydraulic piston, like King Leonidas’ sandal, and plowed into his sternum.

“Back off, creep!”  she yelled as he staggered back about six feet.

There she stood, eyes flashing, face burning with shame and anger, hands shaking and knotted in fists at her side. One leg was poised slightly behind the other, lightly on her toes, as if she was daring him to try again.

“What the hell is your problem?” she yelled.

“Hey, come on, chill bitch, it was just a joke,” he said reaching out to grab her. Why was he doing that?

He never got a hand on her. One hard little fist pummeled the inside of his forearm, batting it away, and she lunged forward with the other in a stiff arm to his chest, knocking him back again.

“I said, back off!” her voice was quieter now and she was unmistakably crouched in a martial arts stance.

“Come on, Jack, are you going to take that? Show that little bitch who’s boss,” Deek gave him a push from behind.

Jack reached out to grab her head with both hands but she was not there. She was behind him. A foot stomped on the back of his knee and it buckled. He threw his hands behind to catch himself, but she wrapped both of her arms around his head and twisted him around her hip. He spiraled face down on the ground and she dropped a hard, pointy knee into his back as he hit. He tried to roll over and grab her ankles but she bounced away.

“What the hell is your problem, dude?” The girl’s friends were surrounding her and a crowd had gathered, cellphones out like paparazzi cameras.

A pair of khakis pushed through the swarm of lenses. “What’s going on here?”

“Bitch went crazy!” The words tumbled out of Jack’s mouth.

“He grabbed me,” the girl retorted. He couldn’t tell if she was frightened or angry or both.

“That’s it! You, pick yourself up. Both of you follow me. Principle’s office, right now.”

Jack picked himself up and eyed the surrounding crowd. Cell-phones were still out snapping pictures right and left. He could practically hear the videos whirring. Perfect. This was probably going to be on youtube in five minutes. He didn’t know any of these kids.

Deek was nowhere to be seen.

End of Life Decisions in the Emergency Room

End of Life Decisions in the Emergency Room

In this case study, a 32 year-old lawyer named John had a history of chronic anxiety, heavy alcohol use and intermittent depression related to his worry about possibly developing Huntington Disease, the disease which killed his mother. Huntington Disease is an autosomal dominant neurological disorder, usually manifesting between 30-40 years of age. It results in chorea (abnormal, involuntary movement), depression and psychological disturbances, and inability to control skeletal and facial muscles. Neurological deterioration is progressive, and irreversible, leading to inability to walk or swallow. Quality of life is extremely low, and death results within approximately 13-15 years of diagnosis (Merck, 2013).

John had told many people that he would rather die than live with the deterioration of Huntington Disease. Worry about the disease caused him to seek psychiatric counseling. 3 months prior, John noticed some facial twitching and sought diagnosis separately from two different neurologists. Each confirmed a diagnosis of Huntington’s. When he told his psychiatrist about the situation he requested help killing himself, which his psychiatrist refused to do. John then reassured him that he had no plans to kill himself in the near future. However, upon returning home he pinned a note to his shirt explaining the situation and refusing any medical help that might be offered, and then ingested his entire supply of antidepressants.

When his wife returned home and found him, she was unaware of the situation and did not see the note. Instead she transported him directly to the Emergency Room and requested treatment. There the ER staff found the note pinned to his shirt. The question is, what action should the ER staff take? (UWSM, 2013).

The question of how much the ER staff knows is a bit of a distractor in this case. We may assume that they do not know any of his back story except the few lines he scribbled on his note in which he may or may not have described his Huntington diagnosis. However, for the purpose of the ethical conundrum of the ER staff, the Huntington diagnosis is a non-issue. Whether or not the patient has a terminal diagnosis is irrelevant to the treatment of the immediate life-threatening condition of anti-depressant overdose. All patients who come into the ER have a terminal diagnosis. Whether or not the ER is successful in saving their lives, they will all die in some unknown time frame in the future. In this case the outer limit of that time frame is known. However, this does not lessen the value of the patient’s life.

Instead, this ethical conundrum revolves around the patient’s right to refuse treatment (UWSM, 2013). The patient’s wife, either not reading the note or not caring, brought him to the ER to seek treatment. In the case of an obtunded patient, consent of a family member is usually considered sufficient. A close family member usually takes on the role of a competent, authorized decision maker known as a surrogate decision maker. Their role is to determine what the family member would have wanted if they had been able to make decisions (Andrews, 2011) (Purtilo & Doherty, 2011, Pg. 263).

