Spirituality, Religious Wisdom, and the Care of the Patient

Control in the Context of Illness:  A Catholic Perspective

Daniel P. Sulmasy, O.F.M., M.D., Ph.D.
daniel_sulmasy@nymc.edu

The aim of this program is to stimulate an interfaith, interdisciplinary, inter-institutional dialogue about spiritual problems that arise in the context of illness.  Our aim is not to ask each speaker to address these issues in the neutered language of some generic spirituality designed to be inoffensive to all and therefore meaningful to none, but to speak in the full richness of his or her own tradition.  Subsequently, what you are about to hear from me may start out rather general, but will end up explicitly Christian and Catholic.  I hope no one finds this off-putting.  It is intended to break the question wide open, and while such openness may be disturbing, it is intended to be constructive and ought not be offensive.  In fact, if our experience from last year repeats itself, this method may result in our mutual discovery of some differences in the approaches of various faith traditions.

That would be instructive and useful.  Far more often, however, our experience last year was that if we share at a deep enough level from the full richness of our spiritual traditions, the resonances and similarities between and among traditions far outweigh the differences.  I hope something like this might happen again tonight.

This program is also designed to allow us to address the spirituality of being a health care professional as much as it is the spirituality of being a patient.  The topic of control is very rich.  It is often a problem for both patients and professionals.   But I thought it impossible to do justice to both sides of this equation in the time allotted, and therefore chose to focus my remarks. 

In fact, the issue of control is only a practical clinical issue when it is an issue for both patient and professional, since if it is only an issue for one, this generally means that the other party has acquiesced, and hence no one notices.  Physicians, in particular, tend to recognize the issue of control as a problem (perhaps even calling an ethics consult) when patients appear to be behaving in a controlling or manipulative manner.   Physicians tend to be completely oblivious to the fact their own control issues are necessarily at play in such a case, and have probably been an unaddressed issue in every other case, and would have been recognized but for the fact that the other patients have simply submitted to the physician's control.  So, I chose tonight to concentrate on the issue of control as a spiritual issue completely from the side of the health care professional, especially from the perspective of the physician.  The case discussion will take us later to the patient's side of the equation.

I presume most people are familiar with the story of Prometheus.  Prometheus stole fire from the gods, and as punishment for this transgression was chained to a rock where vultures ate away at his liver, which the gods caused to grow back every day only to have the cycle repeated.

It is of no small interest to the topic of tonight's colloquium that, in a recent article in the New England Journal of Medicine, a scientist wrote an editorial lauding the possibility of cloning human embryos with which to create a pool of stem cells for each of us, leading us the brink of immortality.  She evoked the myth of Prometheus to support this romantic idyl, presenting as a great hero the new Prometheus, defying the gods and the death they impose on us mortals, who might soon have the power to regenerate our own livers through cloning.

We still want control of the fire.  And despite all protestations of scientistic atheism, our secular culture believes strongly in the gods who would keep that fire from us.  We believe in a jealous, zero-sum spiritual universe in which the gods can be diminished if we can steal their fire.  That is why a scientist who wants to clone human beings can see Prometheus as a romantic hero rather than a pathetic creature.  Despite the fact that our livers might be plucked at by vultures, we can now revel at the prospect that even the regenerative fire that perpetuates our own punishment might soon belong to us.  We imagine ourselves happier if we could control even our own punishment.

We want to be in control.  For many persons today, this is central to the meaning of life.

Many bioethicists believe that the central goal of ethics is to promote people's life plans and to maximize the control they have over their own futures.  We think this is the philosophical foundation of informed consent.  Studies have shown that it is far more common for patients to seek assisted suicide because of loss of control than because of pain.

Control is probably of even greater importance for health care professionals than it is for patients, and still more important for physicians than it is for nurses, chaplains, social workers, and others.  We have three great attachments -

The need to be in control

The need to be effective

And the need to be right.

We abhor patients who are non-compliant.  We are frustrated by those diseases that resist the power of our increasingly sophisticated potions.  We sneer superciliously at the local docs who have missed the obscure diagnoses that we make in our medical Meccas.  For many of us, our accomplishments as professionals have become the chief source of meaning and purpose in our lives.  We cure some diseases, attenuate the effects of others, and conduct research that we promise ourselves will one day eliminate them all.  We appear to hold the fire in our hands.

Of course, all this belief in control as the eternal flame of life's meaning appears very odd if one takes a few steps back and begins to look at the larger picture.  To begin with, we have no control over the fact of our existence.  We did not, in any literal way, create ourselves.  And this lack of control cannot be overcome through genetic engineering.

