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

Original Sin: Well, Could be Worse

When talking about the idea of Original Sin, which is the idea that there is at the beginning of human history a sin which taints all subsequent generations, sometimes Christians are accused of an existential pessimism. This appears to be a doom-and-gloom outlook on life which is popularly supposed to rob us of all our joy. Far be it from me to deny that such may often be the case! However, in my opinion this is often merely a misunderstanding of an honest, but fundamentally cheerful outlook on life.

Christians, and indeed, all people who watch the news, are distinctly aware that the world is often an unpleasant place, rude, hateful, petty and sometimes just plain senseless. Where most people act shocked and ill-used, as if this were somehow a personal insult to them and often end up concluding that the whole thing was a bad business from the start, the Christian has the doctrine of Original Sin to fall back on. Something unexpected happened in an otherwise good and useful system, some person did something that made no sense, and it threw things out of whack. We feel the effects of it today, much the way a baby born to a crack addict will feel the effects of crack addiction. We even add to the effects. So much we admit. Life is often tragic, absurd and ugly, but surely the fact that we can recognize that argues a deeper awareness of joy, reasonableness, and beauty? And does not the awareness of that fundamental defect somewhat take the sting out of it?

Rather like two guests, both staying at the same out of the way, Mom & Pop Inn in Nepal may have totally different experiences because they have totally different outlooks. One is expecting a five star hotel, and is frustrated by rolling brownouts, unreliable internet, spiders in the bathroom, no menu to choose from, and 58 steps to climb just to get to breakfast. The other realizes that this is what it is, an out of the way, Mom & Pop Inn in Nepal. Given that realization it is not nearly so bad as it might be. We have power quite often, the internet sometimes works, the spiders don't bite (or at least haven't yet), the food is healthy, delicious and plentiful, and at least a little exercise is guaranteed every day, just getting to breakfast!

In the same way, when you finally accept the fact that the world has that existential flaw which we call "Original Sin," you are free to recognize that these flaws are evils in a good system. The world itself is not evil. Certainly as a paradise our world falls quite a bit short, but for most of us it certainly is not a hell either. As worlds go it might be much worse. All in all, I would say it is not that bad. Good still happens, surprising and yet refreshing when it does, indicating that redemption, though difficult and incomplete just yet, is perhaps possible. That, to me, sounds suspiciously like hope.

Threshhold Life

Do not call me a dead man;
Say, rather, unborn.
Call me not an evil man;
Say only, “Unformed.”
Unformed, embryonic, a teeming mass
Of cells, undifferentiated,
Potential unmapped
Unabated because untapped.
No not evil.
I have committed no crimes.
I am not a devil.
But I am a product of my times.
I have spent my score of years and seven
Waffling about between heaven
And the space inside a zero.
I have built a fortress out of sheer possibility
And I guard its ramparts like the true hero
Of false humility;
Firmly entrenched in the zero space
The liminal space
The nowhere space
Between a thousand “Yeses.”
Not lost;
I know precisely where I stand
Trammeled about by guesses
More educated than most.
 
An acorn is free to roll,
But not free to grow.
No.
For that there is a toll,
And the toll is rootedness
Fixedness
Differentiation in anticipation.
And before that there must be a split
A tearing
A rupture of the skin as from within
Tender green and white things like earthy wings
Must thrust through the crust into the dust
And dirt, in search of fertile ground. It hurts.
And before even that there must be the time
Of lying
And crying,
And dying silently on the forest floor
Half buried under dead leaves.
Pelted by rain and hearing
The snortings of pigs and scurryings of squirrels and fearing
And feeling lost and cold, as the frost takes hold.
All too often only thus is softened
An acorn’s shell.
And it cannot tell
That only thus is it free
To be
Rooted.

The Fate of Sin

And I ask, through angry tears, how can it be

That we who love still fall again and again?

In spite of prayers and acts and words of love, unfree

We daily fall to fear, and sin, and pain.

My Grandpa said, as his life began to wane,

“I sometimes ask, ‘Why did this happen to me?’

“But I know why, if I’m honest. The answer is plain

“I smoked for fifty years, and soaked up UV.”

Even at the end, in pain, eaten up by cancer,

He said “Without the pain I would never have come to know

How it is to float, embraced in a sea of love.”

Perhaps, under the Mercy, sin will have the same answer,

And that which beat and scarred us down below

Might yet, perhaps, be worship up above.