However, in this case the wife’s choice of requesting treatment is known to be in contradiction to the patient’s last specified wishes. Based on the note, at a minimum the staff knows that he attempted to commit suicide, and at the time that he swallowed the pills he did not want to be resuscitated. Three specific issues present themselves:

1)    How legally binding is a post-it note pinned to a shirt?

2)    If the note is legally binding, can the decision to refuse care be waived in the case of suicide?

3)    How competent was the patient to make this decision?

In the case of a patient who is dying from unknown cause, the ER uses its full resources to save the patient’s life. They do this based on the assumption that the patient, if able to make the decision, would want to live. This may not, in fact be the case, but in the absence of indications to the contrary ER staff act upon that assumption.

However, in John’s case, the patient has made a statement of his wishes, albeit not a verbal one. Thus the ER, in attempting to save his life is acting in clear contradiction to the patient’s last stated wishes. There are arguments both for and against an evaluation of the note as legally binding. Some physicians say that the note should not be equated with the legal status of a Do Not Resuscitate (DNR) order (Cohen, 2013). The DNR is an advance directive written while the patient is competent. It is verified by a witness and/or legal counsel and in conjunction with a living will describes the patient’s wishes to be followed when they are incapacitated (Andrews, 2011) (Purtilo & Doherty, 2011, Pg. 263). Some professionals regard a suicide note as part of the suicide itself, that is, having been written under the same depression or other mental disorder that prompted the suicide in the first place (Cohen, 2013). Thus, under this view the note lacks the most critical feature of a DNR, i.e. that it was written during a period of known mental capacity to do so.

However, other ER physicians maintain that such a note does constitute a valid refusal of treatment. In fact, addressing exactly this type of scenario, some physicians consider attempts to resuscitate as presenting the risk of subsequent civil action for assault and battery (Cohen, 2013). If the note is regarded as a legally binding refusal of treatment, some ethicists would consider any resuscitation efforts as a breach of patient autonomy and a case of paternalism (Geppert, 2010). Others would argue that to the contrary, a note as a statement of intent is no different from the act itself as a statement of intent. As one internist stated, “There should not be much misinterpretation… of what it means for someone to put a gun to his or her head and pull the trigger” (Cohen, 2013). When the patient has attempted suicide and this is abundantly clear based on the mechanism of injury, witness statement or note, the intent to die can be assumed, and most ERs would continue to provide treatment.

Even allowing the legal validity of the note as a statement of the patient’s wishes, or assuming the patient had a valid DNR, some physicians would act to save the patient’s life, arguing that the DNR does not apply to self-inflicted injuries (Cohen, 2013). This argument has come under heavy criticism in recent years, due to its breach of patient autonomy. The provisions of case law clearly and unequivocally support the patient’s right to refuse treatment (Geppert, 2010).

The argument has been posed as a conflict between the ethical principle of beneficence and the principle of patient autonomy (Geppert, 2010). However, a critical component of informed consent or informed refusal of treatment is mental competence (Purtilo & Doherty, 2011, Pg. 254). Mental competence is often called into question in the case of suicides. In standard practice the ER acts to save the patient’s life based on the assumption that the patient is suffering from a mental illness and the suicide decision is the result of that mental illness, which, if treated, would lessen or remove the suicidal ideation (Geppert, 2010). In fact, this is often found to be the case. According to Guy and Stern, (2006) “Overall, there is strong evidence that psychological and social factors (e.g., comorbid depression, hopelessness, loss of dignity, and the impact of spiritual beliefs), rather than the physical ones (e.g., functional status and the level of pain control), are the chief determinants of the desire to hasten death.”

This is where the patient’s clinical history does have some bearing on the case. If the wife described to the ER staff the patient’s longstanding history of anxiety, depression and alcohol use, this might give them reason to suspect the existence of a treatable mental disorder. If the note described his recent diagnosis of Huntington disease, this would provide a history of a significant precipitating event (Bagge, Glenn, & Lee, 2013). Cumulatively the argument could be made that this supports a suspicion of the suicide as a result of clinical depression, further calling into question the patient’s mental competence to make a decision to refuse treatment.

