November 14, Boston College and the Atlantic Monthly sparked
a public conversation on the consequences of faith and launched
what is intended to be an annual forum under the title "Belief
and Nonbelief in Modern American Culture." The participants
were two renowned medical practitioners -- one a believer, the other
a non-believer. Before a rapt audience of 600 at the Copley Theatre
in Boston's Back Bay, they spoke of their search for meaning in
the moments of extreme suffering and anguish they find in their
profession. Oncologist Jerome Groopman, M.D., a professor of medicine
at Harvard Medical School, spoke from a perspective of faith. Sherwin
B. Nuland, M.D., a clinical professor of surgery at Yale School
of Medicine, spoke as a nonbeliever. Margaret O'Brien Steinfels,
editor of Commonweal, moderated.
The evening transplanted to Boston a tradition that began in Milan
under the leadership of the city's archbishop, Carlo Maria Cardinal
Martini. In an event known as the Chair for the Nonbeliever, Martini
has presided annually over an exchange between two prominent individuals
who share the same walk of life but have different grasps of life's
Martini's celebrated enterprise, which is open to the public and
held at the Cathedral of Milan, has brought together philosophers,
psychiatrists, poets, politicians, and artists.
In a lecture that he delivered at Harvard University a few years
ago, Martini explained his intent: "I do not distinguish between
believers and nonbelievers but between people who think and people
who do not think. My presupposition in doing this was that there
is in each of us a believer and a nonbeliever. Why, then, not try
to give voice to this inner struggle?"
The Boston dialogue was broadcast live to the BC campus. In addition,
some 100 alumni viewed the event via satellite at the Willard Hotel
in Washington, D.C., where the discussion afterward was impassioned
(Distance Learning). Excerpts
My perspective is that of a physician who has deep religious roots
and who seeks in some way to draw wisdom, strength, and insight
from that religious sensibility. In a curious way, I don't have
a large sense of tension being both a scientist and a person of
faith. My mother's family were Hassidim who came from Eastern Hungary,
the Carpathian mountains -- Elie Wiesel country, so to speak. They
were deeply religious people who looked to the world around them -- a
very grim world -- but tried to find within it a divine spark and
reasons for joy. My father's family represents another strain of
Orthodox Judaism. They were Lithuanians from outside of Vilna and
had a more intellectual approach in terms of rigorous study and
Talmudic debate. The mixing of those two gene pools, if you will,
or schools of Jewish theological thought, distilled for me a very
deep and abiding humanism -- a sense of love for one's fellow man
and woman, and a sense that each person whom you care for as a physician
is, in the classic biblical sense, a reflection of the divine image,
made in the image of God.
A few vignettes will illustrate how faith can function to the good
and to the bad in the context of clinical medicine. The first concerns
a woman named Elizabeth, a very noble Protestant woman. Her husband
was a minister. In her late 50s she developed breast cancer, and
I cared for her as an oncologist. Elizabeth was a person of deep
faith, and I worried as I cared for her that her faith in some way
would be tested and that the outcome would be that her faith would
be lost or that she would, in some way, see her illness and her
suffering and her travail ultimately in a negative light. But in
fact she did not see her illness in a classical religious paradigm -- as
I don't -- of reward and punishment, where illness is so often interpreted
as retribution for one's sins. Rather, she acknowledged to me that
she simply couldn't understand the reason.
I thought about the great Protestant theologian Paul Tillich, who
said that the basis of all true faith is doubt -- questioning. Yet
I assumed, as I watched Elizabeth deal with a situation of spreading
cancer and increasing debility -- which she faced and handled with
extraordinary equanimity -- that this was a woman whose doubts somehow
had been put to the side. This was a woman whose theological questions
had either been answered or were no longer pressing. She found in
her faith tremendous strength to care not only for herself, but
for those around her. Her husband, the minister, interestingly,
was having much more psychological difficulty with her imminent
loss, as were her children. She drew on a faith that believes strongly
in an afterlife and felt that regardless of the travails of this
world, she would be delivered to a place of peace and rest.