Ask Thugfang: Confession Part II

His Right Dishonourable Loathsomeness, Master Thugfang, is a demon of great infamy among academic circles. He is a frequent columnist for “Tempter’s Times”, an assistant editor for “Wickedness Weekly” and current chair of Tempter’s Training College’s Department of Defense Against the White Arts, after the sudden disappearance of the most recent head under mysterious circumstances. Now, His Right Dishonourable Loathsomeness takes your questions. Having problems with a particularly troublesome patient? Meddlesome enemy agents stymieing you at every turn? Don’t wait, write immediately to “Ask Thugfang” C/O “Underworld Magazine.”

 

Dear Master Thugfang, I am writing to you from a special assignment. My patient is a Catholic. His erstwhile handler was reassigned on short notice because of the patient’s troubling habit of weekly confession, and I have been placed in charge of the case since I have had some success with this in the past. I even wrote an article for Wickedness Weekly entitled, “How to Keep your Patient from Going to Confession.” Unfortunately, all the tricks and tactics I have used before seem to have no effect on this particular patient. It persists in its stubborn adherence to this habit, so I am writing to you to ask if there is any other technique you know of which I can use?

Sincerely, the Obfuscator

My Dear Demonic readers, in my last column which you may read here, I addressed the unfortunate Obfuscator’s question with advice on how to meddle with a patient’s confession before the patient enters that little white box. It appears, however, that he asked for my advice too late. Apparently someone must have hinted to the lowerarchy that the Obfuscator’s skills were not what he had led them to believe, and he has been sent for retraining to bring them up to an acceptable level. Very sad I am sure, but a salutary lesson for all of us on the dangers of pride.

So now I shall enlighten my general audience, and particularly our dear Obfuscator’s successor, on how to make best work of the patient’s post confessional period. Remember, the Enemy has just effected a reversal of your work in the first spiritual order. Your natural reaction is discouragement and despair, but you must fight through that. You must be waiting at the door, so to speak, so as soon as your patient walks out you are there, braving the toxic illumination of Grace to begin your work all over again.

Obviously, our first tactic is distraction. That should go without saying, but I am amazed at how many young demons try the most subtle and complex approaches on patients who clearly do not need it. Keep it simple for Hell’s sake! Once the patient comes out of confession, the less time he spends thinking about it the better. Distraction, distraction, distraction. The sooner you can get him to put the whole thing out of his mind and forget about the Enemy and what He has done for him, the sooner you will be able to get back to the business of stealing his soul.

Never forget, my dear Obfuscator, the patient is half animal. He can no more see his own soul than he can see the inside of his head by rolling his eyes back into his skull. He was never meant to spend his life staring at his own soul. He was meant to stare at the Enemy with his whole soul and everything attached to it, so naturally, it is impossible for a human really to see himself. The most advanced ones have long since ceased to try. They are too busy staring at the Enemy, blast them. But the patient’s inability to see his soul means that he cannot see what was done in his soul.

You see, confession, while it does admittedly destroy every vestige of our work at the very deepest level of the human, it does not (usually) destroy all our work at shallower levels. Think of your human as a series of concentric circles. The very center is the soul, the actual patient, what we want to feed upon. Then around that is the will, which is the gateway to the soul. Outside of that are your patient’s subconscious thoughts and feelings, his conscious thoughts and feelings, and all the ephemera of phenomena that he generally refers to when he says, “myself.” The center is what we want to control, but we have to go through all the other layers. Confession does whatever it does at the center, and the effects spread outwards from there. How far they spread is determined by how closely those outward areas are aligned with the soul. For most average humans, especially young ones, the alignment is not that close. As a result, while the soul is cleansed, and perhaps the will is slightly re-oriented, the imagination, emotions, thoughts, and especially the fears, remain largely untouched. We must keep it that way. That is our only foothold. Distracting the patient from thinking about the work of forgiveness prevents him from trying to bring his outer circles in line with the inner reality. It stops him from becoming an integrated whole, disrupts the flow of grace, and keeps our foothold secure.

