Friday, September 9, 2005

Session 6: The Medical Vocation, Then and Now

Council Discussion of Richard Selzer’s story,
“The Whistler's Room”

CHAIRMAN KASS: Why don't we get started?  a lot of the work that this Council has done has been informed less by the brand of bioethics that takes off from sort of medical ethics where questions of informed consent and things of that sort loom large but we have — and part of what's distinguished what we've done is that we've also been taking up questions that are — if you speak in terms of academic disciplines, belong more to the philosophy of technology and to think about technologies, human meaning and its social implications. 

But as I hinted before the break, several strands of our work really impinge upon the doctor/patient relationship and on the ethical character of the medical vocation.  a growing number of aspects of life have come under the medical umbrella through the expansion of psychiatric diagnosis, enhancement technologies and the treatment of various aspects of behavior,  now with the advent of neuro-imaging techniques to bring these further within the orbit of medicine.  And we have, from time to time, talked about medicalization but not about medicine. 

We, in the regulatory discussions, have looked to the importance of professional self-regulation; however, loose in governing what takes place when health care is given and when the technological innovations reach the public.  And for many of these matters, a medical license and the ability to understand and use medical innovations is an indispensable union card for actually making biotechnology common to human use. 

And finally, as yesterday's discussion made clear, there is a limit to what medicine can do.  Old age, dementia and dying most emphatically expose those limits.  Every doctor's patient eventually dies no matter how good the doctor is.  And the question of a good death came up in the discussion yesterday and a question can be raised as to whether the doctor is primarily to be seen as the moderate day St. George against the eternal dragon or whether he is either a companion or as the other story by Richard Selzer, that we distributed indicates, the doctor might even be something of a priest.

I talked with Dr. Selzer last week, asking permission to use the first story that went in the briefing book and he told me, he's very touched that we have shown such interest in his work but he told me that if I really wanted to read something that he thought was very effective, I should get his latest collection and read the story, "The Atrium," and I'm not sure I can lead a discussion of this dry-eyed.  This is an astonishing story.

While you're collecting your thoughts, let me just make sure everybody's got the main point, and then I'll pose a question.  While eating lunch in the hospital atrium, amply described, this retired physician now turned writer, notices a boy in a wheelchair who is looking at him.  The boy who is 14 years old looks to be 10, all 80 pounds of him.  He's terminally ill with some malignancy. 

He's bald, lips encrusted, attached to intravenous drip.  He is all eyes and ears.  Selzer, self-identified as the doctor and writer but also the narrator of the story, observes quote, "He hasn't the time for shame or restraint, only for honesty."  So the two of them talk.  Tony, the moribund boy, quote, "ill in every way but not ill at ease," assuming a pseudonym, Thomas Foggarty, presses forward his one concern, quote, "What will you do on your last day on earth?"  The doctor/narrator conveys his fantasy about dying, envisioning a former student, now a great surgeon, transporting him to an ancient forest.  He gradually becomes part of the woods. Quote, "The whispering leaves more guessed at than seen," as well as keenly aware of the mystery of life.

The forest sprawls across his mind. Quote, "The night becomes a confusion of stars and fireflies, the here becomes there as he becomes one with the other." His death then is, quote, "a painless transition, that's all, no more."The next morning the boy dies, but not before dictating a letter in which he conveys his gratitude for and understanding of the story told to him earlier by the narrator. And Tony's nurse delivers this to the old man.

One could say that the narrator ex-physician or question mark, physician and writer has, at least in the story narrated, somehow I tried to help prepare this boy for death, though hopes to save him, as he says, by immortalizing him thanks to his gifts as a writer in this story, but I'm interested not so much in the immortalization of the boy but in the deed of Selzer in that conversation.  And I guess the question I would ask is this: Is that a doctorly deed?  Was that a physicianly act, that conversation, or was that — I mean, was that somehow a deed of an old man himself close to the end? 

PROF. CARSON:  I'll break the ice on this one.  First of all, you have to ask yourself, you know, what is a physician? 

CHAIRMAN KASS: Exactly.

PROF. CARSON:  And you know, I personally see a physician as a healer.  Now, if you're going to be a healer, I think you have to be able to encompass the entire organism.  That includes the environment in which that organism lives, everything, in order to bring vitality to that organism.  Now, physicians, at the risk of sounding obnoxious, have more education than anybody in our society.  They take the longest amount of time to be trained and have access to enormous amounts of information, or at least should.

As such, I think it's improper to confine themselves to narrow spectra and I'm constantly talking to medical students about this; how physicians tend to get into their laboratories or their societies or their operating rooms or their clinics and forget about the rest of the world.  And we can sometimes do that with patients as well and look at the organ system that is involved and forget about the entirety of that human being.  So I believe Dr. Selzer has done us an enormous service by showing that there is not only the flesh and the bones, but it is really the mind and the soul that distinguishes us from a piece of meat.

CHAIRMAN KASS: Thank you, Diana.

DR. SCHAUB:  Yeah, I think I want to quarrel a little bit.  Yeah, I want to quarrel a little bit because it seems to me that the doctor himself says he is not behaving as a doctor in that moment.  Now, it may be that he writes with the intention of getting us to reconfigure and reconceive what a doctor is, but he has the explication.  I mean, this is a very odd structure to this piece.  You know, it looks like a personal essay and then it becomes a kind of short story and then he attaches an explication.  I mean, novelists don't usually attach explications to their own work and they're usually ill-advised to do so.  But since he's done it, he says he is no longer a physician, a man of science.   He has reverted to a more primitive form of being, one who is receptive to certain subtle influences and to intuition.