I'm not sure, and I think none of us scientists can really know
for a fact. But I saw in Elizabeth an extraordinary abiding faith
that allowed her to weather the storm of her illness and pass through
it without flinching. She gave me a gift shortly before her death
of a large stone, which I have in my office, which is engraved with
the words from one of the Psalms: "Oh, Lord, teach us to number
our days so that we may attain a heart of wisdom." This was
a woman who had an understanding of her faith so that she had numbered
her days and clearly faced the end of her life with a heart of wisdom.
A second vignette is an example of when my faith and my belief were
tested. There was a young Irish Catholic boy named Matt, whom I
wrote about in The Measure of Our Days, who had survived
acute leukemia only to fall ill with transfusion-related AIDS. His
father, who drove a delivery truck, was a deeply believing Irish
Catholic, closely tied to the Church, and he watched and waited
for God to intervene to save his son. He believed that we, the physicians
caring for this child, were in some way the extensions of God's
arms. And we failed. We failed to save his life, and therefore God
I had no answer for this father, and indeed I found myself empty
and unable to rationalize in any way as a believing person such
a horrific tragedy. But over time I saw the father create meaning.
A meaning that was not given to him de facto, but through
his church. He felt that the way to honor the memory of his son,
and in some way to sustain his faith, was to act to help other children
similarly afflicted. He found that within the language of the Church
and within its structure. And it made me reflect on the nature of
I speak specifically of the prayer that is said in synagogues for
people who are sick. Every Saturday a part of the Torah is read.
Toward the end of the reading, the reader asks if anyone knows of
someone who is ill; then that person's name is announced, and a
prayer is said for healing. The prayer in Hebrew says, "Refuat
ha'nefesh v'refuat ha'guf": "There should be a healing
of the soul and a healing of the body." I have listened to
this innumerable times, having been brought up in an Orthodox tradition,
and only recently did I begin to ask, Why that order? Judaism is
very much a this-world, practical kind of faith that doesn't have
a well-formed concept of an afterlife. Why should there be first
a petition for the healing of the soul, and only then for the healing
of the body? I thought, Well, people say you need a strong spirit.
You need a healthy soul in order to endure illness. Therefore, in
some way that should be the first goal, and then from that would
follow clinical healing -- physical healing. But as Sherwin Nuland
has written, there are many people with great spirit and deep soul
and determination who don't make it -- who don't have a healing of
the body. The facile statement that "he made it because his
spirit was strong" may have helped some particular person,
but there are many whose spirits are strong who don't make it.
Then I thought some more about this Jewish prayer. Ultimately, there
will come a time when the body cannot be healed. All of us are mortal,
all of us will develop a condition which is fatal -- incurable. But
the soul can always be healed, even to the last breath of a person.
The unreconciled conflicts in a person's life, the difficulties
that he or she faces from a moral point of view or a relationship
point of view -- these can be addressed and in some way repaired.
So when prayer focuses us in the context of illness, it makes sense
over the course of a lifetime to understand first that the always-present
opportunity is to heal the soul; and then, of course, if possible,
to heal the body.
It's that kind of sensibility that I think faith and thought -- grounded
in a sense that within all human beings there is a divine spark,
regardless of the theology or the religion -- can bring to bear to
make medicine truly a humanistic profession.
SHERWIN NULAND: I should say at the outset, categorically
and definitively, that I've never been able to convince myself -- even
during the days when I still had some religion -- that life has inherent
meaning. This, I believe, is precisely the great glory of the human
spirit: to find meaning, to create meaning, to so imbue an individual
with the importance of meaning that he or she -- whether realizing
it or not -- may devote a life to the search for meaning. I would
submit that meaning for us as human beings is to be found in the
notion of the aesthetic of beauty, the beauty of human love, and
the aesthetic of nature -- the order, the magnificence of nature.
Let me talk for a moment about love, because love is the ultimate
source of meaning in our lives, whether it's love of God, or love
of humanity, or love of both. Here I'll invoke a book that many
of us read in high school, although I understand it's nowadays rarely
on the syllabus: Thornton Wilder's The Bridge of San Luis Rey.
Wilder won the Pulitzer Prize for this book in 1927. It's a series
of interconnected stories of love so strong that, despite the fact
that it's not acknowledged by the recipient of the love, sometimes
not understood by the recipient of the love, sometimes even rejected
by the recipient of the love -- none of that makes any difference.