My position on this case is that the ER staff should treat the patient for anti-depressant toxicity. The treatment is relatively straightforward, primarily cardiac monitoring, administration of sodium bicarbonate for symptomatic ventricular tachycardia with QRS widening, and supportive care for hypotension and seizures. Activated charcoal may also be used, but must be weighed against the risk of aspiration, and the patient’s airway should be protected (Jacob, 2014). These are not extraordinary measures by any means.

The patient’s wishes, as stated in the note pinned to his shirt, are in my view not binding. In fact, given his history of depression, even if the patient came awake during treatment sufficiently to murmur, “No, I want to die,” I would still consider him to be in no mental condition to be competent to make that decision.  I would continue treatment unless he became sufficiently alert and oriented to make his case, cogently and coherently and sign a legal Against Medical Authority (AMA) form. Short of such explicit refusal of treatment I would not feel any legal or ethical responsibility to cease care. I would resuscitate the patient, and then attempt to assess and address his underlying mental condition when he was sufficiently recovered.

Patient autonomy is an important principle of medicine, but is it an ironclad principle? Dr. Atul Gawande discusses medical paternalism and patient autonomy extensively in his book “Complications: A Surgeon’s Notes on an Imperfect Science.” He examines the now sacrosanct concept of complete patient autonomy and gently challenges it by questioning whether, when seeing patients making a terrible mistake, should doctors simply do whatever the patient wants? He proposes that sometimes true kindness consists in gently steering the patient in the right direction in accord with the patient’s best good (Gawande, 2003).

Is this paternalism? The question is a great deal too complex to answer definitively here, but it is nevertheless a question that each medical care provider must wrestle with and personally answer. However, I would propose that the issue is not one that can be settled either on legal or economic grounds, but is instead concerned with the very meaning of life and who we are as individuals and as a society. Our current cultural climate, which values convenience over greatness, and seeks to escape adversity rather than courageously to endure it (Brooks, 2014), finds a morbid and final expression in current debates underway on the value of life (Hensley & Hensley, 2004). These debates extend far beyond this case study, and include discussions of suicide in general, euthanasia, and physician assisted suicide. When the highest value of life is simply the avoidance of pain, then opting out of terminal illness and pain by killing the patient does indeed make sense, even if the patient is a minor, as is currently legal in Belgium (Crawford, 2014).

However, if there is more to life than simply avoiding pain, if, in fact, there is value to be found in suffering met with courage, then do we not do a disservice by denying patients that opportunity, rather than at least pointing out the possibility to them? As psychotherapist and Auschwitz survivor, Viktor Frankl said, “Those who have a 'why' to live, can bear with almost any 'how',” (Frankl, 1984).

What if there is an opportunity for psychological, emotional, and even spiritual growth precisely through and in suffering? What if there is a desperate need in society for the witness of suffering courageously endured and compassionately shared with others? (Brooks, 2014). What if the opportunity for the patient to grow in his relationships, in his understanding of what is truly valuable, and in his service to others is the best medicine for him? (Hensley & Hensley, 2004).

We who lived in concentration camps can remember the men who walked through the huts comforting others, giving away their last piece of bread. They may have been few in number, but they offer sufficient proof that everything can be taken from a man but one thing: the last of the human freedoms--to choose one's attitude in any given set of circumstances, to choose one's own way (Frankl, 1984).

This discussion admittedly goes far beyond the original question of what the ER staff should do in the case of John. However, I believe that it is not merely enough to decide on a legally justifiable course of action, but rather to search for the most moral course of action and to understand the reasons for it. Therefore, I would challenge those who ask and answer questions such as these to question whether pain and disability are the problem, or whether the real problem is not hopelessness and the feeling of not being valued. There is, of course, no way to force a patient to take the undeniably hard road of searching for meaning in suffering. Such a concept is a contradiction in terms. Nor is intimidation, shaming, belittlement or any other coercive psychological tactic rightly to be used in promoting such a view. This philosophy must be offered to patients with compassion or not at all. It must exist with compassion or not at all. Even with compassion, those who offer it may still find themselves accused of paternalism. However, if Dr. Gawande is right, and true kindness does sometimes require a physician to steer the patient gently in the right direction (Gawande, 2003) then perhaps we should at least hold out the option?