You and I must face the unfortunate fact that the Enemy’s Son Himself is active in that little wooden box, in a mode of such presence and power that it scorches my mind even to think about it. Your patient is spared such awareness. Why? I don’t know. Probably some nonsense about “freedom” and such claptrap. Who cares why? That is our opening. The patient can be quite ignorant of the fact that He is present, actively doing something of cosmic spiritual magnitude. To the patient it is a vending machine, and eventually just a habit. Soon he won’t even think too closely about what precisely that machine is vending. Isolated from the majority of his life, the sacrament’s transforming power dwindles to nothing.

That foothold then becomes the starting point for our counter-attack. As long as the human is ignorant of how little of himself is truly surrendered to the enemy, we can use the un-surrendered bits to draw his will back to what his body, mind and emotions have been conditioned to desire. Retaking the same ground over and over and over again is tedious, I know, but that is simply another result of the Enemy’s obscene love for matter and insistence on creating temporal creatures with souls.

The battle changes slightly when the patient does start to think about forgiveness. Obviously we still want the patient to labor under as much delusion as possible, so keep him ignorant of the real nature of forgiveness. Encourage him to expect the sacrament to erase all the effects of sin on the surface level, which is all he can see. Let him expect that all his addictions, habits and sinful inclinations which he has so carefully conditioned into himself over the years are going to be wiped away by the sacrament. Odds are that it won’t happen (the Enemy rarely interferes on such a superficial level) and then he will fall into sin again, and be disappointed and discouraged. Keep this lie up as long as you can. If you can keep the patient expecting what was never promised for long enough, he will eventually give up trusting the Enemy’s promises, and therefore the Enemy, never realizing that it was never the promise that was untrustworthy, but only his private mental vision of it. No matter which, for us, as long as it drives the patient into apathy and despair.

An observant human, on the other hand, will not be fooled by that delusion forever. Eventually he will learn that, even though the sacrament forgives, it is up to him to live up to that forgiveness and overcome his remaining habits. This is a very dangerous level of awareness, for us, because it guards against false expectations, and is dangerously close to humility. There is, however, one last little trick that I have used successfully on a patient at this juncture. This patient was a very successful middle-aged businessman who was a weekly penitent. He was well aware that the sacrament forgave, but did not erase his compulsion, and that might have caused him to seek out the Enemy’s grace, both in prayer and in the form of professional counseling. He was very nearly lost to us (unbeknownst to him.) While he was seriously considering going into therapy his old caretaker was reassigned and I was brought onto the case, which I successfully turned around in short order. I was able to convince the patient that his continuing life of sin after every confession was simply his “old habits” and that he was “working on them.” There was no need to go to any extremes to root out this habit. All that was necessary was that he “try his best”. In reality he maintained a quite lovely double-life for years, without ever realizing it. He would confess every Saturday afternoon, go to Mass on Sunday and stay clean and sober for the week. Then on Friday evening he would quite matter-of-factly stop by the strip club and have a few drinks while ogling the female humans. This was to “get it out of his system.” Just in time for confession on Saturday. How convenient! “Trying his best!” Such an elegant euphemism. It really only meant that he would grit his teeth a few times before walking in the strip club door, when any half competent priest would have told him that it ought to mean taking measures to make himself unable to drive there in the first place. “Working on it,” consisted of a few manufactured tears in the confessional every now and then, some eloquent promises to his wife, and the occasional orgy of self-loathing, all the while casually feeding the habit which ultimately devoured him. Fool! Just sorry enough to be miserable, not sorry enough to make any real attempt to stop.

Oh the exhilaration of that battle! My career was at stake, a soul was on the line! Enemy agents waited at every juncture, ready to leap into action at the first sign of real intention to reform. I was positively surrounded by some pretty fearsome characters, let me tell you, and they meant business. All he had to do was open his mouth and talk to his brother, or get someone to give him a ride instead of driving. Anything, the slightest action, would have called forth a perfectly terrifying firestorm of grace and I would have been lost. But I kept my head, and whispered soft lies, and he slept through it all. First he robbed the sacrament of its transformative power, and then he closed himself off to its forgiveness as well. He is now safely residing in one of our more bland and uninteresting summer residences. Presumption is another of my favorites, and a very secure sin, because generally the patient has no idea he is committing it.

In summary, my Dear Demons, confession is a most terrible weapon of the enemy, and one that we must never underestimate. The habit of going to confession is almost the worst habit a human can have. You may look at my medals and awards and think that you too can snatch a patient’s soul from the very jaws of the confessional, but I warn you, do not risk it. For every daringly successful attack like mine, there are a thousand failures. We here in the lower circles of Hell are not the least bit interested in vainglory. All we want are souls, as many as possible, by the surest and safest routes possible, as fast as possible. If you lose us a soul by your idiotic presumption, be warned!