It is metaphysically impossible to choose one's own biological parents.  Even the wildest proponents of so-called regenerative medicine talk only of indefinite life-extension, not true immortality.  And perhaps most importantly, we cannot control whether someone else loves us.  In the very exercise of such control what we received would cease to be love.  So, if the quest for control is the meaning of life, life's meaning would necessarily exclude existence, family, death, and love.  Even if life's meaning were more cleverly defined as the quest for control over the things one could control, and existence, family, death, and love were considered as mere givens of which everyone partakes, what remained would seem rather paltry, not to mention boringly bereft of spontaneity.  It would hardly seem to make life meaningful.

And yet, despite all this profound lack of control, we know and experience ourselves as free agents.  We do things.  We make choices that change us, change others, and change the world.  We do make plans.  We are expected to do so.  We are responsible for what we do.

This is especially true for health care professionals.  We have pledged to help the sick.  We draw up care plans.  We aim to control our patients' symptoms and to cure their diseases.  We do want to exert control over the world, and to exert that control for good.  We have the power and the opportunity to do so.  We know that doing so is right.

Perhaps our problem then is just that too often we lose sight of the limits of our control.  These limits are imposed by the nature of who and what we are, and by the nature of the universe. 

We are limited by our own finitude.  Physically, intellectually, and morally, we are finite.  We are limited by birth and death - our own and that of others.  We are limited by a universe that is given to us, not created by us.  We are limited by the freedom of others.

So what, then, do we control?

We dispose of our own freedom in the context of our limits.  This is one way of describing what the moral life is.  Virtue is freedom deployed precisely at the point of intersection between possibility and necessity; between malleability and resistance.  It is where we live our lives as human.  And the choices we make as physicians, nurses, and other health care professionals are the moral choices that make our professions human.

We can dispose of our freedom both with respect to our inner lives and with respect to the world around us.

The internal disposition of our freedom concerns our desires and inclinations.  This is the provenance of the classical cardinal virtue of temperance.  Temperance is the virtue of proper self-control.  It is the mean between self-indulgence and being repressed.  As Aristotle noted in the Nichomachean Ethics, the former is very common.  The latter, Aristotle said, is so uncommon that it barely has a name.  He would be even more correct today.

But there is also a temperance with respect to the external world - how we dispose of our freedom with respect to our families, our communities, our environment, our colleagues, our patients. 

This aspect of temperance is part of the cardinal virtue of phronesis (practical wisdom).  It has never had a separate name, but I would call this part of wisdom the virtue of sagacious engagement - temperance in our exertion of control over the world around us.   It is a vitally important part of the virtue of practical wisdom.  The vices opposed to this virtue would be fatalistic docility on the one hand, and controlling, contumacious manipulativeness on the other.

I think it is fair to say that we live in a culture dominated by intemperance.  We err towards a lack of control internally and err towards over-control externally.  That is, as a society, we tend towards being both self-indulgent and contumaciously controlling at the same time.  We are all well-aware that these vices lead to a myriad of illnesses in our patients. 

But it would be naïve to think that we as health professionals hew to lives of temperance and sagacious engagement and are free of these vices ourselves.

Older physicians, for instance, are beginning to complain about younger physicians' emphasis on "lifestyle" in their career choices.  One can certainly make the case that several previous generations of physicians led overly controlled, repressed lives, sacrificing too much, even damaging their own families through overzealous dedication.  But one can ask whether the pendulum has begun to swing too far.  Does the world really require that so many of the best and the brightest should become dermatologists and ophthalmologists?  Are patients losing too much continuity of care to a succession of covering physicians arranged to assure more acceptable schedules of night duty? 

And while the majority of health care inflation is not due to physicians' fees and salaries, should any physician be making one million dollars per year off the predicament of the sick?  At least these questions ought to be raised.

But the biggest questions for physicians with respect to control are not the classical, internal aspects of temperance, but the external aspects.  A lust to control, dominate, and conquer disease still leads far too many physicians to over-treat their patients.  We have all seen them suffering bitter deaths in the intensive care unit.  Sometimes, however, the confluence of the attempt to control what cannot be controlled and the belief that control gives meaning to life leads to a different but equally noxious place. 

Some physicians' sense of helplessness when they cannot cure, when the disease is beyond their control, can be coupled with the belief that control gives life its meaning.  Sharing these beliefs with their patients, they offer them euthanasia and assisted suicide. 

