The Practice of Medicine as Being in Time 9783838274270

Citation preview

ISBN: 978-3-8382-1427-6

ibidem

Series Editors: Alexander Gungov, Friedrich Luft

Raymond Barfield is a pediatric oncologist, palliative care physician, and philosopher with an interest in expanding the role of the humanities and the arts in the formation of physicians. He has published widely in medicine, philosophy, and literature.

The Practice of Medicine as Being in Time

This is an exciting, but difficult, season for the practice of medicine. The effects of corporate transformation on the practice are part of a larger cultural crisis. The arena of medicine is a proving ground for our responses to this crisis, because it is so intimately and immediately related to our bodies. Our answers to contemporary challenges in the practice of medicine will depend on, and probably shape, our answers to philosophical questions at the core of our existence: How do we inhabit our unpredictable and limited lives in a way that allows us to flourish, and how can the deep practice of medicine help? Time is the condition for all human experience, but for mortals like us, time is limited. This limit gives our lives the arc of a story, with a beginning, middle, and end. Unfortunately, many of us in the modern world avoid thinking about limits in our lives—especially the limit on our time called death. The practice of medicine serves people who are facing limits in their lives brought on by the threats of disease and death. Because good doctoring is so intimately related to the complex impact these threats have on our limited lives, this book argues that the significance and meaning of the practice of medicine is inextricably bound to existence in time.

Raymond Barfield

“Is Raymond Barfield a physician who happens to be a philosopher or a philosopher who happens to be a physician? One thing is for sure: he’s able to use words in ways that remind us of their overwhelming meaning—words like “disease,” “love,” “death,” and “How can I help today?” As our vast healthcare systems suffer from the illnesses of managed care and the bottom line, this book is an urgent and humane exploration of what the practice of medicine is all about.” Prof. Scott Samuelson, author of Seven Ways of Looking at Pointless Suffering and The Deepest Human Life

Studies in Medical Philosophy, vol. 8

“Dr. Barfield has incredibly insightful words for these changing times in medicine. His exquisite craftsmanship in this text is impressive, but especially his keen ability to expertly circumnavigate this complex topic that is so important to us all—health and human life in the modern era.” Dr. David Markham, Emory University

Raymond Barfield

The Practice of Medicine as Being in Time

ibidem

Raymond C. Barfield

The Practice of Medicine as Being in Time

STUDIES IN MEDICAL PHILOSOPHY Edited by Alexander Gungov and Friedrich Luft ISSN 2367-4377

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David Låg Tomasi Medical Philosophy A Philosophical Analysis of Patient Self-Perception in Diagnostics and Therapy ISBN 978-3-8382-0935-7

2

Jean Buttigieg The Human Genome as Common Heritage of Mankind ISBN 978-3-8382-1157-2

3

Donald Phillip Verene The Science of Cookery and the Art of Eating Well Philosophical and Historical Reflections on Food and Dining in Culture ISBN 978-3-8382-1198-5

4

Jean-Pierre Clero Rethinking Medical Ethics Concepts and Principles ISBN 978-3-8382-1194-7

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Alexander L. Gungov Patient Safety The Relevance of Logic in Medical Care ISBN 978-3-8382-1213-5

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Ken A. Bryson A Systems Analysis of Medicine (SAM) Healing Medicine ISBN 978-3-8382-1267-8

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Dmitry Balalykin Galen on Apodictics ISBN 978-3-8382-1406-1

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Raymond C. Barfield The Practice of Medicine as Being in Time ISBN 978-3-8382-1427-6

Raymond C. Barfield

THE PRACTICE OF MEDICINE AS BEING IN TIME

Bibliografische Information der Deutschen Nationalbibliothek Die Deutsche Nationalbibliothek verzeichnet diese Publikation in der Deutschen Nationalbibliografie; detaillierte bibliografische Daten sind im Internet über http://dnb.d-nb.de abrufbar. Bibliographic information published by the Deutsche Nationalbibliothek Die Deutsche Nationalbibliothek lists this publication in the Deutsche Nationalbibliografie; detailed bibliographic data are available in the Internet at http://dnb.d-nb.de.

ISBN-13: 978-3-8382-7427-0 © ibidem-Verlag, Stuttgart 2020 Alle Rechte vorbehalten Das Werk einschließlich aller seiner Teile ist urheberrechtlich geschützt. Jede Verwertung außerhalb der engen Grenzen des Urheberrechtsgesetzes ist ohne Zustimmung des Verlages unzulässig und strafbar. Dies gilt insbesondere für Vervielfältigungen, Übersetzungen, Mikroverfilmungen und elektronische Speicherformen sowie die Einspeicherung und Verarbeitung in elektronischen Systemen. All rights reserved. No part of this publication may be reproduced, stored in or introduced into a retrieval system, or transmitted, in any form, or by any means (electronical, mechanical, photocopying, recording or otherwise) without the prior written permission of the publisher. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages.

For my parents, Pearl and Ray Barfield

Contents Preface ...................................................................................................... 9 I.

The Disclosure of Anxiety in Cartoonlandia ............................... 17

II.

Being Thrown ............................................................................. 35

III.

Primordial Totality ...................................................................... 51

IV.

Average Everydayness as the Very Point of Departure .............. 65

V.

The Clearing ................................................................................ 75

VI.

History as a Problem ................................................................... 89

VII.

Hiddenness and the Symptoms of Disease ................................ 101

VIII. Curiosity, Falling, and That Which Shows Itself in Itself ......... 113 IX.

Idle Talk and Interrogated Questions ........................................ 125

X.

Judgment, Assertion, and Ambiguity ........................................ 135

XI.

Buried Over ............................................................................... 143

XII.

The End ..................................................................................... 151

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Preface I am a pediatric oncologist and palliative care physician. A few minutes ago, I walked out of the room of a teenage athlete who was recently diagnosed with Ewing’s Sarcoma after two months of pain. He is an outstanding student, with only a few courses left in high school. He wants to build something in business. I hope he gets to do that. If he does, it will be in part because oncology teams have run carefully constructed research protocols over decades, systematically trying to improve cures for cancer in kids. Progress has required scientific creativity, passion, fiscal ingenuity, logistical genius, risk, partnership, tenacity, and outrageous courage on the parts of patients, families, and medical caregivers. This is beautiful to me. I could describe a thousand moments from my own practice that are beautiful in this way. I could describe a thousand moments in the careers of friends who have chosen all sorts of paths in medicine, and who have become better human beings because of their encounters with the profundity of human existence, gifted repeatedly through their patients. I could describe the work of nurses, housekeepers, administrators, financial analysts, and others who contribute to the complex work of helping the sick, the suffering, the dying. The practice of medicine brings together an astonishing variety of talents, gifts, and services at some of life’s most difficult moments of crisis, worry, doubt, and fear. At the same time, I believe the corporate transformation of American medicine is often at cross purposes with the good I have seen in the practice of medicine. I believe this transformation threatens to turn human suffering into a commodity leveraged for profit. I believe that the good in the practice of caring for sick and dying human beings has been diminished by this transformation. I believe some of the more brutal corporate practices are evil, and that they use the history of good medicine to disguise themselves as good, thereby improving public relations to increase profit, which is the fundamental value of the corporation. I believe much of what has been called “burnout” (inaccurately) is a result of this corporate transformation with its obsessions over money and power, its disregard for the pace and value of human experience, its disdain for distributive justice, and its degradation of some of the most important parts of human life.

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This book is a philosophical argument for the foundation upon which those beliefs rest. I could make an argument that is not overtly philosophical, but that argument would still be rooted in philosophy. I am probably wrong, or at least hyperbolic, in parts of my thinking. This book is a preface or prolegomenon to my own very personal attempt to account for what I have witnessed in my life as a physician. I am trying to find my own footing in the strange new world of medicine, where life-altering human events are sequestered inside contemporary corporate structures that generate massive profits by monopolizing the tools created by non-corporate ventures over centuries that were aimed at addressing human suffering. The clarity of a philosophical argument depends in part on the reader’s familiarity with philosophical terms. Such language is not the usual parlance of medicine. That is one problem with writing a philosophical book about the practice of medicine. Another problem is that philosophical terms, while they might act as placeholders for mysteries or gesture toward mysteries, do not make the mysteries any less mysterious. This kind of philosophical language can sound strange and vague, rather than clarifying. It can seem unnecessarily opaque, which is annoying to many people. It is frequently annoying to me too. Nonetheless, such language serves a purpose. It can be provocative, if only because it makes us see familiar things in unfamiliar ways. It can help to maintain humility in the face of the mysterious so that we resist the temptation to carve up the world too neatly. Vague language is sometimes the best language for talking about realities that do not have clear contours, but which still affect us. The risk of vague language, however, is that it can claim to be pointing to something real that does not exist. It is easy to get lost in vague language and the language of gesture. This is not a reason to avoid it when no other language suits the process of philosophical exploration. It is simply a reason to remain humble and open to correction, both of which are habits fitting to the practice of medicine in which a toorapid presumption of clarity about diagnosis can blind us to the deeper reality of what is happening to a patient. The chapter titles I have chosen riff loosely on the language of one of our more bewildering philosophers, Martin Heidegger. At first glance they might seem like examples of needlessly obscure language. Maybe they are. But I also find them suggestive. They have helped me think through several aspects of the practice of medicine for which I was given a clear language in medical school, only to discover that the apparent “clarity”

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derived from a simplistic reduction of human realities. This reduction carried me away from the truth rather than toward it. Reductionistic thinking has been important in the effort to achieve practical solutions for many of the problems that disrupt the biological function of the human body. But it has also eased the monetization of human illness and suffering by corporations fixated on efficiency as a means of increasing profit. This malevolent development is my motivation for taking a second look, rethinking the nature of the practice of medicine, and resisting the neat categorization of human experience that allows the corporate transformation of medicine to proliferate unchecked. Once the assumptions undergirding the worst tendencies of the contemporary practice of medicine have been exposed, perhaps the strange language can be discarded. Meanwhile, think of it as a kind of playful testing of ideas, keeping in mind the importance and seriousness of human play. In the first chapter I address the concepts of disclosure and anxiety. The odd title of this book, The Practice of Medicine as Being in Time, is a slightly tongue-in-cheek nod toward Heidegger’s strange and beautiful early work. But it also underscores the uncanny backdrop for the practice of medicine, which focuses on the complete human being whose participation in the world depends upon a body that lives for a time and then dies. Transience, uncertainty, and mortality are the kinds of things that provoke anxiety. We often hide from them. Telling the whole truth is difficult. The practice of medicine is one very important arena in which disclosure, and therefore anxiety, occurs. But facing disclosure and anxiety can also lead to growth and genuine discovery for both patients and doctors. Whatever growth and discovery might follow from courageously facing the truth of reality, the experience of showing up in any form and context in this life is an experience of being thrown into the world. Chapter two begins with a couple of disarming facts: we did not choose to exist and we cannot choose whether or not life ends in death. In between birth and death, we find ourselves inhabiting bodies we did not choose, cultures we did not choose, and languages we did not choose. Disease likewise comes upon us without our consent, and we are thrown into circumstances over which we have no control. This heightens anxiety and we are again tempted to hide reality from ourselves. Understanding the character of thrownness is important for understanding the dynamics of the practice of medicine as being in time. Patients and families find themselves thrown. So do doctors. From the start of their training, most new doctors feel

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thrown into something larger than themselves. They frequently work under the false belief that they have to be big enough to face the entire enterprise on their own and that they must show no “weakness” of any sort— including fear, doubt, anxiety, fallibility, or incomplete knowledge, all of which are as common as they are profound in the life of a person. This is a recipe for disaster. We know this, because the disaster has already occurred and the consequences are becoming ever-more apparent. We are thrown. Over time we become aware of our condition. We do so within a dawning reality that is variably veiled and disclosed. Primordial reality underlies the truth we discover in the course of our lives. The practice of medicine is a philosophical cauldron in which people experience threats to their own existence over time against this primordial backdrop. To say what the practice of medicine is, what it ought to be, and why it ought to be one way rather than another requires a sense of the larger context and the local circumstances of the practice—a concept of reality as a whole. Chapter three explores this idea of primordial totality and its relevance to the practice of medicine as an arena in which we become newly aware of the human condition. However strange existence might be, we cannot live in continual upheaval and crisis. We experience the rhythms and repetitions of our days as normal, our version of average everydayness. This is what is disrupted by the crises we experience when we are thrown into disease. Chapter four considers the importance of understanding what is interrupted in the life of a patient as the starting point for decision making and care within the practice of medicine. Chapter five turns to the physical, philosophical, and ideological spaces within which medicine is practiced. These spaces have been radically changed by the corporate transformation of contemporary medicine. Within the structures deformed by corporate greed, some spaces can be redeemed even without institutional change. One of the most important of these spaces is the clinic or hospital room. Within such rooms, after the door is closed, the practice of medicine as being in time can continue on a human scale. The room can become a small theater in which human-sized needs, hopes, fears, and realities are played out. But seeing and shaping rooms in this way is to make a deliberate philosophical choice that requires intention and long work to achieve. History is the larger story of forces that have shaped the practice of medicine. The way in which history is told affects our understanding of

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what the practice is and what it should be. Justice and injustice weave through the history of the practice of medicine, determining the effectiveness of the practice as definitively as human biology does. Individual histories are also fundamental to the practice. Any decision that cannot be determined by biological realities alone (which includes nearly every decision made in the practice), must turn to history for insight into the possibilities and goals that make a decision good, right, and fitting. Chapter six considers the importance of history and the problems we encounter as we try to explore historical realities. Part of the history a patient brings to a doctor is the history of symptoms that suggest the nature of disease. Part of the problem of history is the hiddenness of symptoms. Chapter seven addresses the reasons we sometimes hide our symptoms from doctors, from family members, and even from ourselves. Hiddenness can obstruct the diagnostic process. But it can also be a necessary part of achieving goals besides cure, if those goals are deemed more important than the agenda of medical intervention. Understanding the nature and role of hiddenness is important for understand the doctor-patient relationship, communication, and the value of discerning the fears, hopes, assumptions, and goals of patients. Chapter eight turns to three philosophical concepts operative in the practice of medicine as being in time—curiosity, falling, and that which shows itself in itself. Curiosity is a benevolent orientation toward hiddenness that values the patient by valuing knowledge of what is hidden while respecting the reasons it is hidden. It is one important condition for the disclosure of what is hidden. We cannot control the hidden because we do not know what it is. Because we cannot control it while it is hidden, the process of disclosing what is hidden feels like falling into the meaning of what is disclosed and the effects of the disclosure. We know nothing with certainty. But the work of disclosure is done with a sort of philosophical faith that it will bring us closer to reality and lead to knowledge of that which shows itself in itself. This kind of knowing is a basic act, depending only on the actual encounter with that which shows itself in itself. The concepts discussed in chapter eight depend on a skillful use of questions and a deliberate openness to answers. Chapter nine explores the nature of questions and answers, as well as the sources of distraction that interrupt the discovery process of asking and answering questions. When questions lead to answers that cause anxiety, fear, or pain, we are tempted to avoid them and to engage in idle talk instead. This avoidance is neither