We grow hungry!

Cheers!

Thugfang

 

 

Ask Thugfang: Confession Part I

His Right Dishonourable Loathsomeness, Master Thugfang, is a demon of great infamy among academic circles. He is a frequent columnist for “Tempter’s Times”, an assistant editor for “Wickedness Weekly” and current chair of Tempter’s Training College’s Department of Defense Against the White Arts, after the sudden disappearance of the most recent head under mysterious circumstances. Now, His Right Dishonourable Loathsomeness takes your questions. Having problems with a particularly troublesome patient? Meddlesome enemy agents stymieing you at every turn? Don’t wait, write immediately to “Ask Thugfang” C/O “Underworld Magazine.”

Dear Master Thugfang, I am writing to you from a special assignment. My patient is a Catholic. His erstwhile handler was reassigned on short notice because of the patient’s troubling habit of weekly confession, and I have been placed in charge of the case since I have had some success with this in the past. I even wrote an article for Wickedness Weekly entitled, “How to Keep your Patient from Going to Confession.” Unfortunately, all the tricks and tactics I have used before seem to have no effect on this particular patient. It persists in its stubborn adherence to this habit, so I am writing to you to ask if there is any other technique you know of which I can use?

Sincerely, the Obfuscator

My Dear Obfuscator,

You poor dear idiot. You allowed your ambition to control you, you opened your mouth among your betters, and now look where it has gotten you. You are in up to your horns, and about to go under. Yes, I read that article. Amateurish at best. The sort of thing I would have given a barely passing grade when I was teaching. No originality, no imagination, just a list of techniques gleaned from the standard textbooks. But you had to go and set yourself up as an anti-confession expert, and your controllers took you at your boast.

Well, well, well, looks like it falls to poor old me to get you out of this mess. Pay attention because this may well be too advanced for you.

Obviously, the best place for confession, or any sacrament at all, is on the other side of the universe. We want our patients not to know that they exist. No slightest whisper of the hope that has been placed in front of them should ever reach their ears from a fellow human, and we have largely been successful in that regard.

But some do hear about these weapons, and then we have to scramble to keep them from making use of them. That is what you have been trying to do and it is undoubtedly the right answer. Horrible things happen in the confessional. For one thing, it is typically a no fly zone for us. The only way we can even be present in any useful capacity is if we are invited by one of the humans, and even then we usually cannot bring any real influence to bear unless the human has already come pretty much under our power. These are rare cases. For the average Catholic the power of that sacrament is such that even our most skilled agents are blinded and choked by the atmosphere. Hence, we have no chance to observe and document what really happens. We see only what goes in and what comes out. What goes in is a human soul with our little foothold well established, or even a large foothold, even almost total control. What comes out is a soul completely freed from our work. Every single vestige of our presence and influence has been wiped away, and we must begin all that tiresome work over again. Worse, the soul that has confessed reflects some of the light of the Enemy Himself, and that is a toxic work environment.

How does it work? I don’t know, and I don’t care. Probably the only reason we cannot see or understand it is because it is really total nonsense. The whole concept of “forgiveness” is utterly irrational, the sort of sentimental twaddle the Enemy constantly pontificates about. We in Hell do not believe in forgiveness, do not want it and do not need it. It does not exist. There is no such thing. There is only some (currently) poorly understood mechanism by which the Enemy regains some lost territory.

So, let us just say you cannot keep your patient from confessing regularly. The question then becomes, how can you use confession to your advantage. You cannot prevent it so you must corrupt it.

As I said, you won’t be able to get into the confession itself uninvited, so your work must be done entirely in the time outside of the confessional. You cannot attack the sacrament directly (although research is underway as of this writing) so you must attack the patient’s use of it.

The easiest way to do this is to encourage a “vending machine” mentality towards confession. Encourage your patient to think of the confessional as a forgiveness machine, a process. He walks in and rattles off the major sins he happens to be able to call to mind, (not the really serious ones, just the ones that most struck his fancy as being really sins. As a rule a patient should be utterly unconscious of his most sinful tendencies.) He sits impatiently through thirty seconds or so of platitudinous advice he has heard a hundred times before, says a few Our Father’s and Hail Mary’s and “Cha ching!” Forgiven.