Euthanasia, of course, is just as ironic a statement of control as is the regeneration of livers through stem cells.  In regenerating his own liver, the Prometheus of the stem cell researcher shouts out at the gods in whom he professes not to believe, "So, I can't be immortal and you've punished me for trying, eh?  All right, then, I'll show you.  I'll punish myself!"  In euthanasia, we shout at the gods in whom we profess not to believe, "So, I can't be immortal, eh?  All right then, I'll show you - I'll kill myself."  Both over-treatment and euthanasia are born of the attempt to control what we cannot control. 

Both are conspiracies of mutual self-delusion with our patients.  Superficially, the oncologist who will never stop treating and the internist-psychiatrist who dispenses prescriptions for assisted suicide appear very different.  But they both suffer from the same spiritual malady.

Physicians so delight in manipulating patients.  I recall with horror the experience I had as a first year medical student in a small group clinical experience with a psychiatrist.  He said, "I can bring any patient to tears in ten minutes."  He then asked that an arbitrary patient be selected from the ward to demonstrate.  His psychiatric rape took him less than five minutes.  We were supposed to be impressed.

And why are physicians so cynical these days?  Cynicism is born of the belief that everyone else is in control of everything around us.  When things do not go our way, it is always someone's fault.

Now I have heard it said that the central theme of Dante's Divine Comedy is that, in the end, each of us gets what each of us wants.  Whatever you want most deeply -- you get it - forever and ever and ever and ever.   If what you really most want is money - that's all you get - you drown in piles of it forever.  If what you really most want is pleasure, all you get is pleasure - which ceases to be pleasurable very quickly if it never stops.  And if you really want is the power and control to regenerate yourself - you become the new medical Prometheus - making your own stem cells to feed the vultures who will pluck them out of your liver, forever and ever and ever. 

Christianity offers a profoundly different choice.  Hear what St. Paul tells the Philippians:

If there is any encouragement in Christ, any solace in love, any participation in the Spirit, any compassion and mercy, complete my joy by being of the same mind, with the same love, united in heart, thinking one thing.  Do nothing out of selfishness or out of vainglory; rather, humbly regard others as more important than yourselves,  each looking out not for his own interests, but (also) everyone for those of others.  Have among yourselves the same attitude that is also yours in Christ Jesus, Who, though he was in the form of God, did not regard equality with God something to be grasped. 

Rather, he emptied himself, taking the form of a slave, coming in human likeness; and found human in appearance, he humbled himself, becoming obedient to death, even death on a cross.  Because of this, God greatly exalted him and bestowed on him the name that is above every name,  that at the name of Jesus every knee should bend, of those in heaven and on earth and under the earth, and every tongue confess that Jesus Christ is Lord, to the glory of God the Father.

The Christian message is that we do not need to steal fire from the gods.  God has already freely given fire to the world.  We can use this fire for treating the sick, in compassion and mercy, being of the same mind, united in heart, thinking one thing.

I do not need vainly and desperately to try to make myself into a god, because God has already reached out in love and become one of us.

The spiritual economy of the Christian universe is not a zero-sum game.  The fact that I can cure pneumonia does nothing to add to my greatness or subtract from God's greatness.  I do not need vainly to try to show that I am in control and make myself into something I am not.  In Christ, my freedom is God's freedom.

We can do this, Christians believe, as Christ did it - by plunging into the depths of our humanity, into the reality of our humanity, into the humility of our humanity.  Our salvation comes not from trying to be like gods, but from trying to be more completely what we were created to be - human beings.

So, for the Christian, the virtues have a radically different meaning.  Augustine defines temperance as "love giving itself entirely to what is loved."  He defines practical wisdom as "love distinguishing with sagacity between what hinders it and what helps it."  Temperance in action, for a Christian, is the wisdom of which Niebuhr wrote in his famous serenity prayer - the wisdom love requires to give itself entirely over to love in all of its actions, knowing the difference between what hinders love and what helps it.

This love is the "one thing" of which St. Paul wrote in his letter to the Philippians.  I have no idea what the movie of a similar name is about.  But I believe with all my heart in one true thing -- the love of God made manifest in Jesus Christ.  And if that's what I really want, I believe that's what I'll really get - forever and ever and ever.

It is also my faith that any physician, nurse, chaplain, or social worker who believes in this one true thing need not always be in control; need not always be effective; need not always be right.

