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Medicine and Mystery: A dialogue

Medicine and Mystery, IllustrationOn 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 meaning.

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 follow.

JEROME GROOPMAN: 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 failed.

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 prayer.

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.

: 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 woman.

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 to heal.


Following their initial remarks, Groopman and Nuland took questions.

: 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.

: 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 is.

GROOPMAN: 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.

NULAND: You live in the O.R., you learn a lot of good jokes.

GROOPMAN: 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.

STEINFELS: 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?

GROOPMAN: 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.

NULAND: 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 view.

STEINFELS: 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.

NULAND: 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.

GROOPMAN: 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. That's paramount.

: 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?

NULAND: 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.

: 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?

GROOPMAN: 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.

: 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 to you?

GROOPMAN: Yes, I agree with that.

: Why do you think that's so?

: 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.

: 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."

: 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."

: 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.

NULAND: 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 belief.

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.

: 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.

GROOPMAN: 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.

: 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.

NULAND: 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 (Viking, 1997).

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 Square."

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