Perspective

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It was a weekday Mass, and we were spread

Pretty thin. You know, one to a pew

Or maybe two.

The Our Father came, time to hold hands

And the elderly Korean lady in front of me reached

Out to her left to her equally ancient friend

And grasped her hand. Then reached back to the right

Towards me, and left her hand outstretched.

I took it.

We never held hands at Our Lady of Good Counsel.

Father was old school and did not approve.

But I could not help but notice that in reaching

And stretching herself for her neighbor, left and right,

She shaped herself into a cross.

Cannot

Not.

Not I.

Not, cannot,

I cannot be good.

Be nor do,

Cannot do good,

Nor try,

Try good.

Not try, nor want, nor even see to know.

I cannot love nor live,

Give nor bless I cannot.

I cannot pray

Nor say

Nor sing

Nor ring the rounding bell

Nor tell

Nor teach

Nor preach, prophesy or praise.

I cannot add one moment to my days

I cannot lift up my gaze, my eyes,

Nor know the skies,

Nor even the mud that makes my form

Nor warm my heart

Nor finish any good work, nor even start.

I cannot

For I all but am not.

Am nought, What?

I am not aught but… what?

At my center a gap, an emptiness.

An abyss, a nothingness

An utter lack, a longing, a space

A place, an empty womb or tomb wherein I miss.

Miss whom?

Miss Thee, as Thou hast created me to.

My emptiness fancies itself a thing,

Tries to give, to live, to be, anything

But I cannot

For I all but am not.

Am unfilled, longing

(With strong longing, Thine,

All Thine, not mine) to be filled

Full, fulfilled, filled full well

As Thou hast willed,

Emptied so as to be filled,

Spilled out so as to be overflowed

And spilled ad majorem

Dei gloriam, filled and spilled and filled for aye,

All, ever, saecula saeculorum! I

Give up, and offer Thee nothing.

Fillest and killest though my nought, with Thy I AM.

Newman On Logic

I have just finished reading John Henry Cardinal Newman's "Apologia Pro Vita Sua," (minus the superabundant appendices) which is the story of his religious development and eventual conversion from the Anglican faith to the Catholic Church. It was an interesting read, to say the least, despite the fact that I had either no idea whatsoever, or a vague idea at best, of the nature and details of the controversies enumerated in the course of his narrative (writing like this is a side effect of having read Newman). I know enough of the true doctrine of the Church, as expounded in the Catechism, to give me a very general notion of what the controversies might have been about, but as Newman writes under the apparent assumption that his readers are well aware of their details, beyond that I was somewhat in the dark.

Despite this difficulty, the book was nevertheless fascinating, not least for the force and vitality of Newman's thought, his clarity and eloquence of expression, and a certain level of iconoclasm in regards to previously held notions of his character. I had always thought of Newman as something of a logical rigorist, firmly invfested in following the argument, the dialectic, wherever it went and acting accordingly. This assessment, if it may be called such, was based both on the thoughts of others writing about Newman, but reinforced, I must say, by his very excellent "Idea of a University," in which he ably and vigorously championed the value of a liberal education founded upon reasoned inquiry into the great works. A deeper reading of that work might have led me to suspect a balanced view of the utility, nobility and yet potential pitfalls of logic, but it did not.

Imagine my surprise, then, upon reading the following:
       "Non in in dialectica complacuit Deo salvum facere populum suum" -- I had a great dislike of paper logic. For myself, it was not logic that carried me on; as well might one say that the quicksilver in the barometer changes the weather. It is the concrete being that reasons; pass a number of years, and I find myself in a new place; how? the whole man moves; paper logic is but the record of it. All the logic in the world would not have made me move faster towards Rome than I did; as well might you say that I have arrived at the end of my journey , because I see the village church before me, as venture to assert that the miles, over which my soul had to pass before it got to Rome, could be annihilated, even though I had been in possession of some far clearer view than I then had, that Rome was my ultimate destination. Great acts take time.

And again, speaking of the infallibility of the Magisterium:
"I am rather asking what must be the face-to-face antagonist, by which to withstand and baffle the fierce energy of the passion and the all-corroding, all-dissolving scepticism (sic) of the intellect in religious inquiries?"

Newman was not, of course, denigrating reason, or denying it its noble and necessary place in the totality of effort which is man's religious response to the Divine invitation. In fact his very next sentence goes on to say: "I have no intention at all of denying that truth is the real object of our reason, and that, if it does not attain to truth, either the premiss (sic) or the process is in fault; but I am not speaking here of right reason, but of reason as it acts in fact and concretely in fallen man... I am considering the faculty of reason actually and historically; and in this point of view, I do not think I am wrong in saying that its tendency is towards simple unbelief in matters of religion."

In fact, recollecting "University" in light of this statement of Newman it fits well with his thoughts upon the real value, but ultimately the limitation and inadequacy of the liberal education. My unfortunate lack of a copy of "University" prevents me from quoting any relevant passages. Nevertheless, if my memory may be trusted, Newman discusses the limits of the liberal education at length in the chapter on being a gentleman. He maintained that the gentleman was a worthy, but secular ideal. It could make a man interesting, erudite, healthy, cultured, reasonable, fair-minded and many other excellent things. The one thing it could never make any man is a saint. The Church and the University exist in different but contingent spheres, and for different, but mutually supporting purposes. Thus it is incumbent upon the Church to support and encourage worthy secular pursuits, never forgetting that they are ultimately subservient to the higher goal, which is the eternal salvation of her members.

I see in this a direct corollary to Newman's thoughts on logic quoted above. While logic is a noble faculty of the human person, indeed, one of the highest, it is nevertheless not the highest. The will, the interior center, Newman's "the concrete being," is what moves, what loves, and what chooses the beatific vision. In some sense external logic is as much a marker of the invisible decisions of the inner person as it is their guide and cause.

I find strange points of contact between this notion and the insights of certain mystics (Julian of Norwich, notably), along with the metaphysics of many medieval philosophers, which postulate the existence of the interior self which, despite the stumbling, misery and confusion of the superficial ego, remains at peace and secure in God's peace through all its existence, in a "peace which passeth all understanding."

However, this is more than I can know. The practical ramification of this notion is a renewed awareness that the being which is in need of conversion, salvation and sanctification is deeper, perhaps infinitely deeper, than my superficial efforts at change. It re-emphasizes the gulf between my attempts to save my self and my utter incapacity to do so, and forces me to rely solely upon the mercy of God and the mysterious action of the Holy Spirit "intimior intimo meo" to create a new heart within me. I cannot do it myself.

The name of that reliance is faith.

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