The doctor in the story knows that he's performing a secret, sacred initiation upon the boy.  He hurls himself into this primitive rite, recklessly forgetting himself, forgetting himself as a doctor and as a writer, until that very moment when he hesitates and says to the boy, "That's all there is.  There isn't any more." And he almost describes that as a kind of failure of nerve at that point — that he doesn't go all the way with this new sort of, you know, doctor as shaman or doctor as priest. 

So — you know, and he also says that, you know, this is a story that flies in the face of science.  So, I mean, it may be that doctoring is — I mean, is something different from science and exists at some kind of intersection of — you know, of science and mystery, or somehow keeps those two things together that's separated at some earlier point in history, but I would be resistant to saying that he simply behaves as a doctor in this moment.

CHAIRMAN KASS: Peter.

PROF. LAWLER: I sort of agree with Diana.  I was very moved by this, but I don't know why — sort of "there's a mystery about the mystery" or something.  And the strange explications, which is mighty strange, he says at the top of page 254, he compares the forest to the atrium, the atrium, the architectural denial of death, and he says in the very first sentence, "It is what a hospice is in contrast to a hospital, the ultimate refuge, a triumphant place where the imagination reigns and one is free of the agony and terror of mortality."

So what frees us from the agony and terror of mortality is a free reigning imagination.  And so that would seem to me that modern technology enhances and definitely the agony and terror of mortality.  So he says at the end of the next paragraph, "The story 'Atrium' flies in the face of science," as Diana says, "it tries to keep the mystery of life from being mowed down by the juggernaut of technology.  So the danger is that modern medical technology will eliminate the mystery of life, making the agony and terror of mortality unbearable."

And then in the next paragraph he says, "This is a sentimental story." So his anti-scientific job seems to be to keep the imagination alive against a scientific project to eliminate human mystery.  And the big question is, which I can't get from the story one way or the other, does this mystery have any real foundation, or is it simply the product of the human imagination which has to be kept alive even though it's unreal?

CHAIRMAN KASS: Let me bother both of you before things get further complicated.  It's true that the explication, which is quite unusual, lays some of that rather starkly, but if you took the story without the explication, you have on page 252 and there's some very nice explanation of the two meanings of atrium in this story — the antechamber to the heart and the — and I think even "heart" is to be understood both literally and metaphorically there, and the antechamber to this place that does battle with death, but seems somehow to deny it.  But then he says, he tried to save him not as a human being, but as a character in the story so that he will not be lost.

That's the comment of Selzer, the story writer.  But then the next paragraph, "I had given him as well one of my dreams to play with.  It was a ruse, a deception, I know.  I, who believe in nothing supernatural, made use of it to prepare this boy for his death."  And here's the line, I think, causes difficulty for what the two of you have been saying.  "It was as if after years of retirement, I had once again put on scrub suit, mask, and cap, and take up my scalpel."  That suggests that the vocation of — that he somehow having retired from medicine, was acting insofar as he was speaking to that boy, in the same way that he was when he was a surgeon taking something, I think tacitly agreeing with Ben's view, of what the medical vocation is when in the operating room with a scalpel.

At certain times with a tail that will ease a person's exit, when one can do no more than that.  What would you say, either Diana or Peter, I mean, to that?

PROF. LAWLER: I don't disagree with that, but let me ask the doctors in the room, is it the job of a physician to prepare — this is not very Socratic in a way, because preparing a young man for death by telling him a lie, a sentimental lie, kind of a pantheistic story, and is kind of a paradox, because the boy before says he's beyond self-pity — he's beyond all that.  He's beyond all the anger and shame and all that, and all that's left in him is honesty.  He wants to honestly face up to death and so it's sort of a paradox that he is prepared for death by being told sort of a sentimental pantheistic tale about death.

And so the big question for me, for which I have no answer is, is there something real behind the tale or is the tale just a tale? 

DR. HURLBUT:  He specifically says in the earlier part of the story, "I see at once that this boy is rare, that I must not falsely console or cajole." And I think the explication works against the notion that he is simply spinning a therapeutically useful ruse. 

CHAIRMAN KASS: Diana, please.

DR. SCHAUB:  Yeah.  I want to — in a way I think the boy knows more throughout this story than the doctor does and that — and there are moments when the doctor recognizes that as early on when he says, you know, "This boy is passed the need for stories." But yet he does tell him the story because it is his own dream.  I mean, he actually — he's opening himself up at this moment.  He tells him, you know, "This is a dream of mine," and the dream he tells him is, as Peter says, this pantheistic story.  You know, it's transcendentalism, it's Bryant's poem, "Thanatopsies."  I mean, it's — they're very close to that kind of vision, but know what happens when the boy takes that story.  He doesn't just take and accept that story.  He actually gives it back to him in a very different form, and it is transfigured in that. If you look at the letter or just think about the writing of the letter, what the doctor tells him is, you know, "Give yourself up to this vision of a painless transition and merging together with the cosmos and the unity of all life," and the boy takes that and what does he do on his last day, he doesn't just give himself up to that vision.  I mean, we know already he's come down to be in the atrium and to make human contact.  He then goes back up to his room, he's suffering, he knows this is the last day of his death and he writes a letter, a letter that costs him tremendous pain. 

His transition to death is not painless and it's not painless precisely because he reaches back out to the doctor, the writer and the old man.  And I mean, we're told it's painful for him to speak, and yet he dictates this letter.  And the letter says, "It's just as you said it would be," but of course, "It's not as you said it would be because what I did instead was write this letter."  And then he makes some very interesting changes in the dream. 

The doctor's dream ends in darkness.  It ends with the stars and the fireflies and the twinkling of lights in the darkness, but the boy's dream ends with dawn, "a moment ago when the dawn came, it took me by surprise as if it were the first dawn that ever was, rose yellow."  I mean, it's a different dream.  He has transfigured it, I think, because he has brought humanity back into it.  The doctor's dream doesn't have much humanity in it. 