It's love that's directed toward individuals who, although they
don't recognize their own need for love, have an absorbing necessity
for it in their lives. Yet, they are far less enriched by it than
those who give their love, those in whose breast it originates.
The human spirit recognizes the need for this deepest emotion of
which we're capable. Even should disaster strike and the people
or the person we love should die, the power of that feeling continues
to sustain us, those who love. I'm convinced that Wilder really
won the Pulitzer for the last few sentences in the book: "Even
memory is not necessary for love. There is a land of the living
and a land of the dead and the bridge is love, the only survivor,
the only meaning." I don't know what Wilder's religious beliefs
were. I know only that he found the meaning of his life in love.
Several years ago I wrote a book called The Wisdom of the Body.
In that book I put forth my notion that the human spirit does not
arise from anything in celestial spheres, but arises out of biological
needs within our bodies. I was invited to discuss this at Albertus
Magnus College in New Haven -- a Catholic college, the president of
which, Julia McNamara, is a friend of mine. After we discussed this
issue, President McNamara said to me, "I think I know a single
word that unites your sense of what is spiritual and what has meaning
with mine. And that word is wonder." For me it is wonder
at the marvels of nature and most specifically the wonders of the
human body and the human mind. For Julia McNamara it is wonder at
the marvels of God and His divine love.
The organizers of this symposium set a number of topics that we
might discuss, and I've chosen three that I want to address. One
of them is, "Have you faced specific medical circumstances
in which you found yourself grappling with your lack of belief?"
And, yes, I have.
I'd like to offer you a case study. The year is 1977 and I'm called
to the emergency room at about 10 o'clock in the evening to see
a 72-year-old woman who's been having severe abdominal pain, increasing
over the previous 16 hours. After examining her and doing some rather
rudimentary tests it becomes obvious that she has a disease that
we call mesenteric ischemia, which means that her intestine is not
getting enough blood. In her case, it was due to congestive heart
failure. At that time the only thing we could do was to operate
on such a person in the hope that the area of involved intestine
would be small enough that we could take it out and the patient
might survive. But it was not to be. As it turned out, her entire
small intestine was involved, and much of her colon as well. I closed
her abdomen, took her to the intensive care unit, and went out to
speak to her four children -- four grown children. I didn't tell you
when this happened except for the year. It happened in late September
of 1977. It happened on the eve of Yom Kippur, to an Orthodox Jewish
I stood next to her in the intensive care unit, thinking not of
her suffering, because she was beyond suffering. She had about 12
or 16 hours to live. It would be easy to sedate her. I was thinking
of those people -- her children -- suffering with their anguish through
the night. The question you ask me is: "Have you found yourself
grappling with the limitations of your nonbelief?" Let me tell
you what I went through. The awe, the holiness, the wonder of that
night would not leave my thoughts. The thought that in the midst
of that wonder I was leaving this family to spend the entire night
outside in that waiting room, coming in periodically to see their
mother, was more than I could bear.
I did something that you can't do anymore, but that you could do
in 1977. I asked the nurse for a syringe of morphine with about
four times the required dose, and I injected it into her intravenous
tubing. And her life ended.
I'm going to stop right there with that story. This was the result
of my grappling with the limitations of my unbelieving outlook.
Here I am, someone with no belief in anything supernatural, and
yet the wonder of the power of religion has never left me, as it
has not left many agnostics and a fair number of atheists I've spoken
to as well.
Another question: "Have you ever been tempted, or seen colleagues
be tempted, or patients be tempted, by the notion of a doctor as
possessing potentially Godlike powers? Or, in contrary fashion,
have you ever succumbed to despair brought on by your ineffectuality?
How does your nonbelieving outlook support this situation?"
Well, here's another case study -- actually, in a way, it's an experience
I've had dozens of times. I'm making rounds, and there are two or
three students with me and a couple of residents, and I come to
the room of a woman on whom I operated a long time ago for an advanced
malignancy. She hasn't done well, and she is very near death. I
turn to the house staff, and I say that the woman is tired, she's
exhausted, and that for her own good we should leave her and go
on to the next room -- where there just happens to be someone on whom
I operated very successfully the day before.