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good nor bad in itself. It is good or bad only in relationship to goals, purposes, values, and ends. But there is also a danger that these sources of distraction allow cowardice and lying to infiltrate the practice in subtle and insidious ways that persist under the cover of the benevolent protection of hope. Chapter ten turns to the moment of decision in which judgment, assertion, and ambiguity shape action as we choose one path over another. Judgments are made in light of our awareness of reality, including the reality of a patient’s own purposes, goals, and values. Assertions are made based upon our judgments. Though we always work within the limitations of our knowledge and insight in an atmosphere of uncertainty, we make assertions as though our judgments are correct. But because we know we are limited in our knowledge and insight, sustained engagement with difficult decisions requires humility and honesty toward the reality of ambiguity, which is ubiquitous in the practice of medicine. Even when we have done our best to disclose the hidden, to come to terms with reality, and to work through obstacles to good decision-making, we can still decide to bury over our discoveries. Chapter eleven considers the reasons we bury over realities even when we have traded time, money, and labor to gain access to them. Individuals bury over realities and communities bury over realities. But burying over is not simple denial. It often has an important role, and many cultures have rituals and liturgies to guide the burying over. The practice of medicine allows doctors to witness many circumstances in which burying over occurs, and this is a great privilege. Burying over is conditioned by time as a limit of human experience. Grasping the functions and reasons for this human act is a subtle but important part of the practice of medicine as being in time. Finally, chapter twelve addresses the end of human life as an everpresent reality in our lives. Two senses of human “ends” are relevant. First, our lives end. We die. This is an unavoidable and central part of how human life is framed. Second, when we examine our lives, we discover purposes that drive our choices. These constitute our telos, the true end of our life. Both senses of a human “ends” are indispensable for understanding and shaping the practice of medicine as being in time. This is an exciting time for medicine. It is also a difficult time. Contemporary medical practice is complex. The good is complex, and the evil is complex. The effects of corporate transformation on the practice are not limited to medicine. I believe this is a large-scale cultural crisis. But the

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arena of medicine is so intimately and immediately related to our bodies that it functions as a proving ground for the crisis, a place where many people first wake up to the effects of the crisis. At the start of this project I worried that I was overstating the crisis. I now believe that overstatement is nearly impossible. It might seem odd that I think philosophy holds some of the most important keys to creating good in the middle of a crisis created by a power as enormous as the corporate juggernaut. But I do. Part of the reason is that philosophy, by its very nature, is a continual reorientation toward reality that draws on every resource, and that functions as a nexus for every mode of human discovery and enjoyment of the world. Another reason is that philosophy is inefficient and meandering, capacious in its methods, voracious in its curiosity, tender toward human fallibility, courageous in its openness to the strangest parts of human life, and delightfully annoying in its manner of reveling in the accusation of uselessness. It fits no metrics and it can never be relegated to a spreadsheet. It makes no money, but it does make people uncomfortable. It smiles at odd times, laughs in weird places, and uses everything from poetry to stars to Coke cans to make its point. Therefore, it is uninterpretable by corporations. It cannot be translated into any corporate language, so it walks the halls invisibly, even as it changes lives by changing the way we see the world. I am grateful to philosophy. It has allowed me to fail in so many spectacular ways—my efficiency-and-profit-metrics might be terrible, but I love being a doctor. I am deeply grateful to Alexander Gungov for his invitation to write a book for this series and for his insightful comments along the way. My own views are always evolving, and my best teachers are my patients and their families. I am grateful for the countless gifts they have given me through their invitations to join them on their journeys. I am also thankful to Pearl Barfield, my mother, who deciphered and typed this manuscript from a draft that was rapidly written between weeks on the inpatient oncology and palliative care services, and that exemplified another characteristic ubiquitous among doctors—terrible handwriting.

I. The Disclosure of Anxiety in Cartoonlandia Being a physician who simply shows up, who helps people, and who finds happiness in practicing medicine is fine. It is more than fine. It is deeply good. But the institution of medicine is troubled right now. So are its doctors. We need more than the daily language, protocols, and routines of medicine to understand and address this ailment. Understanding the practice of medicine is a philosophical act that includes questions about the body, the mind, justice, mortality, beauty, and value. Philosophy shines light on the moral, emotional, intellectual, and spiritual significance of problems in contemporary medicine. It is indispensable if we want better doctors. Part of the philosophical task of understanding the practice of medicine is to understand what doctoring is and what the obstacles to good doctoring are. The word “doctor” is not equivalent to the word “physician.” One of my mentors in medicine used to tell me—repeatedly, insistently— that not all physicians are doctors, and not all doctors are physicians. But I happen to be a physician, and I am concerned about my fellow physicians. As a group, we are not doing well. Many of the physicians who think they are doing well are not doing well. The fact that they think they are doing well in our current system is sometimes a sign that they are not doing well. This book plays with the language of philosophy more than most books concerned with doctoring and the ways doctors have been harmed.1 I believe philosophy is important for the good practice of medicine and the practice of good medicine. But philosophical language is sometimes tiresome rather than enlivening because it tries to talk about things that do not easily fit into language. Death, for example. Socrates said that all philosophy is preparation for death. The practice of medicine is likewise preparation for death in a sense, because our need for the practice of medicine is an acknowledgement of our fragility, our mortality, and our ambiguous relationship with death. Death is our most mysterious limit. It limits the 1

Because readers might not be familiar with some of the more esoteric language of philosophy, I will briefly discuss several philosophical terms in footnotes as they arise.

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duration of meaningful embodied human life measured by the passing of time. Medicine and philosophy are both oriented toward death in one way or another. Death is a limit. The limit is in time. Good doctoring is inseparable from the complex meaning and value of this temporal limit. This is why the significance and meaning of the practice of medicine is bound to existence in time. Be patient with unfamiliar language: we need it when we are talking about things that are as strange as they are common. My own experience as a doctor is part of why I think strange philosophical language disrupts medicine in a way that makes the practice more beautiful, true, respectful, and good. The starting point for my own journey into this unconventional perspective was a form of anxiety I slammed into on the pediatric oncology ward in medical school. A friend of mine died of leukemia when we were sixteen. In medical school I was assigned to the same oncology ward where he was treated. I admired the work the doctors and nurses did, and the patients and families moved me. I was disconcerted by how little I understood about the medicine, but I was more afraid of how little I understood about the agony, the courage, and the onlyway-through-is-through attitude that so many of the patients, families, and caregivers lived every day. I went to medical school to be a surgeon, but on that pediatric oncology ward I decided to become a doctor who would try to cure patients like my high-school friend. I was leaning into a fear I did not know how to name, though I would not have described it this way at the time. Cancer is a uniquely scary threat to many people, perhaps because it is made out of the building blocks of our own bodies but it does not obey the rules. When treatments do not work, we can only watch it spread, knowing it will lead to death. That is scary enough. But the cancer and its treatment can also be terribly disfiguring, destroying our limbs, our faces, our ability to eat, and other bodily functions. When all this happens to a child it seems especially threatening. During my first experience of the pediatric oncology ward, I was drawn to the ways the children, families, and staff interacted with each other in the middle of this very scary thing. Somehow the feared thing had arrived, and yet they were carrying on. The opportunity to witness this was a privilege. It changed the way I viewed the practice of medicine. It also shifted something in my experience of being human. Despite some lingering doubts and fears, I lunged toward it.

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During my residency, the three-year-old son of one of my pediatric professors was diagnosed with metastatic neuroblastoma. It had spread throughout his body and the progression of the disease had made the little boy very ill. I was one of his doctors in the ICU, and I was with him night after night. I watched my mentor with her son. I watched her go from being a professor to being a terrified mommy. She began to suggest irrational ideas to me, grasping at things to save her son. He was hooked up to all sorts of intravenous medicines. He was unable to sleep and he was in pain. He was unhappy. We all knew he was actively dying. It was excruciating for me to inhabit the role of doctor to my mentor and her son while her child was dying in the intensive care unit. One day she was lying next to him in the ICU bed. He was miserable. She looked at me and said, “We’re going home.” I was stunned. But I did everything we needed to do to get ready for her to take him home. She and her husband took their little boy home and put him in their bed where they laid together for a few more days. And then he died, surrounded by his family in his own home. That was when I realized something important. Curing children of cancer was only part of why I wanted to be a pediatric oncologist. What I truly wanted to learn was how to stand by patients and families even when I had no way to cure the cancer. That desire rubbed against the grain of my own formation as a doctor. It took years to learn how to do that part of doctoring well. Those years came with a cost to my time with my family, my health, my happiness, and my ability to be well outside the pediatric oncology unit. I was not equipped to carry what medicine asked me to carry, using only the tools my medical training had given me, but missing what medical training had taken away from me. Contemporary corporate medicine as an institution creates products to meet consumer demands related to illness, suffering, and death. It sequesters its products in hospitals, and then creates conditions for the sake of profit that interrupt the human dimensions of care to the detriment of both patient and doctor. Doctors rarely go to patients’ houses. They are often given 15-minute time-slots to meet “customers,” with little regard for what the person’s needs might be, nor what the doctor’s needs and responsibilities might be that day. A doctor’s ability to care is diminished when the institution of corporate medicine uses revenue generation in a spiritually toxic environment as the primary measure of value. I have

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experienced this the majority of my career, but it has become far worse in the past ten years. The problem is not merely that corporate institutions (and increasingly institutional leaders, who are often figure heads in service to profitdriven boards) do not care about humanity. The problem is that these institutions have no coherent notion of what humanity is, beyond a customer’s capacity to consume. Taken as a group, contemporary leaders in medical institutions focus on finance, risk management, documentation motivated by avoidance of liability, and superficial public relations. But they are not skilled at shaping human institutions in ways that create radical good independent of corporate greed. Despite my respect for people who are willing to engage with the enormous forces shaping medicine, much of the administrative output worsens the agony of the sick and the agony of those who care for the sick. Corporate transformation has destroyed medicine as a communal activity. But leaders seem baffled when doctors encourage their children to avoid medicine as a career, despite the growing physician deficit that is predicted to reach 120,000 by 2030 in the United States. What are these corporate leaders missing? They fail to recognize that practice of medicine is living philosophy. It is a cauldron where human meaning is revealed, a place where our most important questions emerge. At the bedside of a patient who is suffering or dying, philosophy’s questions suddenly seem urgent. What kind of universe do we live in? Is there anything after death or is it all just a bunch of random atoms bumping together? Should I tell the truth even though I am about to die? How can I know what to do next? How do we know what we know? Is there a God or is there not? Why? Why? Why? Socrates was right when he said that philosophy is preparation for dying. But for people who have largely ignored philosophical questions during their busy lives, dying is preparation for philosophy. The threshold of death might be the first time they ask some of the questions that are most important for human beings. We are not here very long. The way we choose to use our bodies, minds, and limited time matters. We must not forget how important the theater of medicine is for many crucial parts of the human drama. This book explores doctoring through the lens of philosophy. I fully accept that many people who have not gone to medical school engage in a rich and valuable kind of doctoring directed toward human beings who are

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ill, suffering, or dying. But I am the kind of doctor who is also a physician. Because my experience is limited in this way, I will use the word doctor in a narrow sense to refer to people who have come to the practice of medicine through the route of medical school and subsequent training, and who work in clinics and hospitals that are within the mainstream institutions dedicated to healthcare. I have no doubt that other kinds of doctors would deepen my critique and add insights into important things I have not yet seen. I am aware that my recovery from the damaged and damaging practices of contemporary medicine has been slow, and I still have much to learn. The terms of this critique depend on the strange-sounding formulation I chose—the practice of medicine as being in time.2 I apologize for the strangeness of the phrase. It seems important to me, and it was my way into this book. There may be better ways to say it. The practice of medicine as being in time concerns the human experience of being an embodied mortal. The mystery of embodiment has been hidden in contemporary medicine by practices, processes, and structures that bizarrely recapitulate the early stages of a doctor’s formation in gross anatomy, where medical students dismantle a human body, turning it into parts. This dismantling was an important part of my own education. It affected my sense of what the body is and what embodied existence means, but in a dis-enchanting way that evacuated mystery. 2

Readers familiar with the work of Martin Heidegger will hear resonances between the language he uses in his philosophical expositions and the language I use to talk about the practice of medicine. The resonance is intentional. Heidegger’s work has impacted my own philosophical imagination, even in the (many) places where I disagree with him. Despite the resonances and the handful of terms I borrow from his complex philosophy, my language does not map onto his in any exact way (though an interesting philosophy of medicine could be written that integrates his philosophy more thoroughly into the analysis). The phrase being in time is one obvious example. I am grateful to Alexander Gungov who suggested that the phrase existence in time might be more consonant with Heidegger’s language. He argued that Dasein (which is the vernacular term in German for “existence,” and which refers to creatures like us) is that which exists in time and has a history. All other things are but they do not exist, in Heidegger’s technical sense. Only Dasein has a history while all other things are in Dasein’s history. The significance of patients’ memories, for example, derives from the sense in which the memories belong to the (ontological) history of patients. Things are in time, whereas only Dasein exists in time. This is a fair point. However, because Heidegger uses the term Dasein to refer to the being which is peculiar to humans (and which has the character of existence rather that the being common to non-human things that merely are in time), I chose to retain the uniquely human idea of the practice of medicine as being in time.

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The Practice of Medicine as Being in Time

In gross anatomy, otherwise normal people walk into a chilly room with metal tables on which there are plastic bags. Inside the plastic bags are dead strangers. The students unzip the plastic bags and systematically take apart the dead strangers, memorizing the various pieces. The memorization of pieces is important, but it is not as important or long-lasting as the transformation of a college student into the kind of person who can take apart a dead stranger on a metal table in a cold room between eating lunch and dinner. As the students go through the experience, several important questions arise, variations of which recur throughout their formation as doctors. What kind of person must you become to dismantle a dead stranger in a cold dissecting room? What do you gain by becoming that sort of person? Is there anything you lose by becoming that sort of person? The dismantled parts of the body are transmogrified into the abstractions of data. This transmogrification occurs as a necessary part of the process of memorizing thousands of facts about the body. Doctors in formation create the memory-space in which the names, images, and locations of the parts are stored. Along the way, the actual body parts are discarded. The body of the dead stranger is stripped of flesh and becomes a stringy mess. Students look at each other’s cadavers and learn some of the variations that occur in actual bodies, but the memorized parts are idealized, rather than having the particular dimensions of an actual organ in an actual body. The introduction of computer simulated bodies has streamlined the process of abstraction and memorization. Computer simulated programs are efficient and useful for some aspects of mastering the information necessary to honor the trust given by patients to doctors. The students are tested on this information abstracted from any particular body. Testing is important, but we should remember the difference between successful test taking and the actual practice of medicine. Testing students about abstracted facts is not inherently bad, and in many cases it can be good. But it is only a rudimentary stage in the formation of doctors who are oriented toward the truth of an individual’s particular embodied existence. Testing assesses a student’s short-term retention of abstracted facts, but it also perpetuates concerns about grades as a measure of one’s relative rank among peers. Such measures arguably have pragmatic value for residency selection when the pool of candidates is large, but they can eclipse the philosophical sacredness of the actual practice of medicine.