The other thing that I think is very odd and I cannot make sense of is that he says — he says to the doctor, "Your words remind me of Edgar Allen Poe's 'The Raven.'"  Now that is a poem, you know, "never more."  That is a poem of loss and despair and hopelessness and the bird that brings that word is a bird — is a prophet and a bird of evil.  And yet, he compares the doctor's words to that poem.  It's very odd. 

PROF. LAWLER: Yeah, this is what I was thinking, only deeper.  But the — obviously, after saying the doctor's lines are in fact "Poeish," life-denying, right, it's right before he transforms him, so I have to change it.  I have to improve upon it.   And so to make a long story short, it's the doctor who needs the tale, not the patient.

CHAIRMAN KASS: Rebecca.

DR. SCHAUB:  And the reason that the doctor says, "There's an illness that I need to recover from," I mean, his opening literally illusion is to "The Wasteland," right?  The first quote is from"The Wasteland."

CHAIRMAN KASS: Rebecca.

PROF. DRESSER:  Continuing with what Peter just said, there was a boy and the explication there was a boy, but I — as I was reading through this story, I kept thinking this man is talking to himself.  He's not talking to anyone else.  He's dealing with death.  He's presenting this sort of romanticized version and I was so proud of myself that I was having this insight and then I get to the very end and he says, "Well, yes, there was a boy, it's true, it happened", but then he says, "It takes no great leap of the imagination to conclude that the doctor and the boy, Tony, are one and the same, that Tony is no more or no less than the square root of the doctor."

So I found this story very provocative, which, I guess, shows how good it is, but I was extremely irritated by it.  As I was reading this death story, I thought, this is like Disney's version, or sort of some organic farmer's version of death, and it just seemed way too pleasant and Hallmark-cardish and I thought this guy is talking to himself, but here — this man is a perceptive surgeon.  He's seen the reality, he's seen the blood and guts.  What is going on here? 

And I don't know what's going on here.  I was — as I was reading this, I thought about Sherwin Nuland's book, "How We Die," how brutally honest that book is and he's another Yale surgeon, right?  And I must say, I gravitate more toward his view of death, so maybe that's one reason this irritated me, but I'd be really interested in hearing what other people might think is going on in his mind about preparing for death and in some ways stepping away from the doctor's role and talking to himself, but as you say, he talks about becoming the doctor again.  So I'm confused.

CHAIRMAN KASS: Yeah, but why — this is in a way the — let me add a line to this which I think is probably — well, it's one of the most poignant lines, this is very early, where he gives you the reasons why he goes to the atrium and there are increasing — he starts with the most superficial reasons, he can't see very well, et cetera.  The last thing is to say, "Perhaps I go there to be in the vicinity of the sick and their 'next of kin.'"  Now "next of kin" is a term that's usually reserved for people who are in grief, right?

So that the images, the sick, i.e., the dying and near dead and to be imagined as dead and their next of kin.  "It is with the sick that I feel a sense of belonging.  The sick are my kind."  Now that raises the question: Is that a doctor speaking?  Is that just an old sick man speaking or is it a person who perhaps by virtue of having been a doctor, and not only because he's old, somehow understands more deeply than most of us do that the sick are always "my kind"?  That's puzzling to me.

Can a doctor honestly say "the sick are my kind," or is that the voice of a certain kind of human being with a certain exquisite sensibility or something like that who would see that?  And so your attempt to somehow separate the man and the doctor or the boy and the old man, I think, is very nice to begin with, but the question is, do the fears of the young made more poignant in this particular story and especially the fears of the old, are they not somehow the universal sort of human concerns which doctors, to be doctors indeed, should not have extirpated from them, but somehow could be deepened and enriched?

And I've been away from, you know, medicine too long, and I would really welcome — Ben has already weighed in — but it seems to me on this particular question "the sick are my kind," we do battle with their sickness as if we want them — they are "our kind" especially when they're made well, but the question is whether that kind of human empathy is somehow essential to being a physician and never mind whether the story is true.  We can worry about that, but the boy, even how he's transformed the story, understands the doctor gave him a gift.

He's made something more of the gift, perhaps, than the doctor gave him. And the doctor now has to mourn a life that he knew but briefly and came to love, but the boy recognizes it was a gift and the doctor describes it as a doctorly act and I don't know whether it is or not.  Gil.

PROF. MEILAENDER:  My initial reaction to your question about "is it a doctorly deed or not" was sort of a simple one in the sense that — and it may get me into the separation of the man and the doctor that you're not sure you want to grant.  That one wouldn't have had to be a doctor to do what he did.  It doesn't seem to me that it's in any way essential to that.  Doctors might have more opportunities to do it than some other people, but a person with a certain kind of understanding and insight could do that, so there's that sense in which it's not a doctorly deed or not only a doctorly deed.  That much seemed clear to me.

Now, I took it, though, that what you were interested in though, maybe actually, I see now that you're interested in more than just this, but at least I initially took it that you were interested in thinking about whether we would somehow deform our understanding of doctoring if we thought that it didn't have to include this.  That one could do doctorly deeds that were entirely, as it were, that entirely bracketed all of this kind of consideration and still sort of be satisfactorily acting as a doctor.

And I mean, I do think that the story suggests — for me anyway— a kind of "no answer" to that question.  I'm not actually crazy about the story he tells the boy, but in terms of the larger story, I think it does suggest that some — a notion of the medical profession that thought of it well more as technical and technique, and not alert to these larger dimensions, would be an inadequate notion, right where Ben started in a certain way.