Reference:

Andrews, M (2011) Making End-of-Life Decisions is Hard on Family Members. Kaiser Health News. Retrieved April 9, 2014, from http://www.kaiserhealthnews.org/features/insuring-your-health/michelle-andrews-on-end-of-life-care.aspx

Bagge, C. L., Glenn, C. R., & Lee, H. (2013). Quantifying the impact of recent negative life events on suicide attempts. Journal Of Abnormal Psychology, 122(2), 359-368. doi:10.1037/a0030371

Brooks, D. (April 8, 2014) What Suffering Does. The New York Times. Retrieved April 10, 2014 from http://www.nytimes.com/2014/04/08/opinion/brooks-what-suffering-does.html?_r=0

Cohen, B. (2013) Should you Resuscitate a Suicide Patient? Medscape Article. Retrieved from http://www.medscape.com/viewarticle/812112

Crawford, D (February 13, 2014) Belgium's Parliament Votes Through Child Euthanasia. BBC.com. Retrieved April 9, 2014 from http://www.bbc.co.uk/news/world-europe-26181615

Frankl, V. E. (1984). Man's search for meaning: An introduction to logotherapy. New York: Simon & Schuster.

Gawande, A. (2003) Complications: A Surgeon’s Notes on an Imperfect Science. New York, New York: Metropolitan Books/Henry Holt. ISBN-10: 0312421702.

Geppert, C. M. A. (2010) Saving Life or Respecting Autonomy: The Ethical Dilemmas of DNR Orders in Patients who Attempted Suicide. Internet Journal of Law, Healthcare and Ethics, 7(1) Retrieved from http://ispub.com/IJLHE/7/1/11437

Guy, M. & Stern, T. A. (2006) The Desire for Death in the Setting of Terminal Illness: A Case Discussion. The Primary Care Companion to the Journal of Clinical Psychiatry. 2006; 8(5): 299–305. Retrieved from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1764532/

Hensley, E. & Hensley, S. D. (2004) Depression in the Elderly with Emphasis on Terminal Illness. The Center for Bioethics and Human Dignity. Retrieved from http://cbhd.org/content/depression-elderly-emphasis-terminal-illness

Jacob, J. (2014) Antidepressant Toxicity. Medscape Article. Retrieved from http://emedicine.medscape.com/article/812727-overview

Merck Manual Staff (2013) Huntington Disease. The Merck Manual for Health Care Professionals. Retrieved from http://www.merckmanuals.com/professional/neurologic_disorders/movement_and_cerebellar_disorders/huntington_disease.html

Purtilo, R. B. & Doherty, R. F. (2011) Ethical Dimensions in the Health Professions, 5^th Edition. St. Louis, Missouri. ISBN 978-1-4377-0896-7

University of Washington School of Medicine (UWSM) (2013) Sample Case Study. Ethics in Medicine. Retrieved from http://depts.washington.edu/bioethx/tools/cecase.html

Thanatophobia

Oh, you poor thing! You poor, poor hideous

Ancient crippled thing! Once you were the prettiest

Maid, the handsomest youth! The slow insidious

March of death has brought you here. How piteous!

My heart bleeds for you, after a fashion.

I hate death and sickness! With fierce passion

I denounce this slow wasting, this crashing

Crushing, cresting wave of disability,

And in my deepest, most heartfelt compassion

I offer you escape from your senility.

Go on, I say. It is quite all right. Utility

Outlived, it is quite right to embrace the finality

Of the morphine drip.

                                      (But do you know how much I

Hate you for the crime of being fat?

Of not being perfect? I hate the disgusting flab

That flips and flops and slides across your lap

When you try to sit up in bed. I hate the gasps

Of weakening breath, of death. I want to slap

Your wrinkled, flabby face for blocking my path

With your hobbling. I hate you at meal and bath

And checkout line. You stand condemned by the math

Of usefulness. Keep up or else incur the wrath

Of my generation.)

          You shall not waste in futility

But railing against it you shall dare to die

And cease to remind me of my own creeping mortality.

Thus shall I cure you of death. When once you lie

In convenient, forgotten darkness, on the slab

In the morgue, (or in the assisted living facility

Dying by slow degrees of useless drab

Aloneness,) then I will forget at last that I

Too must die. 

Rather a dark poem, so here is a little lightness to wash it away. Enjoy!

 

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