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When gross anatomy is over, the bodies are usually cremated. Often there is a ritual of remembrance after the bodies are cremated. In this ritual the community expresses gratitude for the privilege of learning anatomy through the dismantling of the bodies of strangers, acknowledging the cost of transforming someone into a doctor. It is gratitude toward the stranger whose body was dismantled. It is gratitude toward the families of the strangers who might have been uneasy about this use of their loved one’s body. It is gratitude toward the teachers who walked the journey with students. It is a reminder that there is more to the story of the practice of medicine than mere biological reality. But the emphasis on abstract data over the particulars of bodies embedded in larger stories is the beginning of a shift toward the gnostic3 practice of medicine. Using the bodies of dead strangers to teach gross anatomy may or may not be crucial for teaching the needed facts, but it is probably important for the process of becoming a doctor. The three questions students ask about their own identity and character in gross anatomy must be asked throughout the formation process. The bodies of dead strangers allow the students to experience the uncanny as familiar, while conferring a sense of the significance of embodiment for mortals, including the students themselves. A patient’s experience of illness, suffering, or impending death is fundamentally embodied. Patients become aware of the place their body has in their larger story and community. Doctors have unique access to the bodies of other people who are temporarily in the role of patients. Honoring the sacred nature of this access requires insight into philosophical, moral, spiritual, and cultural structures, along with devotion to mastery of scientific knowledge and technical skills. If any of these is missing, the practice of medicine is desecrated. Desecrating the sacred is sin. It is philosophical sin when it fails to acknowledge the meaning and significance of embodiment to people who participate in the practice of medicine, including both patients and doctors.

3

Gnosticism is a view of the world based on the idea of gnosis, which means secret knowledge. Gnostics believed that matter (generally in the physical universe, and specifically in the human body) is evil. They believed that our true self is derived from the spiritual substance that is God’s, but we became trapped in physical bodies. Our spiritual longing is to escape from our bodies. By gnostic medicine, I mean a practice abstracted from the lived experience of particular, embodied people, treating conglomerations of discrete data rather than the whole person referred to as “a patient.”

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It is moral sin when it disregards what is at stake in the act of trusting one’s body to another. It is spiritual sin when the doctor fails to practice with an orientation that is shaped by a person’s values, wishes, experience, goals, and fears in the process of learning to trust and to embrace the consequences of trust. Biology cannot account for most of what constitutes such experiences. The reduction of the practice of medicine to biological terms is a grave philosophical error that leads to many harms. In the practice of medicine as being in time, the biological aspects of doctoring are conditioned by one kind of time. But these aspects must always remain in service to the philosophical frame of the practice, which illuminates other important forms of time and the experience of time that are part of good doctoring. The disruption disease brings to embodied experience provokes anxiety.4 The structure of the word “disease”—dis-ease—is the starting point for establishing the larger philosophical frame that illuminates the complex, integrated components of the practice of medicine as being in time. Disease is not reducible to biology without remainder. With the enormous advances in science and technology, the true nature of disease is easily lost. Modern medicine’s success in developing cures easily combines with the ancient human fear of loss and death to create a skewed understanding of disease, the practice of medicine, and the acts and experiences that comprise the role we call being a patient. If one’s body were merely a machine that could be tinkered with or replaced, disease might cause annoyance without anxiety. But the very character of the disease itself suggests that there is more to disease in embodied experience than the malfunctioning of a machine. We live our bodies in a way no machine lives its own body, suggesting that disease is not merely a mechanical problem. The body is more than a machine. Even if the body were a machine, disease would be more like a malfunction in an airplane flying at thirty-thousand feet than like a malfunction in a lawnmower. We need the machine to function in order to achieve or

4

Anxiety is the fear we feel when some part of the world threatens us we experience vulnerability. In anxiety, we also experience threat and vulnerability, but anxiety does not always have a direct object. Sometimes we cannot point to anything in particular in the world that is threatening us. Either way, anxiety interrupts projects that make things meaningful for us. When we lose our seamless immersion in our roles and projects, we also lose the basic sense of who we are. We feel alienated and the world seems absurd.

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experience anything else in life. Flying in an airplane that is under repair is a fit analogy for the experience of disease and engagement with a doctor. The peculiar anxiety associated with the disruption of embodied experience by disease reveals the scaffolding of a person’s philosophical style. Sometimes this begins with a question as simple as, What is happening to me? The anxiety is often associated with a disease that is clearly and confidently demarcated with a name—cancer, coronary artery stenosis, bipolar disorder. But anxiety can also be experienced as a sign of a looming threat that is as-yet unknown. When the nature of the threat is unknown, it may also be unclear exactly what is being threatened. The contours of such a threat are indistinct and its character is vague. Maybe the threat is not real. Maybe it is conjured by the imagination. In the face of disease caused by known or unknown sources of disruption, or even potential disruption, the predictability of the world is brought into question. Before the disruption, the world’s reliability was assumed. At the beginning of a named disease, or in the face of a vague, as-yet unnamed source of disease, anxiety leads to close examination of what might be threatened—the body, the mind, appearance, fertility, projects, a worldview. The examination takes the form of questions such as, What if it turns out to be X? or What if Y happens? In the middle of such an experience, the extraneous quickly falls to the side. We lean on the people we trust. We embrace the dear or crucial parts of our philosophical world view, which might have been ignored prior to the disease, but which now are the center of everything that matters to us. Discovering the bones and sinews of one’s philosophical style is an experience of great human importance in a well-lived life. The visceral aspects of philosophical style are inseparable from the reality of embodiment—being a body with viscera that register true things about feelings, people, and the world. The kinds of philosophically interesting and important things that appear as bones, sinews, and viscera in a philosophical style include mortality, fragility, and the effects of passing time. These lead to questions about the source of significance, the meaning of meaning, the purposes and aims of a life, the relevance of the kind of universe in which we live, the nature of thought and rationality, the reliability of human knowledge, and large questions such as Why is there something rather than nothing? and Why not commit suicide?

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Philosophical style is our way of seeing the truth of things and the meaning of things. It affects the way we act in the world and the way we experience the effects of the world on ourselves. Philosophical style is explored through feeling and thought, and it is changed by feeling and thought. It is both revealed and shaped though our actions in the world and our reactions to the world, including our interactions with the practice of medicine, whether we are in the role of doctor or patient. The decision to ignore the relevance of philosophical style constitutes one philosophical style, for better or worse—probably worse. The embodied, lived experience of time is the general form of the object of anxiety disclosed by illness, suffering, or impending death.5 The concept of limit is fundamental to the embodied, lived experience of time, and it is inextricably tied to the anxiety associated with disease. It matters to philosophical style because the peculiar form it takes in human experience is mortality—the reality that our lives have a beginning, a middle, and an end. The end of embodied experience is a threshold for which we have no precedent. The arc of the embodied, lived experience of time is defined by its beginning and its end, neither of which are knowable by us. The arc between these two limits has a length, which we also do not know. Uncertainty about the nature and significance of these limits contributes to anxiety for creatures like us. The lived experience of time is the lived experience of change. Change related to embodied existence provokes anxiety because the body is contingent and mortal. The anxiety related to change in time is disclosed when the form of the change is disease, because disease turns the limit we call death into an object of awareness that is difficult to ignore. Disease pushes us to acknowledge the story-form of our lives. It forces us to recognize that time, as the general form of the object of anxiety, is the scaffolding of stories built with sentences, each of which has a tense—past, present, future. To be embodied is to be limited, whether this word is heard as an adjective or as a verb. The body has a form, and form logically implies limit. The aesthetic dimension of anything depends upon limit. The 5

Disclosure is the way things become intelligible and meaningfully relevant to human beings, by virtue of being part a world that is the pre-interpreted background of meaning. We come to understand this holistically-structured background through our practical day-to-day encounters with others, with things in the world, and through our use of language to describe the world.

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limitless cannot be perceived, nor even thought, as a thing. It is a concept that grows from the possibility of altering or negating limits. We cannot experience the limitless. Limit is the condition for human experience. Aesthetics can only address possible objects of experience, which means it can only address things that have limits. Limit is the condition for beauty, whatever beauty is. Limit is likewise the condition for the experience of order, though not all order can be experienced.6 Aesthetics and our sense of order are the principle guides for restoration of form (and function) in the face of disease. Apart from the concept of limit, there is no way things ought to be. We can only describe the way thing ought to be in terms of aesthetics and order (whether that order is physical, moral, or otherwise). Limits that are common, longstanding, or shared are often thought of as normal. Limits that are not normal are often described as limitations, and they are possible targets for elimination, overcoming, or reconciliation. The concept of limit is fundamental to the reality of all form, all beauty, and every story. As such, a limit can be a genuine good in the experience of embodied existence. Sometimes anxiety obscures the value of limits. It can also be a fallible but important indicator that a limit is not contributing to the good in a life. We probably feel anxiety about the limit that is the end of a life more commonly than we feel anxiety about the limit that is the beginning of a life. Both limits are contingent, so either limit might have been otherwise. A desire for a longer life usually takes the form of wishing not to die, rather than wishing to have been born earlier. At one level this seems reasonable since birth is in the past and death is in the future. The time of our birth might have been different, but it is what it is. The time of our death might still be different. The tense of our wish is part of the nature of our anxiety. But the tense leaves open the question whether the anxiety is about the length of our life, which could be different with a change in either the time of our birth or the time of our death, or whether it points to something else, such as our fear of disappearing. Surely not wanting to disappear is one form of valuing a life.

6

For example, in an infinite divergent series such as the harmonic series (1 + 1/2 + 1/3 + 1/4 + ...  ) we arguably do not experience the ordered infinite series, but rather know the series.

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Human value depends on limits. Because gnostic medicine is a practice abstracted from the actual lived, temporal, embodied experience of mortal people, it is a solvent that dissolves the limits necessary for the incarnation of the beauty, forms, and stories that populate a good life. Gnostic medicine acts as a solvent in two ways. The first is through the dismantling of the living body, which is an institutional project rooted in the normative frame established in the anatomy lab. Efficiency and progress in the manipulation of biology requires the division of labor—specialization. Specialization attaches itself to an organ system, or else to a particular set of medical or procedural interventions. The narrowness of specialization needed for efficiency and progress truncates the mind’s ability to see beyond the priorities, concerns, and perspectives of the specialty. The effect of this is to bracket some parts of embodied experience from other parts, or from the whole. This bracketing allows a doctor to have enormous, nearly complete knowledge and technical mastery within a specialty. Such knowledge and mastery are often praised and admired by the doctor’s peers and patients, which makes the damaging aspects of the bracketing harder to notice. The second way in which gnostic medicine dissolves the reality of limits is through the promise, whether overt or implied, that the bracketed knowledge and technical mastery will allow a person to escape disease and avoid death, and thereby resume normal life, whatever “normal” might mean to an individual. Because this promise is often fulfilled in contemporary medicine, the inevitability of limit in the form of incurable disease and death is elided from the imaginations of doctors and patients. This elision often functions under the name of hope, and those who attempt to correct the elision are sometimes identified as enemies of hope, efficiency, and progress. When the reality of important limits is dissolved, the anxiety disclosed in the experience of illness, suffering, or impending death is untethered from its true object, like the engine of a car in neutral. Such untethered anxiety is less likely to provoke the work of philosophical growth. Medicine cannot advertise an ability to change the fixed limit of one’s birth, but it can and does advertise the ability to change the limit called one’s death. Sometimes it does this by actually discovering a therapy that cures disease, so that embodied existence can continue for a while longer. This mode of changing the place of a limit in the temporal arc of a life is the most effective advertising tool medicine has. In most cases, assuming

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lived experience is actually good, such a change is itself good. The good of this mode of change depends on being able to say something about what makes a life good, which is a fundamental philosophical question. Understanding the nature of the good in the practice of medicine, insofar as it is able to affect death as a limit, depends on a philosophical insight. But sometimes the shift in this limit is an illusion, nothing more than a change in the definition of death. When technology can keep blood going around and around, and air going in and out, even in situations of extreme biological degradation, the definition of death becomes ambiguous. The line becomes blurry, uncertain, vague. Anxiety at the threshold of a vague limit gains force and is more difficult to resolve. It can only be addressed when we realize that we cannot define death without first defining life. This requires attention to philosophical questions about a good life. When anxiety is untethered from the object that is both its root and its philosophical remedy—temporal, limited embodied existence in light of some concept of the good—people feel lost and threatened. This motivates their urgent attachment to a vague and sparsely populated concept of “hope,” grounded in “faith” that medicine can resolve the anxiety by removing the threat. The ostensible resolution of anxiety is not related to the actual character of the anxiety, but rather to the temporary removal of the dis-ease that was the occasion for anxiety’s disclosure. If medicine cannot eradicate the disease that discloses anxiety in a patient, the doctors experience their own anxiety. The expensive, labor-intensive, and often painful work of temporarily removing the disease that discloses anxiety can take many forms. Merely testing for the nature and extent of disease can give a person a sense of control—illumination that chases away the shadows of uncertainty. It gives a space of waiting, which the imagination can populate with hopes that nothing terrible will be discovered, or if something is found, that rational and effective interventions will be started. The beginning of treatment for a disease has room for hope because the possibility of failure is merely hypothetical—maybe the treatment will work and the patient will be cured of the disease. When treatment fails, and the anxiety stubbornly refuses to leave, growing in both the patient and the doctor, specialists can be called in. These specialists can lessen the anxiety among doctors by spreading responsibility for the disease and medicine’s inability to eradicate it. If all else fails and the desperate patient continues to dis-integrate, he or she can be transferred to the intensive care unit. There the patient can

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be transformed into pure biology and physiology, and often sedated and silenced on a ventilator. Finally, if disease and suffering persist, anxiety can be resolved by eliminating disease-related suffering through the elimination of the sufferer. The practice of medicine, like the priesthood, has long been bound to individuals who take on the practice as a calling or vocation. This is changing as the institution of medicine becomes more corporate. Efficiency, profit, risk-management, and liability dictate protocols and policies. Within the order of these institutions that now house most of the practice of medicine, established roles gain their own substantial place and nature, irrespective of who fills the roles. This approach is common to the kinds of jobs generally advertised through job descriptions detailing well-circumscribed duties and responsibilities. But there are important differences between a practice discovered in the course of practicing, and a practice defined by rules, metrics, protocol, and policy. When a practice is discovered through the act of practicing or through apprenticeship to someone who has mastered the practice, the measures of good practice are related to goods inherent to the practice. Purpose becomes clearer through long practice. This is analogous to the practice of art, music, or writing. The good, the purpose, and the development of excellence grow in the doing, in the sustained experience of being-a-doctor. But when a role is defined by rules, metrics, protocols, and policies, the measure of good practice is adherence to the parameters of the role as defined by corporate priorities. In a discovery practice, ambiguity is an opportunity for growth. In a rulebased practice, ambiguity is threatening and causes administrative and bureaucratic anxieties distinct from those common to the human condition. The mystery of temporally-limited embodied experience differs from the practice of gnostic medicine in the way reality differs from a cartoon. Cartoons borrow from reality. They shape the borrowed elements in a way that emphasizes a few of the parts to create caricatures in service to a sharply framed narrative. Cartoons often introduced super-powers that relieve the characters of the burdens of reality. The frame of a cartoon is important for controlling the narrative. Frames order the experience spatially, which in turn allows the narrative arc to be ordered temporally. When a character or object reaches beyond the frame, the effect still depends on the order within the frames. In the practice of gnostic medicine, there a bizarre shift of meaning as the cartoon version of reality is redefined as the really real. Gnostic

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medicine moves from the world of gross anatomy toward advances in the unseeable world of molecular biology, the development of imaging technologies that turn the body into electronic pixels on a screen, and the creation of machines with robotic precision in surgical procedures, which become more like video games than tactile crafts. The Electronic Medicine Record allows the storage, ordering, surveillance, and mining of electronic data. The virtual patient within the EMR can be transported in an instant from mind to mind, institution to institution. This electronic version of the patient is the new truth of the patient, the subject of gnostic medicine. But it is an enigma to the patient and must be interpreted by experts. If it is not in the EMR, it is not real, because the litmus test for reality in corporate medical institutions is what might appear in a court of law. This is why gnostic medicine fits so well with the corporate transformation of medical institutions. The reduction of reality to its cartoon version can be resisted. Institutions change slowly, and I do not have much optimism about changing the whole institution of medicine, given the amount of money and power involved. But individuals can change and individual practice can change. Language, for example, is one of the most immediate aspects of the practice an individual doctor can change. The language we use signals what is important to us. Listen to the way doctors talk. Most of their language is biological, mixed with the language of risk management or liability. We certainly want doctors to understand biology. But we need more. We need more if our doctors are going to guide us wisely when decisions are complex. A doctor’s imagination must reach beyond molecules vibrating in a patient’s body, and try to understand the meaning of a patient’s life as it actually shows up in the world. Who is this person? What do they care about? Who do they rely on for advice? What are they afraid of? What is threatened by disease? What do they hope for? Do they gain anything because of the disease? Do they have an unspoken goal that makes a difference in how I might advise them when we arrive at crossroads? Language mirrors the reach of our imaginations. When our doctors use language that is barren, irrelevant, and alienating, it is often because their imaginations do not reach far enough. Why does this happen? An important part of the explanation is rooted in the way doctors are formed.