But then the third thing I thought about, which does bring me back to where I started with not wanting to see this in any special sense as a doctorly deed, though certainly a doctorly deed should also be included, is that at the end, it's the boy who's prepared the doctor for his death and, indeed, their initial encounter is almost initiated by the boy who is looking at him with that glacial intelligence or whatever the phrase is there.  So, "who serves whom here" is a very complicated question or even "who doctors whom" is a complicated question, and that again, suggests to me that while one lesson you might take out of it is that you can't doctor someone without being alert to all these things.

There's a larger sense in which "to be human" is a way to doctor other people, not in technical ways but in helping them to deal with the most fundamental aspects of life, and it doesn't seem to me that that's confined to the medical profession.         

DR. SCHAUB:  Can I ask you a question?

CHAIRMAN KASS: Gil?

DR. SCHAUB:  Leon?

CHAIRMAN KASS: Please.

DR. SCHAUB:  You're putting a lot of weight on the passage where he says that he becomes a doctor in that moment to prepare him for death, but the kind of doctoring he speaks of is surgery, which again, seems to me odd.  I mean, he puts — he said, "The scrub suit, the mask, the cap and had taken up my scalpel."  I mean, he's going to excise something from this boy or perform an exorcism of some kind.  Why surgery and —

CHAIRMAN KASS: What's being cut out?

DR. SCHAUB:  — for the conception — yeah, that's what I mean, but for the conception of doctoring that you're speaking of, it would not seem to me that surgery would be the best model of it.  And I think you guys have had some previous discussion of the Hippocratic Oath.  I wasn't here for that, but was I right in reading a line there where he says, you know, "In the Hippocratic Oath, you know, I won't take up my knife.  I leave that to those who do that," as if — do that other thing, as if surgery is something different from [doctoring].

DR. FOSTER:  Well, I don't think the surgery has anything to do with this story.  He was a surgeon, you know, and there are surgeons and are also physicians and some — you know, so I didn't read into that anything at all about it.  I do — I'd comment in a little different way than I think has come here.  In terms of whether it is a necessity for a physician to have this sort of sympathy, I would say that the one absolute requirement for a physician who is ethical is competence.  I don't care how big his heart is or her heart is, if they're incompetent, they're unethical.  So the first and decisive ethical requirement for a physician is to be competent. 

Now, as Osler, we've been talking about him, said, he added a second [rquirement].  He said that the second requirement was compassion so that the complete physician should be both competent and compassionate in a variety of ways as Ben was saying.  But if you had to sacrifice one, you would not sacrifice competent, you would sacrifice compassion.  I know gifted surgeons who are not very sympathetic at all, but they're who you might want to see if you had something wrong.

Now, my own reading of this story is that he really is talking about a sort of — in my view, sort of a universal question — What does it mean to die?  We're bracketed with non-being.  We were non-being before we were born and we're non-being when we die or might be.  People have always had hopes that we do not cease to be.  I mean, it might be a cycling reincarnation as some sort of an eternity that was going on, or it might be another view of life after death, but everybody has to deal with this.  And very often, I almost would say most of the time, even if never articulated, there's an anxiety and a fear, because even if you read near death visions and so forth, none of us have ever been through that before.

I've never been close to dying.  I mean, I might drop dead while I'm talking here, but I've not had to deal specifically with that fear, but I've seen that many, many times at the death bed, the anxiety and it doesn't — I'll tell you a simple story.  Robby said I'm always telling Texas stories, but this boy was incredibly gifted.  He knows literature, you know, he cites poems and so forth, incredibly gifted 14-year old. 

I'll tell you about another boy.  His name was Edgar Lee, African American.  I took care of him.  I was the attending physician at Parkland Hospital.  He had a lymphoma.  It was a hard time when we had to send him home and I had to call his mother and she wouldn't take him at first.  And I had to explain to her, it wasn't that she didn't want him, it was she didn't know how to take care of him.  He lived on Ewing Street in the most impoverished part of Dallas.  I go to a downtown Presbyterian Church and I teach there, and to my astonishment one day Edgar Lee showed up.  He had walked with his lymphoma.  He was not far from death. 

He had walked six miles to the First Presbyterian Church from Ewing Street.  He had found out that I was — that that's where I was on Sunday, and he came up to the class.  And then he had an IQ that could have been no higher than 70.  That might be generous to give him that, but I was his doctor and he heard I went to church and so he came.  And he eventually asked to join the church, which he did and the — I was teaching high school kids and we would go over to Ewing Street. 

He didn't have sheets on his bed.  There were just newspapers and we took food.  And I wanted the middle class kids that I was teaching to see what this was about.  But what he came for was, he knew he was dying and he was looking for hope.  He was looking for hope and most people have these sorts of fears, and they may not be articulated at all.  Well, you couldn't have a conversation like this story was with Edgar Lee.  I mean, you could love him a little bit and his family asked us to — asked me to speak at his service and the pall bearers were the all Caucasian members of the class that carried the thing there and he, in some sense, found comfort in the idea that — which would be a Christian idea, that life does not cease at the end of — so I see this story really as the universal story cast in maybe almost in a stoic fashion.  You know, there's no hope for anything, but let me just be buried in the beautiful forest and so forth and that would be what the hope is, but I think it was more about — and I have met Dr. Selzer and heard him, talked to him a little bit about some of these things before.  I think he was really writing about the universal anxiety about non-being, about finitude and I think physicians have to — even if they, themselves, have no hope or no faith or anything, they have to be willing to deal with this.