Because those who believe in this one true thing know that only One is really in control; only One makes our meager efforts effective; only One is always right.  And none of us is that One. 

In that truth, the virtue of sagacious engagement with the world -- our temperance with respect to all the choices we make with respect to the world -- is what Christians mean by the virtue of obedience.  Christian obedience is not the slavery that treats human beings as commodities.  Obedience comes from the Latin root, obedire, to listen. 

To be obedient is to listen.  To be obedient is to be willing to serve in response to what one hears.  To be obedient is to hear what is beyond us.

To listen to our patients and their stories and what they tell us; to listen to our patients' bodies and the stories they tell us; to listen to our colleagues and their wisdom and the stories they tell us; to listen to our God, and God's story, and what God's story tells us.

Sagacious engagement with the patient is therefore a dialogue.  This is how one learns when to press and when to let go; when to persuade and when to exercise deference.  This is how one learns to be concerned about the results without being overly anxious about them or defined by them; how to be discerning without being judgmental.  One listens.

Hans Georg Gadamer believes that even the physical exam is a dialogue - a way of listening to the patient's body.  He describes the physical exam as, "carefully and responsively feeling the patient's body so as to detect strains and tensions which can perhaps help to confirm or correct the patient's own subjective localization, that is, the patient's experience of pain" (p. 108).

Likewise, the wise therapeutic decision is one that neither exerts too much control nor fails to assert enough.  When we err in the 21st century, I think we would all agree that it is generally on the side of too much control.  This happens when we fail to be obedient to the situation before us, fail to listen attentively, fail to engage the clinical circumstances sagaciously. 

Again, Gadamer puts it beautifully, arguing that when a medical intervention goes wrong, "it would not be because physical force or power was lacking or too little was exerted, but rather because there was actually too much force in play.  But when the act works, suddenly everything seems to happen spontaneously, lightly and effortlessly. . Genuine success is accomplished in medical practice at just that point where intervention is rendered superfluous and dispensable. 

All medical efforts at healing are already conceived from the outset in light of the fact that the doctor's contribution consummates itself by disappearing as soon as the equilibrium of health is restored." 

So, we do not need to grasp at equality with God.  We do not need to steal anything from Him.  He has already given us everything that we need.  We do not need to claim power or control or knowledge for ourselves.

If one makes some obscure diagnosis or effects some wonderful cure, one may be tempted to wonder whether this comes from one's own power or from God's?  For the Christian, this distinction ceases to matter.  On the one hand, in a sense, it all comes from the God who created us and created the patient and created everything that constitutes the art and science of medicine.  No doctor, professing no matter what religion or even professing no religion, can claim to have created herself, the patient, or the art and science of medicine.  All must be experienced as gifts.  All are given.

On the other hand, each clinician is a free and intelligent, even if fallible, being.  The clinician is inextricable from the healing act.  In this sense, it is 'I' who heal.  But in Christ, this 'I' can be liberated from worrying about how much of a role is 'mine', liberated from trying to possess the fire or control the situation or control the patient.  It makes no sense for Christians to jockey for control with a God who has already given himself completely to them. What should matter to a Christian is what matters to Christ.  It is the healing that matters.  Or rather, it is giving ourselves over to the love that is in the process of healing that matters.

The right amount of control is what the situation -- as it is engaged by the clinician in a spirit of obedient service -- demands.  A Christian clinician need not try to be in complete control.

What happens as a result of his ministrations is not his to determine.  If his therapy fails, he must listen again, sagaciously engaging the new situation that presents itself to him, humbly plumbing the depths of his own humanity and that of the patient.  He tries to be effective, he educates himself so that he will be effective, he acts with the intention of being effective, but he does not delude himself with the need to be effective.  And if some consultant offers another opinion, he does not feel diminished.  He realizes that he is not God. 

Think of those times that you or some other clinician has hurt a patient by not letting go of an original diagnosis, or through the defensiveness that sets in when the patient asks about the wisdom of a second opinion.  The Christian clinician listens attentively in a spirit of obedient service, knowing that it is the healing that matters.

The sin of Simon Magus, the magician whose story is recounted in the Acts of the Apostles, was that he wanted to have the healing power and authority of the Apostles without their faith.  The Apostles of Jesus Christ knew that they could only heal in the Name that is above every other name.  Christians understand that the power to heal in its truest and deepest sense is really only given to those who know that they are never in complete control.

Nicholas Vreeland, "Control"
Control: Introduction
Table of Contents 

Published: September 17, 2004