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Here is a brief review of how we form our doctors. College students graduate and go to medical school. They start with one patient. The patient is dead. They spend hundreds of hours in anatomy learning where all the pieces are. Then they study physiology and learn how the pieces move when they are moving in the right direction. Next comes pathology—the study of pieces moving in the wrong direction or trying to stop moving at all. Then they are given half a white coat and transferred to the hospital wards where they spend two years learning medical and surgical techniques. When pieces go in the wrong direction, the students learn how to make them go in the right direction. When pieces threaten to stop moving, the students learn how to make them continue to move. Then they graduate, and they are doctors. These new doctors quickly encounter the problems that result from spending so little time learning about communication, decision making, and ways to navigate ethically and spiritually complex situations. They discover the cost of trading more time on memorizing the names of hundreds of enzymes than on learning about the impact of social conditions on their patients’ health, their capacity to understand their ailment, and their ability to follow through with prescribed therapies. Students forget many of the enzyme names after they take their board exams. But every day of their practice, they have patients who get sick or stay sick because of their social situation. Doctors are becoming more critical of the ways medical students are educated. They are complaining publicly about the structure of board exams and recertification exams that do not fit the actual practice of medicine nor meaningfully contribute to making doctors better at doctoring. We live in an age of information explosion. No one can memorize all the relevant information. William Osler, who was one of the founders of modern medicine, might have been able to memorize everything known about human disease and its treatment in his day. But if he showed up a contemporary medical school, he would probably focus less on memorization of minutia and more on teaching about the interactions of biological systems, creative problem solving, effective approaches to mining and understanding relevant information, and communication. I hope he would especially focus on communication and decision making, because the decision point determines everything downstream. If decisions do not fit the goals of a patient, then no matter how advanced the medicines and techniques are, the practice of medicine is no longer serving

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the patient. A bad decision that follows from poor communication with a patient and family is like taking a left turn when you should have turned right. Even if your car is a wonder of mechanical perfection, it is carrying you in the wrong direction. Doctors are not formed well. But neither are patients. Patients are formed by pharmaceutical advertisements, corporate hospital slogans, misguided theologies, and the fears perpetuated by a culture in denial about the reality of death. Patients formed in this way expect doctors to fix any problem in any circumstance. This is often a functional system that produces a lot of good, especially with simple problems. I have broken several bones, and each time I have been very grateful when the doctor straightened my crooked bone. But many medical situations are vastly more complex. In such situations, patients can feel lost and unclear about their own goals of care. Doctors can also feel lost, so they do what they were taught to do: they respond to rogue biology with medical and surgical interventions. We train doctors this way for deeply benevolent reasons. We want them to be able to serve suffering, sick, and dying human beings. But new doctors are often thrown into these situations without the skills they need to help a patient and family work through frightening and complicated decisions. The patient, family, and medical team look to the doctor for the plan. The doctor is there to manage the crisis. But what does the doctor do if the crisis involves something the family experiences as mystery—say, a child born with uncorrectable deformities, or with a condition that severely shortens life? When doctors are limited to the language of a naturalistic, reductionist approach to disease, how can they respond to such mysterious sadness? Doctors are formed to think of life as matter-in-motion and to think of the purpose of medical practice as keeping matter in so-called normal motion. But they are not well prepared to be meaningfully present as guides on thresholds of mystery and loss. Death is not the only form of loss to which doctors must bear witness. People lose parts of their bodies, functions, opportunities, and time to do their most important activities. Chemotherapy can lead to infertility, hair loss, persistent vomiting. These are all forms of loss that cause distress and anxiety. They push people into the experience of acknowledging their own contingency, their frailty, and their vulnerability. Patients and families look to their doctors for help. But doctors can become dysfunctional or broken when they chronically face

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such profound expectations with inadequate formation and preparation. They can experience a sense of overwhelming incompetence. It is no wonder that doctors often restrict themselves to the language of biology where they feel most competent and comfortable. But the generalizations of science have no answers for the loss and anxiety a particular person experiences in the face of disease. A doctor can know everything in the electronic medical record—the patient’s sodium, potassium, creatinine, glucose, calcium, phosphorous, magnesium, x-rays, CAT scans, MRIs—and still know nothing about what it is to be this person in the middle of this experience. Apart from the stories patients and families offer, doctors cannot presume to understand the meaning of an experience for another person, nor the effects a decision will have on the remainder of a person’s life. Even if a doctor can cure a patient without knowing the person, there is an entire world of meaning the doctor is missing. Doctors miss such things not only to the detriment of the human beings who trust them, but also to the detriment of their own humanity. The practice of gnostic medicine is a sadly diminished response to the stunning, quickly passing drama of human existence. This is especially unfortunate given the unique access doctors have to the diversity and mystery that occur in the theater of the hospital. So much of human illness, suffering, and dying is hidden from the eyes of anyone besides medical professionals. Part of the reason, of course, is respect for a person’s privacy. But we have also chosen to build systems that hide the sick and dying in institutions rather than building systems in which the sick and dying are invited to stay among us. Sometimes we even hide these things from the person who is actually sick, suffering, or dying. We do not always tell the whole truth. In intensive care units, especially towards the end of life, we sedate patients to the point that they miss their own singular experience. Once such an experience is missed, it is missed forever. That is a terrible cost. Since patients often do not understand everything that is happening in a complex medical setting, they need guides who can reliably walk with them on their journey in a way that fits with the rest of their story. Doctors should not waste the chance to become deeper witnesses to our dearest mysteries. We must help them do better by helping them to be better.

II. Being Thrown We do not have a choice about showing up in the world as embodied beings. But once we show up, we want to be happy. We want to be happy, even if we cannot say what happiness is. To be happy is to be happy in the world. Since our bodies are a necessary part of how we are in the world, our bodies are relevant to our happiness, though our happiness is not determined entirely by our bodies. We do some things through our bodies that are not necessarily about our bodies—actions bound to ideas, love, beauty, moral growth, and so forth. These contribute to our happiness. Other actions that come through our bodies are specifically about our bodies—growing food, building houses, making bicycles and cars, and so forth. These actions contribute to happiness by contributing to the wellbeing of our bodies. They create the space and conditions within which we do things that are not specifically about our bodies. They also increase our enjoyment of our bodies, which is its own good, and which is a part of happiness. The forms and limits of all actions that come through our bodies are conditioned by the forms and limits of our bodies. When disease afflicts our bodies, many aspects of our happiness are threatened. This threat to happiness is part of the experience of dis-ease. Happiness in embodied experience is not merely a matter of pleasure, though pleasure can contribute to genuine happiness. But pleasures of the body sequestered from other considerations of happiness in embodied experience can turn a pleasure into a source of dis-ease. The principle that conserves pleasure as pleasure is not contained within pleasure itself. Pleasure has a place among other good things, but its limits reside in things besides itself. Pleasures are preserved as pleasures by preserving these limits. The good intrinsic to any pleasure is preserved by a larger good that determines and orders such limits—the good of the embodied person as a whole. The character of each pleasure is preserved by limits forged from other goods that are not the pleasure, all of which are ordered by this larger good. The ordering good of an embodied person is happiness, flourishing, what Aristotle called eudaimonia.7 It is a good of relation among other 7

The word eudaimonia is often translated as happiness, but is probably better-translated as flourishing. There are many definitions of the concept (some with religious content, some with an emphasis on supportive goods such as wealth and leisure, and some that

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goods ordered in light of the nature of the embodied person. Order fitting to the embodied person is the object of knowledge most commonly claimed by the practice of medicine in relation to the body itself. But the good of the body itself is not equivalent to the good of the embodied person as a whole: like pleasure, the limits of the body’s goods are set in relation to other goods, and finally in relation to the larger, ordering good. The practice of medicine as being in time requires attention to this larger good of happiness, flourishing, eudaimonia. The pleasure of embodiment is not merely a matter of ease, though ease can be pleasurable as a respite from struggle, or as a mark of practical accomplishment. It can mark the nature of the relationship among the different aspects of embodied existence. Things are in easy relationship to each other when they are proportionate to each other, with a well-ordered relation that brings pleasure. Ease can be a sign that all is well. Ease might also be a sign that nothing is changing, the pleasure of stability. It might refer to the equanimity that exists between an embodied person and the world. The practice of medicine as being in time requires an understanding of nature of our experience of ease and the realities that define it. This is important because medicine addresses dis-ease, and we must understand what has been disrupted in order to address it well. Helping someone return to the ease that has been disrupted might seem like a reasonable goal in medicine. But this goal can also signal a failure to see something important about the experience of disease, a common blind spot in the practice of medicine: even if ease is understood along with the sources of its disruption, and something like the cure of disease occurs, the experience of disease itself reveals the contingency and frailty of ease. We may escape disease, but the recovered ease is lived in a new light and with a new awareness of fragility as part of reality. This new awareness is philosophically important, and it merits good stewardship, which is to say, wisdom. If we return from dis-ease to ease, part our new experience of ease is the reconciliation of ourselves with difficult parts of life, not as a form of giving up, but as the achievement of peace. Disease—whether or not medicine is capable of curing a particular instance of it—provides a view it as independent of any worldly good). One of the earliest and most important discussions of it comes from Aristotle. For him, eudaimonia is the highest human good. He argues that the primary goal of ethics and political philosophy is to figure out what eudaimonia is and how to achieve it.

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philosophical, spiritual, and physical space in which we can become aware of embodiment’s arc in time, which includes our vulnerability to inevitable change, possibly as growth or new strength, but also eventually as decay. The work of achieving ease-as-peace in relationship to reality constitutes one of the most fundamental areas of philosophical and spiritual growth. The possibility that we can face disease in this way illuminates the human condition. Such possibilities for philosophical and spiritual growth in the face of disease also illuminate the practice of medicine as being in time. The daily work of the practice can be described in terms of biological manipulation, tests, measurements, and the creation of institutional structures and protocols for doing such things more efficiently. But the meaning, purposes, and responsibilities that constitute the matrix within which these things occur is not reducible to biology, technique, or administrative enthusiasm. Disease does not occur in tissues, but in embodied people. Biological changes are value-neutral without reference to the needs and goals of embodied people, and so they do not constitute disease. A liver cannot experience dis-ease because it cannot experience anything. Tissues do not have experiences, or if there is something that can be called “experience” without stretching the word to meaninglessness, it is an experience of change that is resisted only because of functional habit. Embodied people experience disease: they are the proper subjects of the practice of medicine. Hospitals have been compared to temples and doctors compared to priests.8 As an institutional comparison, this is complex. Contemporary hospitals are most often organized as corporate businesses. The languages most commonly used in the hospital are those of biology, finance, risk, and law. There is not much room for the holy inside these languages if they are sequestered from other languages. That said, many holy events such as birth and death occur inside a hospital. The problem is the relative isolation of holy events from communities that know what holiness is. At the same time, we have asked our medical institutions to fix all problems that arises

8

A similar argument might be made regarding the university as a whole. The university is ideally a place of inquiry into truth, a place of wonder, and a place of learning. Each of these things awakens us to reality and to our place in reality. But when administrative concerns are prioritized over the fundamental work of the university, rather than being in service to that work, the university is degraded. Examination of the parallels between the corporate transformation of medicine and that of the university would be a worthwhile philosophical project.