And somebody asked the question, you have to say, "Well, I wish I knew the answer to that.  I don't know the answer to that," and so forth, but the physician can always be a companion on the way.  I spoke at the death of a Professor of Emeritus who you probably saw in the New York Times here and so forth, and the first thing I said, I mentioned this to Leon, at the service, we talked about good death, I said, "Death is always serious and it's very often somber, but there is such a thing as a good death and Morris Ziff had a good death for two reasons.  There was a respite before he died where he got to talk to the family and so forth, and he died quickly from a heart attack, not from his heart failure and being on an intubator and so forth and so on, and he always wanted to die easy, which he did.  And secondly, he was not alone when he died.  His family was there and I happened to be in the ICU when he died."  So my view is that this is different from what — maybe not different but I think this is what he's addressing is the sort of universal boundary of non-being that — and do you know what, I suspect that I'll probably be, if I have time to think about it, I'll probably be a little scared too. 

I'm trying to — gray matter, there was a famous Communist atheist and I've forgotten his name, Bloch, Bloch was his name, and he was the one who coined the phrase "The great perhaps."  He was a vibrant atheist, but very thoughtful.  And as he contemplated finitude, he talked about the great perhaps.  In fact, one of his students, when he was dying said, "I'm going to look for the great perhaps," you know.  Well, I think that's what this is about.  And this very long answer to your question is, I think the very best physicians — I've already said that you can be an excellent physician without compassion and not the ability to do like Dr. Selzer could or many — but the best physicians even when their black bag is empty, are still physicians there.  You know, even when the black bag is empty, they have a role as physician.

CHAIRMAN KASS: Could I just draw you out a little more, Dan?  I mean, you — just very briefly.

DR. FOSTER:  I'm feeling sorry for the Council having to —

CHAIRMAN KASS: No, no.

DR. FOSTER:  I've talked more at this Council than any meeting I've ever been to.  Yeah, go ahead, what do you want to challenge or —

CHAIRMAN KASS: No, no, no.  It's — it really is — the very last thing that you said, and I think your diagnosis of what's being addressed and maybe even with the psychic equivalent of the scalpel, Diana, is this kind of terror or doubt.  And to extirpate that kind of fear by this kind of speech, or extirpate  might be too strong and maybe that's the surgeon's view of what he's trying to do, but is it in your experience common that one explicitly somehow speaks to that fear or is it sufficient to be somehow present and somehow tacitly address it, but not explicitly?  I mean, does — let me put it more generally: Do the best doctors help their patients to die?

DR. FOSTER:  Well, I don't know whether you can — I guess the answer is, yes, at the very least by presence, which is there.  I came one morning on a Saturday morning, I often times start at the top of the hospital and go down to the emergency room, just to see people that you run into even if I'm not on wards, and I came to the cardiac intensive care unit and one of our residents, Cathy Dotson was sitting there weeping, I'm talking about young people now, not people like Paul and me, who have been around.  And I said, "Cathy, what's wrong?"  And she had a young woman with a postpartum cardio-myopathy.  She was dying in congestive heart failure.  It's a six-month old baby and she had — this is before the 80-hour rule that you can't work more than 80 hours a week, and she had — Cathy had stayed not only her night before in the unit but this night also. 

And what she did was she sat all night with this 22 — I think she was 22-year old Hispanic woman, holding her hand all night long and there wasn't a thing in the world that could be done for this cardio myopathy except a heart transplant and there wasn't any way that she was going to get it.  And I said to her as she was pouring the tears out, I said, "Cathy, I want to ask you one question."  And she looked up to me, and I said, "Did it make a difference that you were here?"  That's a question that — and immediately her tears began to drop because she knew that it had made a difference.  The young woman died within the hour, that she was there  to hold — she didn't offer anything medically but she was there as a companion, so at the very least.

Now some times questions are articulated that are specific, you know, that one may answer you know, but at least there is the presence, and if somebody invites you to come — let's say if somebody has a — that somebody has a religious faith or something.  If they invite a dialogue there, I think that's perfectly acceptable to do.  Never forced, I mean, it's not — one doesn't come in and force one's views on the patient, but invited one may say, "This is what I hope or this is what I believe". 

Nobody ever gets mad if they say, "This is what I believe".  What they get mad at is if you say, "This is what you have to believe", you see.  That's the difference.  That's a long answer, but I think the one thing that Selzer did, if he's writing about himself and the boy, whether the boy is real or imagined, is that there was a human connection there that was a sort of however it ended up, that he was connected to this boy in a way that conveyed to the boy a sort of love.

CHAIRMAN KASS: Thank you very much.  Bill?

DR. HURLBUT:  I think this essay addresses the question that we were trying to ask yesterday about the mysterious question about whether there is  such a thing as a good aging and a good death and how technology plays into that, and how that relates in turn to a more primary quality in human nature and human culture that is in a way being swamped out by our advancing technology and our interventions against nature.  It basically asks the question — and I completely agree with what Dan just said — asks the question of the universal problem of the reality of natural death. 

To me the interesting — I think you mentioned already here beyond the comment that the — what's this phrase exactly, the boy is the square root of the man or how does that go?  It's interesting just before that he says, "It's well-known that mathematicians reach the peak of their genius in their teens", as though he's saying the square root being the solution to a mathematical problem that maybe something beneath our — what he calls the professional pose or the unnaturalness of the hospital is part of our solution that as a physician, we have to be careful to sustain our receptivity to the subtle influences of the intuitive, what he refers to as the secret initiation of primitive right that he's leading the boy through.

And I think there's a comment in here about technology.  I mean, it's a very prominent thing he says.  "The story, Atrium flies in the face of science.  It tries to keep the mystery of life from being mowed down by the juggernaut of technology".  And I think he's saying that the physician in the modern world anyway, is strangely participating in that.

CHAIRMAN KASS: Diana again, please.