Now I may kid the kids; they may believe that what I am doing is
intended for the benefit of this very sick woman. But the real reason
that I proceed to the next room is that I cannot face my ineffectuality
in what has happened to her. I have lost my Godlike stature. I would
submit to you that one of the attractions of a medical career is
specifically that Godlike stature. I would also submit to you that
physicians are not Godlike creatures but require constant reaffirmation -- surgeons
more than most.
It is so difficult to face failure. I have never lost a patient
when I didn't, on some level, honestly believe it was my fault.
It makes no difference that I know that nature takes its course.
We all know that, objectively. But subjectively, we don't. That
loss of my sense of power is devastating. I suppose, were I a man
of religion, or faith, I could share the blame with God's will.
But I can't do that. So I try to square my shoulders, and attempt
to figure out what I could conceivably have done wrong.
A last example: "Can you describe an episode where you have
been convinced that a particular life was worth preserving no matter
how costly the effort? Alternatively, can you describe an episode
where you felt a particular life was not worth preserving?"
When our bioethics committee at the Yale-New Haven Hospital was
constituted, the very first major problem we came up against -- the
year was 1985, early in the AIDS pandemic -- was that we didn't know
very much about the transmissibility of AIDS, about the dangers
to medical personnel of taking care of patients with AIDS. The cardiovascular
group -- the heart surgery group in our hospital -- was refusing to
operate on an I.V. drug abuser who had AIDS and who also had an
infected aortic valve. So we asked a senior member of that service
to come and speak to the committee.
We asked him to explain himself, and he said very simply, "I
can't justify, for an IV drug abuser, risking my life and the lives
of the young people assisting me." Someone on the committee
asked, "Are there any circumstances in which you would find
it justified?" And he said, "Well, certainly. If this
patient had hemophilia." Many hemophiliacs were getting AIDS,
of course, at that time. Then another member of the committee said,
"Wait a minute. You are saying that you rank people according
to how you see their lives as having more value or less value. What's
your ranking?" And he just looked flat out at us, as if of
course everybody should understand that there's a ranking of the
value of human life, and he said, "The hemophiliac is someone
for whom I would take a risk; the gay man with AIDS is someone for
whom I would take less of a risk; the IV drug abuser is the man
for whom I would take no risk. And that's what I'm doing now."
Well, in the end, he did operate on that patient, and the reason
was that he realized, as he was with us, how shocked we all were
that anybody could have created such a pecking order.
But do you know what was most shocking to me? As I left that room,
I realized I had a similar pecking order. Granted, gay men and hemophiliacs
were on the same level, but as I faced the truth of what was going
on in my mind, I realized that IV drug abusers were not. They were
poor white people; they were poor black people; they were poor Hispanics.
I could not identify with them. As you survey members of the medical
profession -- as you watch them for 30, 40 years, as I have -- the recognition
is that the lives that have the most value for us are the lives
that we identify with the most. We've got to fight that tendency
constantly. There was a time when I couldn't have told this story
before an audience of people I didn't know, without feeling shame.
But I think describing it has some value because there's a peculiar
complex of emotions that doctors go through in making any medical
decision, whether we are people of faith or not people of faith.
So what's the lesson in all of this for me, who stands by himself,
who does not rely on faith, who does not rely on the principles
of religious belief, or on a morality that's grounded in religion?
I solve moral dilemmas by trying to recognize the pulls and pressures
of the passions and prejudices that course through my mind, and
by trying to overcome them, and by recognizing that the human mind
is neither a rational thing nor a logical thing, especially when
life is involved. It's in simply making decisions by myself -- without
the aid of religion -- that I learn about morality and its inconsistencies.
By allowing for morality's inconsistencies, and for my own, I can
only hope to forgive myself the human lapses that come with my attempts
Following their initial remarks, Groopman and Nuland took questions.
MARGARET STEINFELS: I'm curious to know whether a surgeon,
like Dr. Nuland, and an internist, like Dr. Groopman, approach questions
of religion, of spirituality, from different perspectives.