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inside our bodies, no matter what the cost, and we want a medicine that solves the problem of death. So, we often die tangled up and sedated in an intensive care unit as a result of what we ask from doctors. This is not holiness. It is an extension of the illusion of control. It dampens mystery and diminishes our access to the resources we need as we approach the limits of our lives, including the limit called death. An important question for doctors is this: What does it mean to be a human being taking care of other human beings who are going to die because we do not know how to fix their problem? When doctors cannot “fix” the problem a patient has, we begin to see what medicine is really about. However much we want to control and avoid death, we are still going to die. Our desperate desire to control death leads to billions of dollars in cost, untold suffering in ICUs, disenfranchisement of some, marginalization of others, and separation from our communities in the hardest times of our lives. The consequences of this desire to control death are enormous. We hear most about the financial cost of practicing medicine this way. But when a confused elderly man ends up dying in the intensive care unit instead of having the opportunity to die in the house that holds the memories of his life, he and his family have incurred a very large loss. Doctors must think about what they are doing when they show up to care for frightened, limited, mortal human beings who are facing death. Otherwise the practice of medicine becomes the creation of sideshows to distract from our inability to fix all problems and avoid death. But a culture that demands such things from doctors and institutions will get the medicine it deserves. Without wisdom, self-knowledge, and courage, we will continue to propagate the illusion that death can be conquered with better medicine, and that we can gain control over the ambiguous, amorphous, and difficult-to-name powers that terrify us. We wage “wars” on cancer, poor sanitation, and poverty. These efforts are intrinsically good. But they do not get to the deeper problem that bothers us, which is the reality that we will die anyway, even if all these problems are solved. Our projects are limited because mortals are necessarily limited. This should change the way we think and act. The reality that time is short can impact our lives in many ways. It may mean that I need to leave you, because time is short and you are harming me. Or perhaps it means I need to forgive you, because time is short. Or perhaps it means I need to partner with you, because time is short, and there is a good and beautiful thing I

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want to bring into the world with you. The practice of medicine as being in time must take these aspects of human experience into account since the shortness of a mortal’s time is often most apparent in the context of illness. Early in my own career as a bone marrow transplant doctor, one of my biggest personal failures was my inability to acknowledge that in some cases I could not cure my patient. I would focus on anything besides the obvious reality that my patient was going to die. Sometimes I would offer experimental research trials. If there were no new trials to discuss, I would find laboratory values that were a little better than the day before, and I would talk about them as though they were a meaningful basis for hope that death would be averted. I could not bring myself to say, “You are going to die from this, so if you have things you need to do, do them now.” Over the years of my practice, patients and their families have taught me about the profound cost of avoiding the truth. When I was unable to say the whole truth, patients missed their only chance to plan their final days and weeks. They suffered more when I could not tell the whole truth. They died on ventilators instead of in their own beds because I did not know how to say the truth. Patients and families also taught me how to overcome my own fears as they learned to acknowledge the limits of their lives and to accept me as a human with human limitations. Their acceptance of my limits helped me to accept my own limits. The reality of our limited time can help us see our lives as precious— to see our days as so valuable that we will only trade them for something worthwhile. Unfortunately, we often do not pay this kind of attention to our own limits. Instead, we continue to ask our doctors and institutions to promote the illusion that we are in control. This illusion can undercut and disrupt the beauty and integrity of our days. There is a different way to be present as a doctor. Doctors can be present as servants who know about medical science, but who acknowledge that the deep practice of medicine in the life of an individual requires much more than knowledge of biology. It requires curiosity about what a patient hopes for, what is interrupting their journey, what they fear. The doctor is a guest in the life of a patient. This orientation can change the experience of the patient, but it can also change the doctor’s sense of what life is, why it matters, what the vocation of medicine is, and what kind of language should be used to meet other human beings in this very complex cauldron called the practice of medicine.

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Technical excellence and competence are non-negotiable. This is not because they help to avoid risk, or improve reputations, or make more money. They are non-negotiable in good doctoring because they are an important part of how doctors serve and how they express love for the people who trust them. The best motivation for a good doctor’s technical excellence is love of the people whom the doctor serves. In return, because the relationship is reciprocal, patients can contribute to the practice of good medicine by acknowledging the humanity of their doctors and by doing the spiritual work of accepting limits within their own lives. When we think of being a servant, we often think of faith traditions. But there is also a negative image of the servant—the indentured servant. This is an image that will resonate with many contemporary doctors. In our medical systems, someone is paying the doctor to serve. Whether the payer is the patient, the government, or the insurance company, this model contributes to the insidious transformation of sick and suffering human beings into consumers of healthcare products and services. The complex financial realities in contemporary medicine tangle our mortal mysteries with strange economic entities such as the Consumer Index of Satisfaction. That is a hideous phrase. It suggests that everything we have valued in various ways through the venerable history of being human—our communities, the ways we use land, our bodies, our hopes—can be translated into an index of satisfaction on the part of someone defined by the capacity to consume, using the vocabulary of money. Hospitals are now rated and penalized based on the “satisfaction” of their “customers.” They stand or fall based on rating systems such as Press-Gainey scores. If the customer is not happy with the purchased product, the doctor or hospital might lose a competitive edge. This could lead to a loss of profit, a lawsuit, or poor public relations. Eventually everyone is forced into service of the same thing— profit, the bottom line. In true service, the religious undertones are instructive. Religious practices have room for the imperfection of the servant caring for those in need. They recognize the value of simply being present to a suffering and lonely person. They embrace this sense of service simply because it is fitting to the human condition. It is fitting that a doctor would be a servant to a patient, remaining present when the patient is afraid or suffering from a disease, whether or not it can be cured, fixed, controlled, or turned into a billing code. When the practice of medicine no longer engages such questions of value, and instead capitulates to efficiency, biological

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reductionism, indices of consumer satisfaction, and profit margins, we lose something important. Doctors are in constant formation. To practice good medicine, even when it runs against the grain of corporate priorities motivated by the desire for more profit, they need permission from people they see as mentors or role models whom they want to emulate. My permission to see the practice of medicine as an act of love first came from an intensive care doctor who was a Sikh. He went to medical school in India. He then went to Oxford as a Rhodes Scholar. While at Oxford, he received his Ph.D. He trained in pediatric intensive care at Harvard, then went to Emory University where I was a resident. He was famous for his journal articles about neonatal pain. Until he did his pioneering research, doctors assumed that neonates did not experience pain because their nervous systems were underdeveloped. They assumed newborns did not need anesthesia or analgesia because they could not feel pain the way older children do. They would open up infants’ chests and perform procedures such as the ligation of a patent ductus arteriosus with no anesthesia. Many questions now come to mind. How could they have done that? How could they think a screaming baby is not in pain? How do you get to a place where you think that babies do not feel pain? It was not a desire to be cruel. It was a form of blindness. But how do doctors become so blind? This question is relevant to many parts of the contemporary practice of medicine, both for doctors and for patients. The abstractions and gnostic tendencies so prevalent in contemporary medicine make it easier for benevolent intentions to lead to horror because they distance doctors from the lived, temporally-limited reality of mortal embodied patients. My mentor had published journal articles that began to transform the way people thought about neonatal pain. I did not know about his revolutionary work when I first started working with him. I only knew he was an amazing doctor whom I wanted to emulate. Twenty years later, I was at a pain conference where he was giving a lecture on neonatal pain. He has hundreds of publications and his talk was a review of his most recent research. But he began his presentation with an image of a guru from India. For ten minutes, instead of talking about his research, he talked about how this man had taught him the importance of love. He told the audience that our experience with our patients’ pain, our research to understand pain, and our work to help people with pain makes sense only if we begin with

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love. He said that everything he does in his laboratory and in his intensive care unit is an expression of love. His association of the practice of medicine with love was transformative for my own practice. Love may not change how we choose antibiotics or calculate doses of chemotherapy, but it does change the nature of the attention we direct toward other people when they are sick or dying. Love helps a doctor see who a patient is. It helps doctors to speak in ways that are meaningful in the lives of particular patients. Love is the key to understanding the practice of medicine as being in time, because the limits of time and the limits of being are granular sources of the joy inhabiting our loves, and they are the granular sources of grief when our loves suffer, lose important things, or die. Disease interrupts our projects, our serenity, our goals, our rest. Only people can experience this interruption. Cells, or functionally related groups of cells, cannot. Cells that turn into cancer, or otherwise fail to function normally, are an important part of the answer to the question, What is disease? But just because a cell acts in one way rather than another, that is no reason to change the cell’s behavior with medicine. If a cancer cell multiplies differently than a non-cancer cell, that constitutes nothing more than a variation on ways cells can divide. It does not constitute disease. Figuring out ways to make cancer cells in a petri dish stop dividing is an interesting puzzle that is enjoyable to solve in the lab. But aside from the challenge of solving the biological puzzle, there is no reason to change the behavior of the cells. Reasons inhere in the minds of people who have purposes, goals, and ends. If I have leukemia, the reason to stop the uncontrolled division of white blood cells is not some value inherent in one kind of cell division compared to another kind. The reason to stop their division is because I do not want to be dead. There might be many reasons I do not want to be dead—fear of death, desire to be with loved ones longer, ambition to accomplish certain kinds of work in the world—and these are the reasons to ascribe value to one pattern of cell division over another pattern of cell division. The practice of medicine is motivated by reasons that are more like fear, love, and purpose than like biology. Our desire for happiness implies a desire to avoid disease, but it is not defined by any biological variation, including the variations that lead to disease. The nature of disease, and the scope and limits of its power in a life, cannot be understood without mature insight into happiness and our

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desire for happiness. Our understanding of what genuine happiness is and our desire for happiness have reciprocal influences on each other. Happiness is the object of desire, but our discovery of the true nature of happiness also depends on well-ordered desire. Poorly-ordered desire can lead to a poor understanding of happiness. Disease can disrupt the momentum of our desires and our pursuit of these desires. This disruption can lead to a revaluation of desire. It can lead to a discovery process that begins with questions about what is most worthy of being desired. Disease can provoke questions about the relative value of different objects of desire. Our awareness of the movement and limits of time in the arc of a life likewise motivates us to pay attention to the questions and to look for answers. Disease intensifies our awareness of the limits of time by revealing the truth of our vulnerability, fragility, and mortality as embodied people. This is why the practice of medicine is fundamentally concerned with ways of being in time. We do not choose disease, but rather find ourselves thrown into disease, just as we have been thrown into our embodied experience in the world.9 We do not volunteer for the experience of disease. We would prefer to avoid it. Our desire to avoid disease clashes with our experience of being thrown into disease. In our distress, we reevaluate objects worthy of desire, awareness of our limits in time, and the experiences of gratitude, hope, perseverance, and mature peace. When we are thrown into disease, gratitude can occur for the other goods in our life that likewise have the character of thrownness. Most of the good things in our lives arrive through no agency of our own. The air we breathe is not something we have earned, and though we often take it for granted, we become acutely aware of our gratitude for it when it is threatened. When breathing is recovered after an experience of disease associated with respiratory difficulty, we know true gratitude for this simple, free, good thing.

9

Thrownness is the condition of everyday existence, which we live in a mostly-unquestioning way and with a certain state of mind that answers the mundane question, “How’s it going?” Within this condition, we are not particularly concerned with exploring or directly seeking to grasp our reality. We are delivered over to our condition. A day in a life just is what it is. When the practice of medicine is made up mostly of protocols, tinkering with biology, waiting for tests, and so forth, the experience of disease is an experience of thrownness. But we can also experience a kind of awakening within the experience that changes our relationship both to our overall condition and to our sense of ourselves.

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Hope comes when we remember the good that was disrupted by disease and wish for its return. There are good reasons for hope, and these good reasons are often grounded in the availability of real solutions within the practice of medicine. Perseverance comes from enduring despite disease and despite the difficulty of therapies aimed at relieving disease. Peace comes in the experience of disease when we relinquish any sense of entitlement and simply feel gratitude for the gratuitous good of existence as a condition for other gratuitous goods in life, fully embracing the true nature of being embodied people. Understanding the disruption that comes when we are thrown into disease illuminates the meaning of the practice of medicine. To be thrown is to experience something important that we did not choose. We are motivated to pay attention when something matters. But understanding that it matters is not the same as understanding why it matters. We can respond to this in several ways. When something important occurs that was not chosen, we can simply “make the best of it” without bothering to ask questions about why something happened. The reality that we have little or no choice in something important can also breed resentment. It can stimulate curiosity, philosophical reflection, wonder, a sense of adventure, anxiety, the feeling of strangeness, and other emotions and thoughts on our palette of responses to being thrown. Being thrown also provokes questions. We did not choose to be thrown into reality, but is everything that is real something into which we were thrown? Is there anything we merely choose? How can we tell the difference between something that is chosen and something that is not chosen? Understand the difference between choosing and being thrown is to understand a lot. We understand something about what mattering is. We realize that being thrown might confer meaning on the things into which we are thrown, even if we cannot infallibly discern the meaning. We become aware that there might be more to the story. All of this affects our experience of being thrown. Part of the experience of being thrown is to recognize the limits of our ability to choose the course of our life. If we truly have no power of choice, everything is something into which we have been thrown. If we have no capacity to choose, and our capacity to change things through our free will is illusory, we are not responsible for failure or success. But if we could have chosen a response to being thrown and do not, that too constitutes a choice: it is a choice not to choose. There are many reasons we

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might refuse to choose a response to being thrown, including fear, nonattachment, or patient humility. When we choose a response to being thrown, we do so in the face of uncertainty. This requires courage. The conditions and meaning of thrownness are always uncertain. But the chosen-ness of the response reduces overall uncertainty simply because to choose a response is to become one thing rather than another. Becoming is a way of being-over-time. It is a powerful form of agency. Solidity of being accrues though repeatedly choosing paths of becoming. The appearance of solidity can also lead us to forget the inevitable reality of uncertainty in our lives. The institution of medicine offers one possible response to the uncertainty of dis-ease, but it often advertises itself as the only reasonable response. Such advertising assumes important, astonishing things. For example, it assumes that the institution understands what disease is. It assumes that the institution’s solution to disease is the solution to the actual root of dis-ease. The advertising institution’s understanding of disease may or may not seem to be an assumption. If an institution is transparent about its fallible assumptions and open to reconsideration, perhaps we can accept that the advertisements are offered in a spirit of humility. But we cannot trust an institution that embraces assumptions unreflectively as background truth—a view from nowhere—or worse, hides assumptions that might be unpalatable to their target audience. Either way, the very nature of an advertisement implies that the institution knows something about what constitutes the right or the good. If the institution has engaged in sustained, thoughtful philosophical reflection on the meaning of happiness, disease, embodiment, existence, the good, the right, and the practice of medicine as being in time, such a claim might be as close to truth as is humanly possible. But in the absence of such engaged philosophical thought, an institution is guilty of false advertising. Institutions that advertise in a misleading way are probably less trustworthy in other circumstances as well. If the institutions that house the practice of medicine cannot be trusted, patients and doctors have a conundrum. If we are thrown into dis-ease, and we accept that the institution of medicine has the only right or good response to dis-ease, or at least the best response, we soon find ourselves wandering in the strange and complex arena of the practice of medicine. If we are passive in our submission to the claims of the institution of medicine, or else truly have no choice because of an unexpected event such as a car crash leading to the delivery

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of our injured body to the hospital via ambulance, we are thrown into the arena of the practice of medicine. The disorienting experience of being thrown into dis-ease is accentuated when we are also thrown into an institution we do not understand, and which does not understand us. We might not understand the rules of the institution, which can lead to the label of problem patient. We might not understand the complex tests, procedures, and therapies the doctor recommends, which can lead to the label of notvery-intelligent patient. We might have a worldview that gives us hope the doctors do not share, which can lead to the label of out-of-touch patient or patient-in-denial. Often the institution asks us to put on gowns that mark us as patients. The patients’ gowns all look the same, and the rooms given to patients look the same. They are nothing like home. There are no locks on the doors to these rooms. Anyone with a badge can walk in without setting up a visiting time or calling ahead. There are rules about which people from the community can visit, how many can visit at a time, and when they can visit. Nurses check vital signs all night, machines beep, residents talk outside the door. It is very hard to sleep. This is exhausting. Exhaustion is important to someone who is sick. People who are employed by medical institutions do not generally experience themselves as thrown into the arena of the practice of medicine. Though there are many forces that influence our choices, the people who work in the medical institution have “chosen” to join it, to stay, and to do the institution’s work. The difference between being thrown and choosing to be in a place (or at least appearing to have made a choice) creates important differences in one’s experience of a place. It creates important differences in the experience of power, thoughts, feelings, and the sense of security. The work, purposes, and goals within the institution are attached to roles. These are divided into roles people apparently choose and roles into which people are thrown. Each of these roles—whether one has chosen it or has been thrown into it—is shaped in accordance with what the institution often refers to as Rights and Responsibilities. Rights tend to be the things one can expect from the institution and the people who choose to work in the institution—confidentiality, respect, and access to advocates if things go wrong. Advocates usually work for the institution, but they are meant to represent patients despite the obvious potential conflicts of interest. Responsibilities can be gestures of respect, insofar as they

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acknowledge the ongoing agency of a patient. But they can also be formulated as rules that seem constructed to mitigate institutional risk more than to express respect. In any case, the reality of the difference between the circumstances of choosing versus being thrown should be reiterated frequently. The difference between being thrown and not being thrown is important. Intention is part of how this difference has meaningful impact on behavior, perception, memory, and experience of both patients and providers.10 To intend is to direct our consciousness toward some specific aspect of consciousness itself, toward its effect on other aspects of the mind besides conscious intention, toward other persons or things in the world, or toward changes in the world that occur in response to the act of intending. Noticing or feeling such details is a gesture of respect toward a patient who needs a doctor to respond to something the patient perceives as important. It is also a chance to know oneself, though intention does not have to be understood to be noticed in a meaningful way. Intentional awareness of the difference between choosing and being thrown is a gesture of respect toward patients who find themselves thrown into disease and disrupted by the experience. It is an act of focused consciousness that affects other aspects of conscious experience. Failure to acknowledge this is disrespect, which diminishes trust. All of us who make an apparent vocational choice to enter medical school experience many forces that are not under our control, whether or not we admit it. This can transform the ostensibly-chosen experience into an experience of being thrown. At first, it can feel like belonging. We are given a badge, a role, and growing authority. We are given access to rooms identified as restricted. We have a place to park. And we go to orientation sessions where we learn the codes, rules, passwords, and expectations that come with the privilege of belonging. The orientation sessions turn out to be more like reorientation sessions. We were oriented before we joined the institution. We knew things

10

The philosophical understanding of intentionality revolves around the ability of our minds to represent things, to have content, and to achieve mental states that are about things or about states of affairs. Our words, pictures, and symbols have intentionality when we use them to express our mental states to another person. Heidegger used the word “care” for intentionality, as a way to distinguish thing-like presence in the world from the ontological significance of individuals who exist and who are conscious of existence.