DR. SCHAUB:  Yeah, I want to — it's sort of on this question of technology.  I want to say something on behalf of the nurse, because the doctor, who is the author of this story, gives her a rather hard time.  He sees her as characteristic of the coldness and the falseness of the modern hospital, that she's cheerful and professional and that there's something false and untrue about that approach to death.  And he contrasts the approach to death in the hospital with the approach in the hospice.  I mean, he says this in the explication, that in a way what he offered the boy, this vision of death, is something that one would find in a hospice rather than something one would find in a hospital where one would be denying death and confronting death and staving off death. 

But it turns out that this nurse is the one who spends the afternoon with him taking the dictation of the letter and promises to deliver the letter and does so.  So that you know, I mean, in a way what I'm suggesting that the doctor in the story is not the doctor who writes the story.  I mean, that  even though this is autobiographical and he uses his own name, he is conveying certain things to us that go against what the stance of the doctor himself in the story.  I also think there are things you could — he's trying to do something with technology in that image of the fountain also because he tells us that the fountain, which is the heart of the heart, right, it's the heart of this atrium, that the fountain appears to be water in motion, like matter in motion, right?  This is sort of a modern conception of the world, just a kind of chaos, matter in motion, these overlapping circles. 

But then we learned that actually the substrate of the fountain there is actually a foundation and a structure.  There is something solid.  There is this pipe with the tunnels or what do you — the funnels branching off from it.  But then that's odd too, because that suggests a kind of mechanism, right, it's a recirculating pump.  So you have the — and that what presents itself as matter in motion is also maybe something mysterious.  I mean, that's what's beautiful.  And the mechanistic trunk is not very beautiful.

So it seems to me he's doing all kinds of things with that image and flipping it and playing with it to try to figure out this question about technology and modernity and mystery.

CHAIRMAN KASS: Paul, have you got something here, doctorly speaking?

DR. McHUGH:  I was wondering when you'd get around to asking me and preternaturally quiet.  I was very — I'm very interested in hearing what you all read into this or read from this because you read this as patients.  I think Rebecca is correct that this is a doctor himself, but I think the reader is, as they often do with doctor stories, they read them as patients and wonder and think about whether they would find in this doctoring interaction comfort or not. 

And so I,too, kind of sense doctoring as  Dan says, is first competence and then compassion, because compassion having an empathetic thing, I began reading this as, first of all, would I do this to a patient, would I speak this way to a patient and would I, on the other hand, get anything from this?  And on those reflections, I absolutely agree that this is a book that tries to speak about how the mysteries of life have been mowed down by the juggernaut of technology. 

Well, in point of fact, this guy's been mowed down by the technology — the juggernaut of pathology in his own spiritual view of this.  He has reverted to a pantheistic position and the best he can say for his last day on earth is he's going to merge with the moss.  Well, you know, first of all, I'd never say a thing like that to patients, never.  I talk to a lot of patients at the end of their lives in various kinds of ways, just like Dan does, and what we talk about is not, "Gee, we're going to slip off into the sounds of the crickets".  We talk about where we came from and who we are and who mattered and how their love for us made it possible for us to flourish and whether we did as good a job as they'd hoped for us or not. And in that way bring them in some way into contact with one another.  The fact that we are people together and somebody at one level cared for us and loved us and in that way, made it possible for us to go forward.

Now, this is only a 14-year old little fellow and he's a bright little fellow, but he's also a suffering fellow and he can only suffer at that level.  And I would have — you know, I would have thought that it was even more accessible to that.  This — let's get it straight, I hated this story and this has its reverberations in Tom Quill and Jack Kevorkian.  It's one day with Richard, the next day with Jack, and why not get to the moss quickly and the like.

No sense of who lives with us, who has lived with us, who has made us what we are and whether there is some form of love itself that lives and shares with us our own suffering.  There is — this is the result of technology really at the level of disparate and fortunately, there are much better things to say to people and one would.

The real question is also whether a doctor — I'm going on, too.  Dan and I both do this.  We go on.

CHAIRMAN KASS: This is terrific.

DR. McHUGH:  Go on and on. 

CHAIRMAN KASS: Is there more to this, please go on.

DR. McHUGH:  Well, no, only in the sense of gee, would you charge in there?  You know, this is a kid you're meeting and he wants to know what are you going to do on your last day and you're a doctor and especially if you're a doctor that thinks anything about the psychological and spiritual nature of a human being, do you plow in and tell him this or — are you not going a little too far?  Where is the inhibition and the sort of sense of gee, what we all mean to" — now, the story is told that by doing this, he did the kid some good and I'm always of the opinion that, gee, I never know what — it's always interesting what people say, did them good.  A great story I like to tell about; after I had been two or three years at Mass General as a neurology resident, I was the Chief Resident and a guy comes in to see me looking very nice and he said, "I want to talk with Dr. McHugh", and I — he said, "Listen, you did me a world of good.  Do you remember me?"  And I said, "Gee, I don't".  And he said, "Well, you saw me two years ago in the emergency room and I was there with this burning in my feet and I was in pain and you looked me over very carefully.  And it was in the middle of the night and you took a good, you know, history and you found out that I had been drinking and drinking a lot", and of course, he had alcoholic polyneuritis, "And by the way, after we were through you told me, you know, stop drinking, and I did, and two years later I'm a lot better and you know, it's very nice".

So you never know what — he was kind of walking out the door and waved back and say, "Lay off the booze", and somehow or another the relationship made it possible for something good to happen and I was, you know, astonished that this happened, because I've spent hours with people telling them about the evils of drink and telling them to do this and do that and had no effect. 

And so you never know and so maybe this guy does him some good, but this isn't my way and but  is it anybody else's?