NULAND: Well, clearly, an internist is the doctor. A
surgeon's associations with patients are limited, but they don't
have to be as limited as I and many of my surgeon colleagues have
made them. Surgery has been characterized as appealing to a group
of people who are able to build a coat of armor to protect themselves
from the pain of the disease and death that they see. Internists,
I think, have never suffered under that delusion. I might also say
that internal medicine appeals to a far more intellectual type than
surgery does. Surgeons tend to be men and women who are fascinated
by our Godlike manual dexterity. I think internists feel a lot more
personal responsibility for the patient's spirit, which I define
in a completely nonreligious way; feel a lot more responsibility
for the humanity of a patient's family; feel a lot more responsibility
for the penumbra, everything that's out there in the shadow that
a patient casts. I worry a lot about that in surgery. When I'm deciding
whether to take the next step, a sense of who this person is would
be much more valuable to me than what I was taught, which is to
limit my thinking to, This is a square place with an organ inside,
and it's my job to take it out and not consider who that person
I think what you're seeing is a surgeon of remarkable humanity,
as you can tell from his writings. I was struck -- we were trading
jokes, Dr. Nuland has a lot of good jokes, which maybe he'll share
with us later.
You live in the O.R., you learn a lot of good jokes.
But there's a joke I heard that picked up on one of his comments:
All the saintly people are waiting to get into the Pearly Gates,
and Saint Peter is checking their credentials -- one by one. It's
an extremely arduous process, but they're saintly people, so they're
very patient and waiting. And then, all of a sudden, from the back
of the line, some guy in a white coat with a stethoscope jumps the
queue. And he walks right into the gates of Heaven. These saintly
people are kind of ticked off, and one of them goes up to Saint
Peter and says, "What gives here? We're saintly people, waiting
patiently to get into the Pearly Gates, and this doctor jumps the
line and walks in!" And Saint Peter says, "Oh, don't worry.
That's God. He just thinks he's a doctor."
There is a tremendous risk of becoming intoxicated with power. Honestly
speaking, for centuries, until the revolution in biomedicine, surgeons
have actually done something, while internists -- "physicians" -- have
really had extraordinarily limited resources, particularly before
the advent of antibiotics. The impulse to step back from that intoxication,
to not imagine oneself as Godlike, is deeply rooted in a genuine
religious sensibility. Idolatry in its extreme is the worship of
the self, because basically what you do is you move God out of the
way, and you see yourself as the center of the universe. It's something
that all physicians, with the powers and the prerogatives that they
have in our culture, are susceptible to.
You don't have to be religious to resist that. But as a person of
religious faith, I read and I think and I see rabbinic opinions
and other opinions where that insight is in sharp focus, and I realize
the limits of my earthly powers; I realize the risks of my ego.
Religious people and even nonreligious people have somewhat common
things they may do to comfort themselves, to try to understand their
condition when they are very sick or dying. One of the most common
forms for religious people, but also reportedly common in foxholes -- because
there are no atheists to be found there -- is that people pray. What
effect do you think prayer may have on persons who are very ill?
Any effect at all?
I am extremely skeptical about what has caught the attention of
the media -- so called "remote prayer." So I'll just address
that briefly. These are the experiments that are being done where
a group of people in Denver pray for a group of people in Dallas,
and the people in Dallas have no knowledge that they're being prayed
for. If you actually go back and look at many of these studies,
they have a group of six and a standard deviation of infinity, basically.
I don't understand or approach prayer as a remote control -- almost
like channel surfing -- where you want to get to the right program.
What prayer does for me is to focus my mind, to connect to those
gifts that God gives us, which are intellect and curiosity. For
me, prayer is a mechanism to look deeply into my mind and into my
heart, in order to do as much as I can for the patient.
There's a certain assumption that spirituality has to do only with
religion, and I would argue that that's absolutely not so. The human
organism is a spiritual organism if we define spiritual as the need
for harmony, order, symmetry, unity, oneness with everything around
us, wonder, and the sense of enrichment that comes as a result of
being uplifted by something that transcends what we are. There is
a quality that lifts us beyond ourselves, and we find it in nature,
and we find it in such things as music, and if you put nature and
music together there's a single category -- it is beauty. It's a sense
of transcendent love which enriches us. So let me recuse myself
from any thought that people of faith have a monopoly on spirituality.
They just have a particular edition of human spirituality. I abhor
the thought of pragmatic prayer. It drives me insane to hear of
how people in foxholes suddenly stop being atheists because they're
being shot at.
To me, faith is love. Faith is the absolute desire to worship this
deity that you believe has given birth to you and life and the world,
and the conviction that this deity is watching over you in a general
pastoral sense. But to ask for individual intervention is something
that I think is a mockery of faith.