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and we belonged to other groups. We understood certain codes and rules that governed our own communities. As we orient to the new institution we have chosen to join, we can feel not merely reoriented, but disoriented. The world of regulations, with which we were only vaguely familiar, turn out to be so complicated that the task of completely understanding them is a full-time occupation. There is a kind of vulnerability to institutional risk we did not know about, and it is very serious. It is watched over by serious and sometimes-nervous people called Risk Managers. There is a dawning gap between the advertised nature and purpose of the institution, and the institution’s true relationship to money, power, and self-preservation. There is an entire world of new legal risk, and institutional lawyers are given the power to approve or disapprove of many things in order to avoid this risk by a large margin—a surprisingly large margin that seems motivated by more than mere mitigation of risk. This background governing motive initially feels murky, dark, and hidden. But eventually it begins to look like a much more sinister combination of greed and fear, which is surprising to many of us. Discovery of these forces in contemporary medical institutions can transform a doctor’s own experience into an experience of being thrown. This experience is unexpectedly pervasive in the institution. No one is free of the institutional forces of greed, fear, threat from competition, ambiguous possible future regulatory changes, complex laws, unanticipated safety issues, government control, placards outlining principles in small print, and rows of binders containing numbered policies. There is no organized and transparent genealogy of these forces identifying the actual people with whom the forces originated, along with their rationales and the reasons we should trust their judgment. The forces are often perceived as authoritative because they are written on paper and placed in files labeled authoritative. There is a substantial volume and complexity to the many authoritative files containing the rules, regulations, policies, procedures, protocols, and contingency plans for hypothetical situations. Because of this, the day-to-day governing of the institution requires vague references to groups of authoritative sources, rather than references to particular, well-reasoned, clear arguments. Phrases such as It is our policy ... or The regulations require ... become a kind of efficient shorthand to justify assertions made by people with “power” attached to their positions, especially at the middle-levels of institutional management. Mere reference to The Legal Department or The Department

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of Risk Management serves to mute objections and create timidity. The freedom and ability to choose within the institution is limited or non-existent in any meaningful way, which leads employees of the institution to feel thrown into a swirl of threats and potential risks that must be feared. In the middle of all this, strange questions arise, such as whether or not medical students and residents can be taught empathy. Perhaps the better question is whether or not it can be remembered: can doctors can remember what it is to be fully human when they work in dysfunctional institutions that turn human illness, suffering, and death into a lucrative opportunity for corporate investment? Empathy is a deep human trait, but something seems to happen in medical school and residency that dulls it. Empathy can be dulled by spending most of medical school discussing disease and interventions in purely biological terms while ignoring other parts of the story that constitute an individual’s identity. It can be dulled by the volume of suffering and death encountered during training and practice that often demands eighty-hour workweeks, week after week, month after month. It can be dulled by mere fatigue. My own capacity for empathy frequently diminished thirty hours into a shift with little sleep. The question whether or not empathy can be recovered can only be answered by asking another question: How have you been injured or ruptured or crushed in ways that make it hard to show empathy to the sick and the suffering, and how can we heal that? If those things can be healed, perhaps empathy can return. Many people are framing these concerns in terms of so-called burnout and compassion fatigue, which have led to a physician shortfall that will take decades to recover from. But the term “burnout” locates the problem exclusively within the physician. And compassion is enlivening, not fatiguing. Perhaps a better term is moral injury, which results from institutional pathology rather than from an individual’s problems. Doctors are fatigued by practicing in circumstances in which they experience compassion but feel constrained by institutional greed or fear. They rip their wings to a bloody mess trying to respond with limited tools inside institutions that construct a surface rhetoric of compassion and healing, while the bones of their structures are risk-avoidance, legal protection, and corporate profit. Part of the problem is a contemporary disregard for aesthetics in the practice of medicine—a lack of attention to beauty and elegance in the arrangement of space in a hospital, to nuance in conducting a complex

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family meeting, or to the ways language is used. Writers of old medical texts reveled in the poetic act of naming things—borborygmus for the rumbling in your stomach, sella turcica (the Turkish saddle) for the bony indentation deep in the head that holds the pituitary gland. William Osler, who was one of the early proponents of a scientific approach to practice of medicine, pitied doctors who did not read literature, because literature reveals the contours of worlds besides our own. Doctors must master the art of imagining the inner world of others if they wish to honor the trust and power granted by patients’ invitations to witness their lives. In the midst of so much uncertainty, mystery, and fear, doctors who want to discover the deep practice of medicine as being in time must engage a patient’s whole story. Otherwise their practice will never be in line with the grain of reality. They will remain oblivious to what is truly at risk and to what is lost when dis-ease overcomes a person. The only way to grasp such a story is to pay attention to the forms of beauty that appear, often in the middle of illness or the end of a life. Doctors and patients thrown into so much suffering and death desperately need beauty as a reminder of a story about the universe that is larger than one season of sadness, suffering, and loss. One sad truth about contemporary medicine is that these profound aesthetic concerns often seem to be at cross-purposes with corporate goals of efficiency, risk avoidance, and profit.

III. Primordial Totality Human experience and the scaffolding of our institutions exist in a universe that is one way rather than another. By universe, I mean whatever is real, including the source of the universe, even if the source of the universe is not part of the universe in the same way that other parts of the universe are parts of the universe. We cannot know with certainty what kind of universe we live in. We know almost nothing with certainty. But we are kind of creatures who want to know things and to see the truth of things as clearly as possible, especially when the stakes are high. There is a way that our universe is. This is the simplest of points. It is a logical point. The kind of universe we inhabit matters, because whatever the universe is and whatever it means, it is the context for our entire experience of being human. This seems obvious, because it is obvious. But the meaning of this fact is not as obvious as the fact itself. Sometimes we think about what kind of universe we live in. More often we tend to ignore the question. There are other so many other things to think about in the course of living a life. But when we are thrown into the experience of dis-ease and our bodies are threatened, we pay more attention to such questions. We pay more attention, in part, because threats to our bodies threaten to change or eliminate our entire future experience of the universe. We also think more about the kind of universe we inhabit because diseases and their treatments often interrupt our projects, leaving us with uncharacteristically long stretches of time during which we are asked to be patient. Given how complicated modern institutions have become, including the sheer volume of paperwork and administrative tasks necessary to deliver the institutions’ “products” to their “customers,” it might seem strange to refer to the nature of the universe as relevant to signing forms or reviewing pharmaceutical billing practices. But untethering medical practices from questions about the universe as a whole leads to human degradation. Threats to our bodies are threats to our existence in the world. They are threats to all our projects and interactions. This is why threats to our bodies are high-stakes threats—they threaten everything. The practice of medicine is a response to the threats our bodies meet through disease, injury, and aging. 51

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Every aspect of the practice of medicine begins with a decision to act in this or that way, for this or that reason. In the day-to-day practice of medicine, certainty is preferred over uncertainty, even though certainty is almost never possible. Thinking about questions with no obvious answer, such as questions about the origin or purpose of the universe, can be viewed as a waste of time. With so much to do, and so little time to finish everything, efficiency dictates that we not allow ourselves to be distracted. This demand is ostensibly for the benefit of the patients, as well as the doctors and the institution as a whole. “Distracting questions” can be criticized, disparaged, and mocked as interruptions of the “real” work. Even the effort to show why such questions are important can be mocked or dismissed. The prediction of the consequences of dismissing such questions, however well-reasoned, takes time and attention, and it sometimes seems like silly doom-saying. This is all quite unfortunate because the kind of universe we live in matters, whether or not we choose pay attention. There are two basic ways the universe can be, based on its fundamental origin. The universe might be uncreated and exist in no relation to anything aside from itself. Or the universe might be created and exist in some relation to its creator. In both of these ways that the universe might be, the universe is. But in the first way, the universe is the only thing that is. In the second way, the universe is not the only thing that is. In this second version, the universe originated from the intention of whatever it is that is not the universe. The central distinguishing feature between these two universes is not the stuff that makes up the universe, but is rather the intention involved in the origin of the second version of the universe. There are universes of the first kind that include a kind of divine element that is related to the universe only by virtue of its force or power, not by virtue of its intention. For example, in Aristotle’s account of the universe, Nous contemplates itself, and only itself.11 Movement in the universe follows from love for Nous, but the divine does not intend the universe to exist or to become anything in particular. A second example is Plotinus’ account of the universe in which everything emanates from the 11

Nous is a concept that evolved in ancient philosophy meant to demarcate the faculty of the human mind that allows us to understand the true and the real, and to think rationally. Aristotle distinguished this aspect of the mind from sense, imagination, and memory. Nous allows the mind to generate and communicate definitions, and to grasp universal categories in logical ways.

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One, which is itself beyond being.12 In these cases, the divine is more mind-like than a stump or an equation in physics, but it has the same kind of place in a full account of the universe that other explanatory, disinterested forces have. A created universe that is intended by the divine is different because the purpose of a thing follows from the intention of its maker, and only intended things have purpose. If the universe is not intended in some way by a maker, it is difficult to imagine how it could have a purpose as a whole. Either way, we must use metaphors to discuss the possible kinds of universes, and we cannot know with certainty what kind of universe we inhabit. We are capable of intention and purpose. Because of this, irrespective of the kind of universe we live in, our experiences of embodiment, embodied action, and threats to embodiment are related to the concept of purpose. Purpose can be limited to small, local needs, cultures, and events, or it can be a larger sense of purpose. Both senses of purpose are operative and necessary in the practice of medicine as being in time. Purpose is interpretable in relation to goals such as relieving pain, repairing injuries, easing mental illnesses based on neurochemistry, providing inexpensive vaccinations to children, and so forth. A great amount of good with nearly self-evident value can be achieved under the rubric of this concept of purpose. But at some point in the arc of the experience of dis-ease, when the biology cannot tell us the next right thing to do, an embodied creature must consider decisions that do not easily fit into one of these smaller forms of purpose. Making medical decisions is choosing one form of life to the exclusion of others. In some of these decisions, only attention to a larger sense of purpose can help us understand and articulate the value of one way of living over another way. Most contemporary medical decisions relate to the smaller sense of purpose, often without overt reference to the concept of purpose. But an inability to meaningfully incorporate a larger 12

The One is an idea rooted in the pre-Socratic philosophical tradition in which explanation proceeded according to the principle that the complex is derived from the simple. This is the idea that our accounts of phenomena and contingent entities must rest on something that does not itself require explanation. Early iterations of the idea were refined until the Neo-Platonists took the concept to its logical extreme, developing a mature version of the idea that has impacted many parts of western philosophy. The name is a placeholder gesturing toward the absolutely simple first principle of all that is, the cause of being for everything else in the universe.

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sense of purpose into high-stakes decision-making can lead to bad decisions based on an unspoken background assumption of purpose. A larger sense of purpose can be minimized by vaguely misleading statements that exist without any explicit philosophical frame or language. Our experience of the purpose of purpose, or the significance of significance, is relevant to decisions we make, if we mean by relevant something like illuminating the place of a decision in a good life. The practice of medicine as being in time must be oriented toward contributing to the goodness of a life, or else it risks being negligent, incompetent, and possibly violent. The tools, techniques, and interventions comprising the practice of medicine are permitted only in well-defined contexts. They would be dangerous, harmful, or evil otherwise. Any context in which the practice of medicine is permitted must include an intentional orientation toward the good of the patient. This requires the participants in the practice of medicine to have some concept of a good life. The concept of a good life is uninterpretable apart from some concept of the good.13 The concept of the good is a philosophical idea that takes different forms among reasonable people. A working concept of the good relevant to actual decision-making must be discovered through conversation between patients and doctors. The practice of medicine follows from points of decision-making in its most practical instantiations, but good decision-making is only possible in relation to a coherent notion of the good in a life. The practice of medicine depends on the philosophical work of grasping the concept of a good life. This in turn depends on grasping the concept of purpose or significance in a mature and non-trivial sense. Threats to embodiment impact the experience of one’s life, both in terms of present experience and in terms of a larger view of the meaning of one’s life. If we lose our bodies, we lose a lot—possibly everything. Even if there is an afterlife, or else the hope of reincarnation with at least .

13

The idea of the Good shows up in the Republic where Plato argues that we should not focus on every form of difference and sameness in nature, but should rather focus on the form of the Good, which is the basis for understanding all other forms. It allows us to understand everything else. Plato compares the form of the Good with the sun, in the light of which we see everything else. The sun is not sight, he says, but is rather the condition for sight itself. The sun’s role in the visible realm is analogous to the form of Good in the intelligible realm, giving us the power to know truth. The Good is also the most valuable object of knowledge to which we can aspire, superior in rank and power even to being itself. Plato’s understanding of the Good, while enormously influential in Western philosophy, is nonetheless somewhat esoteric.