CHAIRMAN KASS: Frank is holding back but Frank reminded us in the last session that there are large parts of the world where this isn't somehow an aversion to some foolishness caused by the march of technology, but is an age old wisdom about the interconnection of nature and the unity of all things and an open minded person would at least entertain the possibility that what two billion people believe can't be entirely wrong and is therefore, worthy of reflection.  That would be the general point to you, Paul. 

But the boy's in isolation.  As far as we know, there is no family and the exquisite understanding is that, "If I tell you my name" — I shouldn't bungle this.  "Now we are strangers more or less anonymous.  By giving you my name, I become somebody who can reach out to grab you to capture.  You could even want to grab me". 

Now the boy is very wise, obviously, about what it means, in fact, to nominate yourself in this personal way and at a certain moment in the story beautifully described, he allows himself to be grabbed by this hand.  This is a boy who's in isolation and one can only imagine is preoccupied with this end and somehow this is a comforting tale to this boy or it enables something to happen.  I like — I mean, I've always known that Diana is a spectacular reader but I've learned two or three wonderful things really that just simply passed me by in the way of the boy transforms the dream and in fact, makes a human connection out and therefore, leaves the doctor grieving for the loss of his connection just for and in need of healing himself.  I think that's quite right.

But I'm not sure that — I mean, the doctor did this boy — deliberately did this boy a good turn and by speaking to him in a way that would allay this terror, not by somehow merging with the moss.  That's the characterature but by making seem somehow less terrible the — making it seem slightly less absolute the transition between being and not being, so that something could calm down and he's capable somehow of making something of these last moments and indeed to reach out in response and maybe give back a gift greater than he received. 

So and we can quarrel with the theology here.  I knew as soon as I distributed this story that this kind of pantheistic teaching would elicit a kind of dissent.  I wasn't prepared for Peter's attack on  noble lies, at least worries about whether people who want the truth ought to be given a tale which is edifying or at least edifying for them but humanly speaking this story is a successful act of healing, at least as I read it. 

And maybe the doctor had enough intuition to see that a speech about all the people who had done him a lot of good or what you say about the nurse is right but when she says, "We'll have a transfusion", we, this boy is too smart to be gulled by that and it doesn't do him a good turn.  There are certain other people for whom that would be fine but you've got to know the individuals here.  And maybe this doctor intuits what this particular human being, how he needs to be spoken to and has found a way to penetrate that terror in a way that can be accepted.  That's more than compassion.  It's a different kind of competence if you will, a competence to know — to recognize who's in front of you and how to speak to them to give the kind of comfort when the black bag is empty but the rest of the doctor's augmentariam is not.  Frank?

PROF. FUKUYAMA:  Well, I don't know.  I don't see why you keep insisting that this is a story about doctors and their appropriate role because it seems to me that what this doctor did is something that any human being could have done.  To me what was interesting was not that this told you something about the specialized question of what are the duties of a doctor to a patient, but it actually reminded me that in a certain way, doctors are privileged because they see people in the situation of that boy. 

The rest of us are so insulated from death and dependency and that kind of need that we never think about it.  And I've always thought that it's kind of a privilege of not just doctors but care givers generally, you know, that they have stories like the one, you know, Dan told or Paul that, you know, that the rest of us just don't have access to and it gives you, I think a very different view of what human life is like because you know, there's this Allistair McIntyre's book "Dependent Rational Animals", he begins it by saying that especially Americans have this view of, you know, the kind of self-sufficient independent, you know, individual is kind of an ideal type and that's what we look up to, but you know, the reality of so much human life is that in fact, we're deeply dependent and needy and so forth. 

And so it's always seemed to me a kind of privilege that doctors had, you know, had access to this sort of, you know, insights about what human life is like.  So that's what I thought was what I liked about the story. 

CHAIRMAN KASS: Let me just respond.  You picked up also on what Gil said.  I didn't mean to say that this was uniquely an office that a physician could render.  The question was whether it could be — whether it should be seen as an integral part.  I mean, I don't know any doctor.  I don't know any doctor who would — other than this one, who would be inclined to say, "The sick are my kind". 

And the question is whether that's a failure of the way in which we've somehow instructed physicians to somehow understand that as the basis of the bond because, look, what we did yesterday, I mean, you're talking about when you're dealing with the patients with dementia and the distinction between those who are looking for pharmacological means and those who are talking about standing with the patient and keeping company.  And so much of the success of our medicine really has been to arm the doctor to be a better fighter against the illnesses.  The question is whether it falls to others to do what has to be done when the fight is lost.  It's a very strange thing, a very strange thing that doctors and one should probably more likely say nurses, since there are more there than the doctors are, preside over the entrance or the exit from life.   That's a very odd thing.  I don't deplore it.  I'm not saying we should, you know, have births at home and nobody should die in hospitals though if you could avoid it humanly speaking, better, but it's very often too much to impose upon anybody to give that kind of care under those conditions. 

But it's odd.  I mean, the priests attend, the minister attends these ultimate moments rather than the person of medicine though at one time and Dr. Pellegrino can comment more deeply than I can by a lot, the distinction between the doctor and the priest was much, much less and the questions of what medicine healed were much, much richer.  And so part of the question is, if we're worried about the medicalization of so much of life but we have a shrunken view of what the medical vocation is and can embrace, then I think we've got even more problems than simply the technologies themselves, especially if the presiders over the uses of these technologies and the people who are in charge of those places where we are born, get sick and die, are people who do not regard this particular thing as part of their vocation, that that belongs to people who have been rendered invisible or in some ways less necessary because the doctors can do more about death or more of life than anybody else can and therefore, their status in relation to these things naturally rises.  That was the point.