How many times have I seen basketball players cross themselves before
they take a foul shot? Now what's that all about? Whose side is
God on? To me, faith is an extraordinarily overwhelming sense of
being guided, of there being true meaning in the world that is given,
not from within -- as I believe -- but from without, because we are
here for a purpose. Prayer is meant to exalt that deity -- to exalt
that power, to express love for that power.
Let's talk about romantic love. It's so easy to express love for
someone about whom you have romantic feelings, and you don't ask
for anything in return except their love. That's what I think prayer
should be. I certainly can't blame people for getting up on a Saturday
morning and making a prayer for the dying. I can't blame people
for going to church and lighting a candle. I understand that. But
I say that's pagan, nevertheless. That's not what spirituality and
love of God should be, as I see it, from this detached point of
Dr. Nuland, in your book you use a phrase that is certainly known
to any medievalists in the group, ars moriendi, the art of
dying, which was the medieval notion of how to help people leave
this life. I wonder if each of you might mention some things that
you think our culture needs to do to create an ars moriendi
for the 21st century.
I'm going to invoke a Hebrew word. The word for funeral in Hebrew
is levayah, which means literally "to accompany."
And the notion is that in an Orthodox funeral you will see, as the
hearse pulls up, four, six, eight men -- whatever -- go to the hearse.
They are friends, they are the closest people who are not relatives
to the person who has died. They will take that pine box out and
carry it, accompany it to the grave. My notion is that we should
begin accompanying the dying from the very moment we know that a
disease which is potentially lethal has been diagnosed. There's
a limit, clearly, to how far we can go. But there is for us as physicians
a pastoral calling we should return to -- that we had until the middle
of this past century or so, before medicine started to be able to
really do things for people.
For those who are family members, for those who loved the dying,
this means restoring the notion of accompanying. Near the time of
death, those who love a dying person tend to become very selfish -- not
selfish in a morally reprehensible way, but we all want to behave
in a way that we can live with when it's over. We always want to
feel we have done the best thing, and we all have different ideas
about what the best thing is.
If I haven't called my mother in two years, and she's dying, I don't
want to see her die; I'm going to get in there and make those doctors
keep working at it, because I feel guilty about my absence from
her life. If I have been close to my mother and understand her wishes,
I may, on the other hand, want to be sure that her comfort is paramount.
W. H. Auden once said that doctors are the least introspective of
all professionals. Some of this has to do with the Godlike aura.
Some of it has to do with our fear of looking into ourselves. But
I think all of us near the time of someone's death must look into
our real motives of love and recognize that sometimes we have to
sacrifice what we think of as our peace of mind in the interest
of the person who is actually making this journey. And I might say
that things are getting better -- that we've made a lot of progress
in the past five or six years.
I agree. It's very hard because of the fear that the dying person
often feels and the fear that the healthy person and the physician
feel, and that family members feel. Part of it is what Dr. Nuland
said earlier, which is the sense from the physician's point of view,
particularly in this high-tech age, that somehow you failed. The
other factor is that death is a mystery, and that regardless of
your beliefs, no one really knows what is on the other side -- if
anything. That lack of knowledge, as sentient beings, whether we
have faith or don't have faith, is often terrifying. Facing death
means learning how to subsume that terror, that fear, and to not
abandon the person, but accompany the person, and comfort the person.
QUESTION FROM THE AUDIENCE: Dr. Nuland, you spoke of
the physician who would not perform surgery on the drug addict.
I'm wondering, when you see that kind of unconscious prejudice in
colleagues, how do you try to help them educate themselves?
The mentality I described was not unconscious on the doctor's part,
and this is the most interesting part of the story. He assumed that
everybody felt as he did, and to a certain extent, I did, too. This
is my argument for introspection. By understanding where our decisions
about our points of view come from, we can sometimes overcome them.
When the doctor realized how out of line he was, in the context
of a group of about a dozen people for whom he had considerable
respect, he didn't change his viewpoint. He didn't feel that the
patient's life was now suddenly more valuable. But he knew that
people he respected were shocked at what he was saying. That's called
moral suasion. And there's a lot to be said for moral suasion. There's
also a lot to be said for each of us living our lives as an exemplar
of morality, whether our morality comes from our religious sense,
or whether it comes from within ourselves and what we learned at
our parents' knees. If there's a single profession that can provide
moral beacons for prejudiced people, especially those who are prejudiced
against particular groups in our society, it's the medical profession.