Once the vending machine approach is well established all sorts of doors are opened. The first and most obvious is to undermine real sorrow for sin. Since it is just a machine, and not a person he is encountering in the confessional he can sin as much as he likes, go to confession and be on his merry way. That is almost the perfect attitude towards confession, second only to complete avoidance. The presumption and lack of a purpose of amendment not only completely negate the spiritual effects of the sacrament, they are also sins in their own right, and wherever sin is committed, we are invited in. That’s how you get into the confessional. You get your patient to invite you in. I have had a patient so firmly in my claw that he and I were merrily occupied planning next Friday’s debauchery while he listening to the words of absolution on Saturday afternoon.

Failing that, I advise you to discourage the use of a regular confessor (unless you can find one of our priests). Instead, send him around to whatever priest is convenient for him at the moment. Do this by working on his subconscious shame of someone seeing him fall into the same sins every week, and by reminding him of the truth that any valid confession will have the same sacramental effect. This will open up more opportunities for you. You can make your patient a connoisseur of confessors by encouraging him to critique every priest who hears his confession (pride). It protects him from the nasty habit of developing a relationship with his confessor. In a really good confessor/penitent relationship, the confessor will do a lot of extra-curricular work on those shallower areas that the sacrament itself is not necessarily touching. The priest might start digging into the patient’s subconscious fears, his hidden assumptions, his attitudes, his imagination. These shallow areas are our territory. We don’t need any holy priest who really knows and cares about the patient to be meddling in those areas. Bad enough he is the agent of a supernatural spiritual healing. So get busy and send your patient to a different priest every week. The less his confessor knows his penitent, the more generic his advice will be, and the more patient will come to despise that advice. He will blame the priest, “That priest just doesn’t know me and my situation.” Instead of sticking with that priest and explaining his situation, he will just toddle on off to look for another one.

This also discourages real self-knowledge. A wise priest will get to know his penitent pretty well, and will pass on that knowledge to the penitent himself. A different priest every week will not have that opportunity, and consequently the patient may go through years of confessions without ever really coming to know himself.

It is also wise to make the patient’s preparation for confession sloppy and haphazard as possible. In this you are aided by the natural human reluctance to think about its own sins. Your work should be fairly simple. He will confess only the one or two items that are really burning on his mind, completely unaware of the serious habits and trends forming in other areas. This will not, at first, negate the power of the sacrament to forgive, but it will hamper its power to transform, since the Enemy wishes these humans to be free agents in their own transformation. He cannot transform what they will not allow Him to, they cannot allow what they cannot see, and they cannot see what they will not look for. This is the biggest reason why we have invested so much energy in giving the “Examination of Conscience” a bad name.

If you cannot keep your patient from examining try the opposite tack. Scrupulosity is a useful sin and, in my humble opinion, one of the most entertaining. A human who thinks that every one of his actions is sinful is in the grip of a very profound lack of trust. From there it is a simple matter to attack the patient’s trust in the Enemy, His mercy, and His sacrament. Paired with the right priest, there is no better way to chase a patient away from confession for life, or to make all their confessions worthless. Despair is, perhaps, the most secure sin.

Unfortunately this column has already grown too long, so I will have to address proper post-confession attacks in my next column. I do advise you to read that column, and in the meanwhile to reread and seriously practice what you have read in this one. I am sure I don’t need to point out what Hell thinks of demons who over-represent their own abilities and lose patients because of it.

Cheers!

Thugfang

 

Fear and Love in Homeschooling

In life there are only two paths: the Path of Love and the Path of Fear. They begin from the same place and travel very close to each other at first, but the farther a man travels along them, the more spearate they become. In the end they diverge so sharply and irrevocably that they lead to opposite sides of an unbridgeable chasm. On one side is life in all its fullness. On the other is death in all its emptiness.

I grew up in a homeschooling Catholic family and I know many homeschooling families, both Catholic and Non-Catholic. I know enough about it to know that no two families choose to homeschool for the same reasons, or in the same way. Some have religious reasons, some have primarily academic reasons. There was a time, when I was a teenager, and a little bit into my early twenties, when if you had asked me how I intended to educate any children I might ever happen to have, I would have said "Homeschool," hands down and given you a half dozen or so well-articulated reasons for that conviction. Since then, however, I have had the good fortune to meet and become very close friends with a number of families, young and old, who have homeschooled some of the time, or most of the time, or all the time. Some used curricula programs, some created their own curricula. Some went alone, some worked as co-ops with other families. Some homeschooled up until highschool, and then sent their kids to the public school or to private schools. I know of two groups of unusually ambitious families who pooled their resources and created their own Catholic schools, one in New York and one in Louisiana.