This is an office of a human being but the question is, is that extra and added to the medical vocation or is it somehow intrinsic and do we have to worry about the character of the medical vocation increasing.  I think that came out all right.  I mean, that was my motive in putting this before us.  Gil and I won't keep us long because we've got public comment.  Four people want to speak and then we'll close it off.  Gil, Paul, Bill and Peter.

PROF. MEILAENDER:  Yeah, this is really just to repeat something I said earlier, but without denying at all the truth of what you've just said or that it's a salutary lesson to draw from this, whatever we call this story or whatever, I just want to repeat that I'm not — as a reading of the story, just as a reading of the story, I'm still not sure that the man ministers to the boy rather than the boy to the man in terms of who takes the initiative in this encounter, who's diagnosing whose problem, and who finally helps whom to face death.

Just as a reading of the story, however, the lesson you draw from it, I'm not quite persuaded yet that that's the first thing the story is about.

CHAIRMAN KASS: a point taken and embraced.  I agree with that comment.  Who was next?  It was Paul.

DR. McHUGH:  Well, as I say, I'm very interested in what you all are saying about this.  I want to draw another analogy though to our Council and its stories, in particularly to your relationship to your last comment about how technology has deprived us of certain kinds of things and I, of course, believe that technology has deprived this person of any — this doctor of any appreciation of the fullness of human love and affection and the deep side of that. 

We began, after all, reading the "Birth Mark" and the "Birth Mark" had as its theme the person was employing technology and forgot love.  And when he forgot love, death resulted.  Here is a doctor now long afterwards with technology at his beck and call, and the best he can do is not to summon up anything other than what he says is the unexpressed love between him and the patient but cannot speak about anything other than this strange falling into darkness, an almost Homeric vision of the darkness came over him and that was it. 

And that's — every reader is idiosyncratic as he reads and this is what I take.  I take it that this is Hawthorne demonstrating to us just where we're going.

CHAIRMAN KASS: Bill.

DR. HURLBUT:  That, I like a lot because the "Birth Mark", the overarching theme of the "Birth Mark" was an intervention against imperfection and then the loss that comes with that.  I think it's plain in this essay, this little story that he's decrying a falseness of the fountain, that it's — he said, "It's an attempt to disguise the true nature and purpose of the hospital.  It's a denial of death in mechanical terms — in architectural terms", rather.  And what strikes me about this and the way it connects with our first — the way we opened our Council three and a half years ago, is how we need to be so careful now as we go forward with our new powers and understanding of the mechanism of nature that we don't mechanize reality to the place where we extract and we distill out the — or we lose the sense of the meaning and myth and story that reconstitutes and preserves this boy's existence.  It's the telling of the story that makes that personal being sustain.

The hospital and the whole bargain with medicine is basically — it's a bargain.  We seek a remedy for health against the entropy of natural death and disease but we take a position against the natural in doing so.  We emphasize intervention and rescue and we create a kind of discontinuity and almost a kind of desperation and I spend many times sitting in those hospital — many hours sitting in those hospital cafeteria types.  They always try to make them look a little nicer.  They're very eerie places, like the — what do you call the flesh of that tree that cadaverous flesh.  They're like that.

The point is that medicine so easily could slip over into an anti-natural enterprise that from which we then lose our connection with reality and I think he's actually decrying the fact that medicine and doctors often do not feel like the sick or their kind.  I think he's saying that — I think this is a warning about modern medicine actually in here and its inability and its strong antagonism towards the natural, it's inability to sustain that longer overarching sense of the integrated wisdom of living in a world where the sirens never cease.

CHAIRMAN KASS: Thank you.  Peter, take the last comment, please.

PROF. LAWLER: Very quickly.  I think what's wrong with your interpretation, frankly, to agree with Gil is, there's no evidence that the boy is filled with any terror that needs to be remedied, right?

CHAIRMAN KASS: Say that again.

PROF. LAWLER: The boy is really not filled with any terror that needs to be remedied.  He seems to be facing up to death honestly.  And not only that, the doctor is sort of an odd man, right?   He spends all day writing by himself.  Then when he goes to lunch, he sits in an atrium all by himself and its architectural denial of death.  And the story says the only thing that gives the atrium any dignity or taste is the boy.  And then it contrasts the boy's — the boy's life with the forest, which is devoid of anything human, anything human which is good and anything human which is bad.  And so this man — I mean, to make a long story short which in filmland, it's almost like this man invents an imaginary friend to love.  I will stop.

CHAIRMAN KASS: Diana is entitled.  Please.

DR. SCHAUB:  One more point about the text and the fountain.  I mean, you begin with this deadly fountain but at the end — I mean, this is a way to say something in defense of the doctor, I think there is a real transformation of him.  He says that by the end, the boy has become like a fountain in his mind.  I mean, yes, maybe an imaginary friend but still it's a new friend that transforms him and he actually does now change his own vision.  It's not that forest merging with the moss and the bark.  I mean, the last words he says in the story proper before the explication is that, "Sometimes I speak to him.  With your eyes I tell him lift this tree up, up until it touches the sky so that you can climb it all the way to heaven".  I mean, there was no vision of heaven in that first dream and now there is. 

I mean, he says, you know, "I had a failure of nerve before.  I would not go past that point of the moment of death," but now he is actually envisioning that so and it does seem to be triggered by his love for the boy.

PROF. LAWLER: Yeah, that's exactly right, to intervene.  So Paul, I agree with you 98 percent of the time but in the final analysis, this story is about the redemptive power of love.  So the pantheistic thing is not the bottom line.

CHAIRMAN KASS: Astonishing.  Really, thank you very much for this discussion.  I think there's — there would be enough to start with at least to continue reflections on the limitations of the character of the medical vocation under these particular circumstances should we be so inclined.