And we ought to be a lot better at it than we are.
GROOPMAN: Before I came here I jotted down a prayer credited
to Maimonides, the great 12th-century physician, philosopher, and
theologian. Every morning he is said to have recited this, probably
as he looked in the mirror: "Let not desire for wealth or benefit
blind me from seeing truth. Deem me worthy of seeing in the sufferer
a person, neither rich nor poor, friend nor foe, good nor bad. Show
me only the person." I agree entirely with what Dr. Nuland
said in that in medicine there's the opportunity and the obligation
to transcend those personal prejudices so that you really can get
at the core of common humanity.
QUESTION FROM THE AUDIENCE:
I'm not in the medical profession, and I'm not particularly a person
of faith either. Do you find that patients who view the doctors
as gods are relying less on faith? Are they less demanding or more
demanding of the doctors? Have you found that people who continue
to have faith in God are not as demanding of the doctors?
People of faith don't say, "Oh, it's God's will. Give me a
B-minus effort to save me." I don't think it cuts that way.
I do think, though, that sometimes people of faith, particularly
if theologically they have a sense of an afterlife, can rationalize
or in some way more quickly come to terms with clinical failure.
NULAND: This gives me an opportunity to ask Dr. Groopman
a question -- about his experience with very religious people. When
danger is near, when they are very sick in the hospital, they tend
to rely far more on medical help, and speak far less about their
religious belief to carry them through. Does that sound familiar
Yes, I agree with that.
STEINFELS: Why do you think that's so?
NULAND: Because I think faith is fragile among all of
us. We must not confuse ritual with belief. In American society
we get so wrapped up in ritual -- especially the two religions we've
been talking mostly about, Catholicism and Judaism. Some people
become so absorbed with ritual that they lose true faith, true love
in the glory of God as I described it earlier, and depend on ritualistic
formulas, among which I include prayer. That may be the reason that
when they're really threatened with something, they turn to the
ultimate authority, which to them is not really God, but mankind
and the magic of mankind's abilities.
GROOPMAN: I would interpret it differently. I'm thinking
of a patient I take care of, a devout woman of genuine faith. An
Italian Catholic from Boston's North End, with breast cancer. I
think she sees the physicians -- the knowledge that the physicians
have and the efforts that the physicians are making -- as the extension
of God, as His finger, as His arms. She is very focused on what
I will do for her breast cancer, and happily it's been contained,
despite its being incurable. But there's no obsessive chanting of
prayer or lighting of votive candles or whatever.
I think prayer need not simply be an equation of give and take -- a
barter with God. I think it can focus someone deeply to try to think
clearly. And by clearly I mean not only clinically and scientifically,
but also in terms of motives, to understand one's own psychology
and to try to connect -- I'm speaking slightly mystically now -- to
try to connect with that sense of the divine, which I believe exists
in all people. It doesn't have to be something that functions as,
"Please part the Heavens, come down and take this tumor away."
NULAND: Once, many years ago, I was speaking to a very
dear friend, who's a Hindu. I made the mistake of saying to him,
in the metaphoric sense -- although he didn't think I was saying it
in a metaphoric sense -- "We do God's work on earth." He
looked at me, and he was offended, and he said, "God doesn't
need you to do His work; God does His work. You do your work. Move
out of His way."
QUESTION FROM THE AUDIENCE: I just wanted to ask you,
Dr. Nuland, if you could help me understand something. In your remarks
at the beginning about the woman to whom you gave an extra dose
of morphine in the circumstance that you described, you said that
it was a result of the limitations of your nonbelief. Can you explain
this? It sounds like perhaps you might have euthanized her because
of the impending pressure of the moment, or it could be interpreted
a number of ways.
I'm glad you've asked this. I find the religious belief of others
overpowering, overwhelming. I have seen religious faith -- rarely,
certainly not commonly -- do some extraordinary things in this long
career of mine.