We can quote statistics about how well homeschoolers do on standardized testing, or invoke stereotypes about the sheltered, socially awkward homeschooler going hog wild on sex, drugs and rock'n'roll in college. No matter how many "outcomes" I have seen I can see very little in the way of a pattern. (Even the evaluation of outcomes must be undertaken very carefully, taking into account that every human being is different and makes his or her own choices.) I do, however, see a pattern in the foundations, so to speak. The motivation behind the choice to homeschool is really a choice between two opposite reasons. The choice is made either out of fear of evil, or out of love of the good.*

Too many homeschooling families that I have known chose homeschooling out of fear, fear of the experience they had in highschool being replayed in their children's lives (with good reason). The choice to homeschool was a reaction against that, a flight from the evils of the world. This attitude of fear is very powerful, but also very posionous. This attitude of fear becomes a prevalent undercurrent in the life of a family, and then in the life of a young person who grew up in that environment. The fear of making mistakes, of failing, of not being the "perfect Catholic" family, of somehow being corrupted by the evil world, all of these attitudes are based on fear. This is the fear that keeps Catholic young people from going to secular colleges for fear of being corrupted, from entering the military for fear of being dragged off to the strip club, from asking that girl to dance for fear of being led into sin or having everyone think you are going steady. It is the fear that keeps men from trying out the seminary, because they might fail. It is the fear that keeps men in the seminary after they have decided it isn't for them, because they don't want to be seen to fail. This fear prevents good Christian boys and girls from spending time together because they fear temptation more than they trust grace. This fear prevents good Christian young people from being friends with atheists, for fear that their faith will be stolen. Fear, fear, fear. We become so enamored of the homely ideals which really only exist in our minds that we run away from the real world, and consequently it goes to the devil. What do you expect when the salt of the earth is horded for our own private recipes, and the light of the world is put under a shade to make it a convenient night light for scared children?

The opposite motivation is love. Some people homeschool because they believe they have a gift to give their children which the world cannot give them. They want to share this gift of life with their children, in the hopes that their children will then go out and share that gift with the world. So they allow their children to ask questions, even challenging or disrespectful sounding questions. They allow their children opportunities to learn from anyone and everyone who has something good, true or beautiful to offer. Perhaps most importantly of all, they allow their children room to make mistakes. They do not try to shelter them from the responsibility to make their own choices, they do not prevent them from meeting people who think differently. They are available to answer questions and aware of the questions that their children are asking, but they are willing to be pushed aside, ignored or not listened to. They applaud the good, no matter how immature it might be, without ever condoning or encouraging that immaturity. These parents are humble enough to realize that they are not in control. They are simply tools in the hands of God, so they can make themselves available but not grasp at control when things don't go the way they planned.

This is the pattern throughout life. The slightest good attempted by the grace of God, even if it "fails" by our standards, is of more value than any amount of evil avoided. Remember the parable of the talents (Matthew 25:14-29), and tremble if you were given great gifts. Tremble, but rejoice, for you have been given the opportunity to do great good. Invest everything you have and everything you are in the mission that excites your heart and sets it on fire. Do not fear the naysayers, whether they wish you well or ill. Listen to their fears, and recognize them as fears. Take whatever truth they offer, and let their fears pass you by.

For we were not given a spirit of slavery to fear, but a Spirit of adoption by which we cry Abba! Father!

Fear not! He has conquered the world. He who is in us is stronger than he who is in the world.



* For the purpose of this blog I have artificially separated and contrasted the two motivations, but in real life they are never that simple. There are very, very few people in the world who are completely motivated by love and never by fear. There are some people who are motivated almost entirely by fear, but I hope not very many. There is a little bit of love in everyone, just a little spark of fearlessness. So don't expect to see real human beings entirely in one camp or another, and don't expect to see homeschooling families entirely in one camp or another either. The distinction is meant to enable us to see which direction we ought to be going. When we start using it as a set of boxes to stick our fellow Christians in, then I think it has become a trap and should be discarded.