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a tenuous connection to the experience our current life through memory, death is still the end of everything I do on earth as myself in this life. Inhabiting the world as a ghost would not prevent the loss of all my projects and relationships. And if we utterly disappear at death, we certainly lose everything, even though we will not know it since we will no longer exist. It is hard to conceive of a worldview in which loss of my body does not entail loss of everything in my life, irrespective of whether or not there is an I that continues to experience new forms of good and memories of the good in this life. When the body dies, one of three things happens: we experience an afterlife in which our identity retains some continuity with our earthly existence (in heaven, for example, or else as ghosts on earth), or we exist in some form without continuity with our earthly existence (reincarnation without memory of this life, for example), or we disappear. Each of these possibilities at the time of death is strange and unprecedented in our embodied earthly experience. The larger view of the meaning of our life and our place in the universe impacts the way we frame threats to our embodiment. The way we frame such threats affects our experience of the threat, our response to it, and our view of the people who say they might be able to remove or delay the threat—doctors, for example. People who can remove or delay such threats matter to us. They have power in our lives. Hospitals have morgues. Schools do not, grocery stores do not, churches do not. Why? Because the hospital is a place where people die. Death is not an unusual event in a hospital, though this fact tends to be downplayed or ignored. When such profound human fears and vulnerabilities converge on one site, as they do in a hospital, that site should be considered sacred, if anything is sacred. There should be a sense of reverence for people who are facing such profound loss, and who must show courage despite uncertainty and mystery. At the very least we should respect ill people who are hospitalized by making the quality of their sleep and food a priority. Eventually the value of our mortal bodies comes into conflict with other priorities in our own lives or in the lives of those around us. This forces us to ask uncomfortable questions. How much are we willing to sacrifice to keep the blood going around and around, and the air going in and out? Should we instead fill our days with art, music, education, great food and wine, and other things that contribute to flourishing? At some point, we will have to face that trade-off. The trade-off is a difficult

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problem. But if I prepare myself for the reality of my mortality, and if I surround myself with people who know what matters to me, then I can say no to expensive and painful interventions that will interfere with something I care about—being at home when I die, for example, or finishing a painting instead of embarking on yet another course of treatment. When disease threatens our continued embodied existence, grasping a larger view of our lives seems especially important. Sometimes it is important as a frame within which we make decisions about the end of life. Even apart from end of life decisions, if reviewing the larger meaning of our lives is ever important philosophically or spiritually, the context of impending death is surely such a time. Opinions about our beliefs, expressed by people who have power in our lives—including our doctors— can affect our experience. If we feel supported and respected in our philosophical reflections and conclusions, we might share them with others and allow our convictions to have more force in our decision-making. If we feel dismissed or disrespected, we might hide our thoughts, or even avoid engaging in such reflections. In the name of vague or specific hopes, or some version of so-called “positive thinking,” we might be encouraged to avoid philosophical reflection about the meaning and implications of threats to our bodily existence. This can be benevolent in a way, as when someone helps a patient to remain engaged in the work of healing, fixing, repairing, and diminishing threats. It can also be a way of avoiding uncomfortable realities such as death or the limitations of the practice of medicine. When “hope” is not based on a reasonable chance of resolving or mitigating the threat, important opportunities for truth and honesty can be missed. Even when the threat of disease is not a threat to continued embodied existence in the world, disease can still remind us of our fragility, contingency, and mortality. Such awareness is a propaedeutic for more concentrated attention to the meaning of our lives, our universe, and our place in the universe. A doctor is a teacher. Because the practice of medicine occurs in the body of the patient, teaching the patient the reasons for a proposed practice, the expected effect, the likely experience the patient will have, and suggestions for enduring or even flourishing during the experience of disease and treatment all comprise important parts of the doctor’s teaching responsibilities. When decisions are high-stakes, complicated, frightening, or urgent, the process of decision-making itself can and should be seen as

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an opportunity to teach through clear discussion of the elements of decision making, clarification of the roles of people involved in the discussion, and effective modeling. Given the most common contexts for the practice of medicine, along with the philosophically relevant aspects of the human experience of disease, the doctor is in a position to support patients, families, and colleagues in philosophical reflection. They might even be obligated to include this as part of the work of teaching. The doctor has a special form of access and authority in many contexts in which the practice of medicine occurs. Responsibilities that accompany privilege and authority should not be avoided, even if other responsibilities are more appealing. The doctor is a teacher who is granted authority. This authority obligates the doctor to attend to these philosophical aspects of the practice. Questions about the meaning of our embodied existence, the universe, and our place in the universe are fundamentally related to time. They are related to time, in part, because the questions are difficult: finding answers that have philosophical integrity for us is a long art. They are also related to time because they are prompted and made urgent by human mortality, which implies not only that time is limited, but that it is also short. They are related to time because the shortness of time for embodied creatures is something that must be noticed and made an object of mindful attention in order to be meaningfully relevant to the course of a life, including those parts of a life impacted by disease. Mindfulness of time is inseparable from mindfulness of questions related to what constitutes a good life. This is not only because the length of a life is an important aspect of life’s relationship to time, but also because life is made up of our experiences of moments, our anticipation of moments, and our recollections of moments all linked in memory, mindfulness, and imagination. Mindfulness of a moment is different than mindfulness of the imaginative abstraction we call duration. Mindfulness of the moment is mindfulness capable of accomplishing something in time, arriving at a new thought, or achieving new awareness of a feeling. Things only happen in the contexts of moments. Duration is an experience of the residuum of moments and the anticipation of moments. But it is a meaningful experience of the idea of time that illuminates our lives, even if it is not itself an experience of the kind of present-time in which we can act. Duration is an experience that is distensible and contractible because it is not the same thing as time. Duration is dependent upon time and occurs in time. It is often the theater in which time is experienced as time. That is

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why duration is often confused with the meaningful human statement, “I need time.” The practice of medicine as being in time is interpretable only if we attend to the desired shape of our experiences in a moment, interpreted in light of memory and imagination, since these constitute the home of our experiences of time as duration—time as meaningful-in-its-enduring. Duration matters to meaning. The limits to our duration matter to human meaning. Medicine is the art of being a wise guide among the complexities of duration. This is at the meaning-dense core of the idea of the practice of medicine as being in time. Fundamental questions are related to the limits of time for embodied creatures like us. Disease highlights these limitations because it is a threat to embodied existence. Mindfulness of the nature of duration is brought into focus by the force of the absolute proximity of death, colored by the uncertain distance of our current moment from our final moment. Mindfulness of duration takes the form of a story in imagination and memory. The form of a story is the way in which duration becomes expressible to ourselves and others. Insofar as the form of a story expresses meaningful duration in the life of an embodied creature, it is also one way in which we endure the passing of time. Philosophical attention to duration as the memory and anticipation of passing time becomes relevant to the lived experience of people only by engaging the stories of those who are enduring in the midst of threat. Unfortunately, the training doctors receive leaves them with almost no language to address questions that arise inside stories, nor even to conceive of these stories in a philosophically interesting, spiritually adequate, and medically relevant way. Doctors’ imaginations are often decimated in their training as doctors. The reasons are complex, but the tragedy of this reality is unequivocal. If doctors are not taught the languages of storytelling, what languages are they taught? Contemporary medicine in a corporate environment occupies itself with four primary languages, all of which are complex and difficult to master. They each have a purpose. They are also institutionally embedded in a way that can mute, disregard, shame, or exclude other languages. The first language is that of biology—normal biology, rogue biology, and medical or surgical interventions aimed at making rogue biology return to normal biology. The mastery of this language begins with the memorization of thousands of unmoving parts inside a dead body. It

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proceeds through physiology, where molecules with normal motion are learned. It goes on to pathology, where the motions of rogue molecules are studied. It concludes with the clinical years of training, where techniques are learned to make rogue molecules behave normally. Mastery of biological language in medicine takes thousands of hours. It is beautiful and important, but when it is bracketed from the language of storytelling, it leaves doctors with a fairly thin definition of life (molecules in motion) and their own vocation (making rogue molecules move in a more normal way). The second language is that of law. Doctors do not generally master the details of this language. They trust it to corporate lawyers, generally because they have no choice. But doctors do carry anxiety about lawsuits in ways that shape their practice of medicine. The third language is that of finance. This language is also relegated to experts—accountants, policy-makers, tax-specialists, and business people. But doctors carry responsibility for the working mechanisms that are billable and profitable to the corporations. The control doctors have over the financial dimensions of the practice of medicine is becoming eversmaller, since corporate models dominate institutions. Revenue generation is arguably the most powerful language of contemporary medical institutions. It is becoming the primary language for of evaluating a doctor’s worth. The fourth language is that of risk management, aimed not at the patient’s benefit, but at the mitigation of risk to the institutions. None of these languages have room for stories that make sense of the lived experience patients or doctors have as they encounter the reality of illness, suffering, and death. Most patients interact with medicine when things are not going well, or might not be going well. But one practical reality of the life of doctors, who are themselves embodied mortals, is that the majority of their conscious life is spent in the cauldron of medicine. The ways they view their work, frame their practice, and act shapes their character. Their institution’s structure, integrity, guiding principles, rules, priorities, and relationship with its “employees” also affect the doctor’s character, for better or worse. Everything that occurs within the practice of medicine is philosophically important and interesting because everything is related to the human experience of birth, death, agency, virtue, suffering, and the desire for some kind of legacy. If the character of the doctor has any relevance to the act of decision making in the middle of such experiences, then the impact

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of the administrative and financial structures of institutions on the character of its doctors is philosophically important. The structures of these institutions, taken as a whole, are morally and philosophically important for the lives of anyone who engages with medicine. Because almost everyone eventually engages with medicine, the moral and philosophical influence of these institutional structures are a matter of collective public interest. They impact our civilization. The influence of the practice of medicine reaches from the most local of circumstances in the privacy of the clinic or hospital room, to the most public of concerns, including philosophical questions of justice, morality, and the nature of knowledge. The practice of medicine is a philosophical cauldron in which people experience threats to their own existence over time against the backdrop of primordial totality.14 To say what the practice of medicine is, what it ought to be, and why it ought to be one way rather than another requires a sense of the context and circumstance of the practice—a concept of reality as a whole. Aspects of the practice of medicine such as individual tests, procedures, or prescribed medications can be used effectively without such large, framing questions. They relieve suffering or improve function in many cases, and the net result of this is good. They are worthwhile in the way that any small service is worthwhile—fixing the brakes on someone’s car, repairing the heater in a house during winter, stocking grocery shelves. Such small-frame goods are so good that they are sometimes used as an argument against the necessity of considering the larger context of the practice of medicine. Patients and medical practitioners are often busy, and managing small goods is satisfying. Achieving such goods is a wonderful way to measure the success of a day. These achievements can mark the end of the day, when it is time to go home and relax. But there is a loss even in the realm of small goods if we do not reflect on the larger context of the practice because we carry these large questions in our bodies and minds. If we ignore the questions, we risk losing an important aspect of meaning in our lives, or else risk living with a sense of chronic dishonesty. The practice of medicine as being in time is situated in a larger reality that is its source of meaning and order. If the practice brackets itself from this larger reality, it commits a philosophical sin that degrades the truth of 14

For Heidegger the primordial is vaguely synonymous with truth and truthfulness. The primordial is that which is closest to the essential nature of Being.

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its own purpose and order, as well as the truth and order of the embodied mortals for whom it has some responsibility. Abstracting the practice from the reality of disease and its implications harms both patients and doctors. Doctors become spiritually dull if they ignore these important questions while living most of their conscious life on the threshold of the contingency, uncertainty, fear, and anxiety that we experience when things go wrong in our bodies. The practice of medicine is the context for many human events of profound significance to embodied creatures like us. These events raise questions about reality that are relevant to the practice of medicine as being in time, because the practice is intimately involved with birth, death, suffering, virtue, stewardship, and our attempts to tell a story about the ineffable path of our singular journey in time with those whom we love. But there is another reality that shapes the characters of patients and doctors— the reality of the institution within which medicine is practiced. Some of the experiences patients face when they are thrown into disease feel too big for one person to carry alone. Likewise, some of the experiences doctors must endure or perform, accepting responsibility for their part in events of great human significance, are bigger than any single individual. Institutions are communal entities with their own character. They are necessary for convening people, and for providing financial, technical, scientific, legal, spiritual, and philosophical support. They enable individuals to do things they could not accomplish alone. Though the language of biology dominates medicine, doctors are not pure biologists: they use biology to help individual people. This requires knowledge about the person’s stories, hopes, and fears, especially at the end of life where many important goals go far beyond fixing rogue biology. Philosophy asks the kinds of questions that matter to people who are sick or dying. It has a rich language to address large questions, and it does not view exploration of such things as silly. On the contrary, philosophy insists that these questions are the central to a good life: What does my life mean? What should I do? What can I hope? What is God? Do I disappear when I die? Can I be forgiven? Doctors attending to people who are sick or dying likewise cannot avoid these questions. At a practical level, philosophy provides an important intellectual, emotional, and spiritual space in which to struggle with conflict when the details of a patient’s biology do not offer clear guidance about whether or not available technologies should be used.

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Obstetricians must answer questions about performing abortions. How late in pregnancy? Are there limits on acceptable motives for abortion? What, or who, is being aborted? Who should be involved in the decision? The mother only? The father? The family? The faith community? The government? Other doctors experience a different set of questions. Should a doctor in the intensive care unit turn off ventilatory support in a brain-dead patient when the family wants it to continue? Is brain-death the same as death? Who knows? Who decides? Can the doctor refuse to turn off life support in a patient who might recover, but whose family insists that the patient would want to die? Would it matter if the family was in line to receive a huge inheritance once the patient dies? Can a doctor give morphine at doses that will hasten death when a patient has intractable cancer pain? Can a doctor do the same when someone has intractable psychological or spiritual pain? The practice of medicine as being in time is a fundamentally philosophical practice. Ignoring the philosophical dimension of the practice is malpractice. This malpractice can be rooted in the assumptions, history, capacities, and choices of an individual. The habit of truth-telling, for example, is influenced by many forces, some of which reach into childhood. But the decision to tell the truth rather than to lie is a decision that occurs within an individual, irrespective of the genealogy of the decision and its dependence on morally relevant forces beyond the individual. Decisions occur in minds, and minds belong to individuals. The accumulated force of policies, historical events, and sources of threat might make us doubt the idea that “decisions” are “chosen.” But even so, when a decision occurs, it occurs within an individual, with habits, virtues, vices, fears, hopes, strengths, weaknesses, and every other relevant trait that comprises the totality of human experience up to a moment of decision. Anything that happens apart from the minds of individuals is in the same category as chemical reactions in a beaker, shifts of tectonic plates, or the output of mathematical algorithms. As decisions are made through time, the effects of those decisions accrue within individuals, communities, and institutions. This accrual becomes the character of the individual, the community, and the institution. The character that emerges from this accrual of the effects of decisions over time has a philosophical flavor, substance, force, and importance. The accrual itself is philosophically interesting and relevant, and it cannot be dismissed by attributing moral or philosophical neutrality to it with statements such as, “It’s just business,

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nothing personal.” Statements like this, when they involve people and consequences in the lives of people, are lies. It is most definitely personal. We commit malpractice through our decisions and actions when we ignore the philosophical content that has accrued over time. Attention to the background reality of primordial totality resists this form of malpractice, negligence, degradation.