It's the power of belief, and not the divinity itself that I subscribe
to, and I have used the power of belief over and over again, encouraged
it in those relatively few of my patients who want to share it with
a surgeon. It doesn't happen very often, but my role is to strengthen
the belief systems of people, and not to eat away at them or wear
them down. The faithful come to death with a whole lifetime of building
these systems, and one of the problems with physicians in general,
as they struggle so hard with their own difficulties and focus so
much on science, is that they tend by example to weaken the belief
systems of their patients. I am in awe of the power of people's
As a physician one should not take so much as a brick out of that
building. If anything, when the bricks are a little weak, you put
a little mortar on them, and that's part of my pastoral function
as a nonbeliever. That's part of my accompanying a patient as a
nonbeliever. The period preceding death is not a time for theological
debate. It is a time for support and strengthening. And I'll tell
you something: It does a hell of a lot for me, too, as a nonbeliever,
to witness the power of commitment to faith.
QUESTION FROM THE AUDIENCE: I am a retired physician.
I have half a century of experience on the front lines. I never
thought I was God. My patients thought I was God, and to the extent
to which that has been lost, patients are suffering. They thought
I was God, but they knew that I couldn't perform miracles. I wasn't
afraid to go to the house of mourning or to the wake, which is rarely
done by physicians anymore, and I just want your comments on that -- the
sense that the patient looking up from that litter does not want
to see a mortal; he wants to see a god.
Having been a patient, I think I agree with you in part. But I think
there's another dimension, in which for a patient it's critical
to understand the fallibility of the physician and to try to communicate
with the physician where the limits of knowledge are. From that
point we can make decisions about whether more knowledge or another
physician is needed. This is something I dealt with in the second
book I wrote. It's so infantalizing to be sick. You become like
a child, looking for an all-powerful parent who is going to sweep
you up in his or her arms and just make it all better. But we know
it doesn't work that way. And as you said, physicians are not God,
omniscient or omnipotent. I think that in a way the modern patient
is much more questioning. And when the physician steps off the pedestal
and moves closer to the patient, it's for the better.
QUESTION FROM THE AUDIENCE: Dr. Nuland, I'm less clear
than I was before about your anecdote. Coming to this conversation
as one who has done chaplaincy in the hospital in a pastoral role,
I think that the pastoral response to a family at the time of death
should be to neither affirm or disabuse them of their faith, but
rather to be present in the moment. And it seems to me, if I heard
you correctly, that you thought that some sort of active response
was needed. I'm still unclear about the relationship between your
perception of the family and their faith and the action you took.
Well, it was a personal response. And maybe in certain ways it was
a selfish response. I was overwhelmed, always have been, by the
awe of that night in Jewish belief. By the solemnity of that night.
There was something about the disgusting details of that woman's
death and what I had seen inside of her abdomen and what that family
was going through -- that it was torture for them, and that they would
be tortured all through this night, which is meant to be, in their
religious belief, a night of wonder and of holiness. And perhaps
to satisfy my own conscience, I decided that I would not allow them
to keep suffering that anguish through the night if I could end
it 12 hours earlier. And that's what I did. You might say to me,
and correctly so, "You were thinking of yourself. You were
thinking about your own pain watching their pain, and so you took
this into your own hands and intervened." I would have no argument
with that, because I would have to accept it. Yes, that's the way
I see it. I may have been completely mistaken. This was my answer
to the initial question, Have you found yourself grappling with
the limits of your nonbelief? And suddenly I find myself as a person
with lack of belief overwhelmed by someone else's belief. And essentially
powerless not to do something about it.
Jerome Groopman, M.D., writes on medicine and biology for the
New Yorker. His books include Second Opinions: Stories of Intuition
and Choice in the Changing World of Medicine (Viking, 2000) and
The Measure of Our Days: A Spiritual Exploration of Illness
Sherwin B. Nuland, MD, writes a column for the American Scholar.
His books include The Mysteries Within: A Surgeon Reflects on
Medical Myths (Simon & Schuster, 2000), Leonardo da Vinci
(Viking, 2000), The Wisdom of the Body: Discovering the Human
Spirit (Knopf, 1997), and How We Die: Reflections on Life's
Final Chapter (Knopf, 1994).
Margaret O'Brien Steinfels, editor of Commonweal, is codirecting
the Commonweal project "American Catholics in the Public
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