IV. Average Everydayness as the Very Point of Departure The practice of medicine as being in time is fundamentally a philosophical practice. Like some of the best philosophy, its starting point is average everydayness15 expressed through a mundane story populated with people relating to each other, to the world, and to time. The practice of medicine as being in time requires that we listen to the story carefully, paying attention to the invisible structures that hold our bodies, memories, hopes, fears, and needs. We must learn to read the prosaic nature of average everydayness well if we want to understand the narrow stretch of time within a life where the work of doctoring occurs. The most basic beginning of any story—Once upon a time—matters to a philosophical practice that attends to the nature of dis-ease, because it clarifies what came before the onset of disease, the moment of disruption in time. It establishes the contours of what is broken by disease. If the world of “once upon a time” is idealized, time itself feels static, moving in small circles of homey, repetitive activity. It is populated by the kinds of things one does every day. It often has a sense of the familiar, the comfortable. It is what we fantasize about in the middle of crisis when we say, “If only we could go back to…” The phrase points to the place of time’s transparency in so-called normal life. We relate to time the way we relate to windows: we do not generally look at a window, but rather through a window at something else. Or perhaps our eyes make a better analogy because of how close we are to the mystery of time as the condition for our experience of embodied existence.

15

Very few of us dedicate time to sustained contemplation and reflection on the idea of Being-in-the-world. Usually we are immersed in just trying to get on with our lives. This is the mode of average everydayness. It is an ordinary mode of being, but it is important. It is sometimes passed over in philosophical explications of the human condition because it is so unremarkable, underscoring Heidegger’s maxim that what is closest to us ontologically is, at the same time, the furthest away. We must pay close attention to the everyday if we are going to avoid overlooking this closest of things. Once we begin to pay attention to average everydayness, we grasp it through patterns Heidegger calls pregnant structures, which are often indistinguishable from our own authentic existence.

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Once ... upon ... a time. Once ... upon a time. When we tell our doctor about the so-called “normal life” that preceded our experience of dis-ease, the stability and cohesive unity of that part of our story comes from its foundation—from the fact that our life was once, strangely enough, built upon, nothing other than, a time. And now everything has changed. So we tell ourselves. Of course, the unity also comes from the way we select and edit memory and mystery as we try to form a true once-upon-a-time. Another word for the process of editing is “forgetfulness.” Sometimes, a more accurate word might even be “dishonesty.” The practice of medicine shows up in the story when we move from the experience of average everydayness and find ourselves thrown into disease. This is signaled by transition phrases such as, “And then one day something completely unexpected happened.” A disruption can be experienced as minor, as important but not a crisis, or as one of those beforeand-after lines in time dividing a life into everything that preceded the experience of being thrown and everything that follows. The experience of being thrown into disease depends on several things. It depends on the severity and chronicity of the disease itself, but it also depends on a person’s perception of the severity and chronicity of the disease. A disease that seems minor to a doctor might be perceived as a severe threat by a patient. Perhaps the patient knew someone with a similar disease who did poorly. Perhaps the disease is linked with other potential threats—a perceived association with some sort of moral failure, for example, or the fear that a disease is the result of a curse. In each case, the experience of disease-as-disruption is shaped by the average everydayness that precedes it. Someone who has many other sources of distress or anxiety in their day to day life might experience a minor, transient, self-limited disease as a major crisis. Someone whose daily practices are aimed at deepening their own peace might be able to face even life-threatening disease with equanimity. The experience of disruption also depends on the response of the people who are the patient’s witnesses, whether family, friends, or the medical team. Mindfulness of the disruptive impact of disease in this part of a person’s story is an important part of doctoring as a practice of presence. The very existence of doctoring implies the vulnerability of the body to disease, even when the primary focus is the maintenance of health. A

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thing requires maintenance only when its integrity is contingent. Vulnerability to disease is part of the body’s contingency. Contingency is an expression of temporality because it is fundamentally an expression of the possibility of change. For mortals, all change derives part of its meaning from its contrast with death, which is the inevitable absence of change. To be dead is to no longer have the possibility of change, because to be dead is not to be. Even if there is an afterlife of some sort, it is after life, and therefore its relevance to the practice of medicine is important but speculative. For mortal embodied creatures, vulnerability to change is part of not being dead, and not being dead is the condition for change. The final change we experience in embodied existence is the change from being in time (and therefore vulnerable to change) to being dead. Because our unidirectional experience of being in time inexorably moves our bodies closer to death, even the pronouncement of good health is only a pronouncement of something that will eventually be lost. When the loss of something is inevitable, the value of that thing is illuminated—assuming we pay attention. This value informs the practice of medicine as it focuses on health, flourishing, and meaningful decision-making, and it underscores the nature of the practice as being in time. The practice of medicine is always related to death as an approaching limit that has not yet arrived, whether the immediate focus is disease or the temporary maintenance of health. Thoughts about dying are part of average everydayness in the lives of some people, while others avoid such thoughts as far as possible. Nonetheless, death is always present, if not in a person’s conscious thought about the inevitability of their own death, then at least in the unavoidable part of average everydayness known as eating, since almost everything we eat is dead. To go to the doctor for any reason, including an annual physical exam, is to acknowledge that something might be discovered that will lead to death. When we hear that everything seems to be in order and the doctor’s exam reveals no evidence of disease, this is an acknowledgment that something might have been found but was not, for the moment. Or perhaps the doctor was wrong and actually missed something or misinterpreted something. Even if the doctor was not mistaken, it is still true that some sort of disease might be found in the future. All contact with the practice of medicine, including the experience of another person who is facing disease, is a reminder of this unavoidable conjunction between the practice and death. The diagnosis of a so-called minor disease foreshadows our vulnerability to the kind of disease that

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might threaten life itself. The waiting room provokes anxiety because of the uncertainty related to the reason for the wait. The waiting room is a reminder that all of life is a kind of waiting, and one thing we are all waiting for is death. Death is an a-temporal reality. It is not in the domain of the practice of medicine, which is always a practice related to being in time. Death is not-being, whether that means annihilation, or else means not being whatever comprises human existence in the world. The practice of medicine as being in time cannot claim death as part of its domain since death is not a form of being nor is it in time, at least in the sense of time we experience during our earthly human existence. Because the arc of dying is toward something that is not in medicine’s domain, death requires partnerships between doctors and those whose work involves attending to family members and friends who are still alive, and taking care of the remains of those who have died. Death usually results in a dead body, so funeral homes are obvious partners. But because death is a mystery that cannot be known by means common to the practice of medicine, partnership with institutions that engage in framing-discourses such as theology are important. These institutions interpret the reality and meaning of death to a community. To serve a dying person well such institutions must be welcomed and given the authority and respect proper to their office. Dying is experienced as meaningful in part because of spiritual interpretations of the meaning of death. Whatever else may be said about the practice of medicine as a whole, dying is a philosophical and spiritual event. It is not primarily a medical event. My death is not part of my story, except in the sense that when my story is told by other people, my death will be part of it. My death is part of my lived story only in the (non-trivial) sense that I am aware that I will eventually disappear from the world and that will be the end of my earthly story. But I will not experience the moment of my death. To say someone died is to say someone’s experience of their own story stopped. Of course, merely saying that a person’s story stops, with no further interpretation of the meaning of a life as a whole, is no more interesting that tearing a novel in half and giving the first part to someone to read. When there are no more pages to read, their reading will stop. But that is not an ending in the meaningful sense we attribute to a story that finishes well. To talk about the end of a story in an interesting way, we must talk about things like purpose, achieving goals, resolving, concluding. Insofar as the practice of medicine

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is being in time, and insofar as it is significant to mortal embodied creatures who desire a good life and who are conscious of death, the practice must be related to the end of our story, which occurs in our experience of time, rather than merely to the stopping of our story, which does not. Stopping is nothing more than a biological fact. Ending is a philosophical and spiritual process. The relevance of the structure of a life story, and its philosophical and spiritual significance, is clearly illuminated in the dying process when a person recognizes and acknowledges impending death. If a person, family, or medical team cannot recognize and acknowledge the approach of the end, important experiences can be missed. Advances in science and technology, for all their good, have made it difficult in many cases to recognize when someone is dying, and this in turn makes it very difficult to acknowledge. A philosophically unsophisticated institution of medicine cannot say clearly what death is. This adds to the challenges of recognizing and acknowledging when someone is dying or when they are dead, especially if the philosophically unsophisticated institution is also culturally viewed as authoritative regarding death. Events that unfold after one is thrown into disease might have been otherwise. This can cause dismay, distress, and disbelief from within the perspective of average everydayness. Disease can have a pervasive impact on a person’s life. Because of this, the practice of medicine is relevant to a person’s story in a causally interesting way that includes all four kinds of causation described by Aristotle—material, formal, efficient, and final. Sciences such as molecular biology give us a detailed understanding of material causes within the body. Formal causes are about the body as a whole, integrated and functioning normally. It is the basis for our discernment about when, and in what ways, a body deviates from normal because of disease. Efficient causality is concerned with the ways in which the form of the body is manipulated through the application of scientific or technological knowledge, in order to restore form and function to the body. Final causality refers to the purposes, guiding goals, and ends toward which the practice of medicine aims. Such purposes, goals, and ends shape the practice of medicine. They are the aspects of the practice that make it good, opening it to the purposes, goals, and ends of patients. Establishing the purposes, goals, and ends that shape the good practice of medicine is a philosophical task.

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Many problems with the practice of medicine result from a failure to attend to formal and final causality, while focusing on material and efficient causality. This tendency is ubiquitous in the education of doctors, not only because of the background philosophical assumption of naturalistic reductionism, but also because of specialization, which is a division of labor that maps onto the division of a person into parts. We fundamentally fail to practice well if we focus only on material or efficient causality in our temporal response to dis-ease, reducing the work of doctoring to dispensing medicine and technology in order to alter the biology of a body. This constitutes a kind of philosophical sin when it is deliberate or a result of hubris. If it is merely a result of isolated ignorance, incompetence, or shallowness, it is still a poor practice that should be corrected. Because this approach is often technically successful at curing aberrant biology, the impoverished practice is pervasive, and the orientation is often exonerated and frequently praised and payed for by insurance companies. If strategies to alter biology constitute the sole basis for decisions in the practice, the decisions become crystal clear, and the outcomes can be measured more easily than those of a practice troubled by philosophical, spiritual, or storytelling influences. Efficient causality defines discretely billable interventions. The sometimes-messy process of reflecting on goals, purposes, meanings, or ends can seem cumbersome and inefficient by contrast. But the deep character of the practice of medicine as being in time is lost if we do not we recognize all four aspects of the causal relationship between the practice and a patient’s story. But to ignore the importance of final causality in the practice of medicine is to ignore the presence of people in the practice—both patients and providers—whose lives are driven by purposes, meanings, ends, and goals. When actions are dictated only by a response to biology, doctors can be blinded to those times when the actions are incongruent with a patient’s goals. This reason for dismissing final causality in decision making can deflate a doctor’s deeper sense of purpose in the practice of medicine. But there are also more insidious reasons when other, unspoken final causes determined by the priorities of the medical corporation are at work. All of this can be confusing. Nonetheless, when we are sick, suffering, or dying, the practice of medicine becomes an important part of our story as a new average everydayness emerges. Our story is changed. When doctors are invited into such intimate proximity to our lives, the good practice of medicine requires that

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doctors pay attention to the impact of their actions on that incarnation of time we call “our story.” Patients depend on the practice to achieve goals such as trying to cure disease, to regain function, or to relieve suffering. Doctors are granted both privilege and authority, and these must be stewarded for the practice of medicine to be a good. When the practice of medicine becomes a part of a person’s new experience of average everydayness, the practice responsibly occupies its place only by understanding the other parts of the story. This includes past and future parts that determine the place and nature of the practice of medicine in the patient’s larger story. The practice of medicine as being in time is closer in its purpose, meaning, and character to the art of storytelling than it is to the temporally discrete and repeatable practices that comprise the ideal of laboratory science. The central relevance of storytelling to the practice of medicine includes the acts of decision making, assimilation of the changes in a life brought about by the experience of disease, and the recognition and acknowledgement of the impending end of a person’s story as death approaches. This centrality is often missed or denied when the practice of medicine is unreflectively built on a philosophy of naturalistic reductionism. Naturalistic reductionism can be methodological, guiding decisions based on knowledge of biology. But it can also be ontological, which is a philosophy that excludes other kinds of knowing.16 Reductionism interprets the body as a kind of organic machine. If the body is an organic machine, and if the practice of medicine is only concerned with the body interpreted in this way, the goal of fixing the machine and keeping it running will guide decision making. Decisions made from within a reductionist frame are often compatible with decisions that would be made with a different frame. But the practice of medicine experiences a crisis when the attempts to fix the machine are at cross-purposes with goals arising from a different way

16

Methodological naturalism grounds the natural sciences’ approach to studying the physical world. It is indifferent to the possibility of non-physical reality because it is neither inclined nor equipped to ask questions about such matters. The sciences study the physical world with instruments and techniques that are fitting only for the exploration of the physical world. Ontological naturalism, on the other hand, asserts that in the totality of what is real there is nothing more than the physical world as it is accessible to the methods of science. It is a metaphysical position, which is not a conclusion of scientific investigation, but a theory that must be argued for in philosophical terms. Blurring the distinction between these two versions of naturalism has led to a great deal of confused thought.

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of framing the body and disease. This is especially true when the body cannot be fixed, because the is no other goal that makes sense from within reductionism. Understanding the patient’s larger story is a gesture of respect. It is an acknowledgement that a person is more than their disease. It is a way of meeting a person as a person. It matters to the patient as a person, but it also matters to the doctor as a person. It is a reminder that the practice of medicine occurs in a much larger human context. Awareness of the surrounding story can also vastly improve decision-making in the practice of medicine, allowing the doctor to adapt the practice to a person’s actual reality. There is a particular kind of dramatic anticipation that imbues a patient’s new average everydayness once a person engages with the practice of medicine—the anticipation of pronouncement at those turning points in which outcomes of tests and therapies are revealed. Uncertainty about future pronouncements can be chronically disruptive to average everydayness. But once a pronouncement is made, it can be integrated into the story with pivot phrases such as, “I seemed to be doing okay, until one day the doctor walked in and said …” After an important pronouncement, the story goes in a different direction that changes the way we tell the story: “And because of that … And because of that … And because of that …” The series of events following such a pronouncement can also bring new sources of anxiety, new sources of dis-ease. The process of explaining the events that follow a pronouncement is often a formal event scripted by a document known as the consent form. Medical institutions use the word “consent” to indicate that a patient has given permission for whatever follows the pronouncement. Consent ostensibly allows patients to participate in their own care, exercising agency first by being informed of the details of a proposed therapy, including the risks and benefits, and then by formally allowing the therapy to proceed. But this apparent agency is murky and problematic, despite the appearance of the patient’s signature on a document containing all the relevant information. Why? First, the patients who sign consents are generally people who have recently been thrown into dis-ease and who are not in the optimal condition to understand new information, weigh risks and benefits, and make decisions in light of goals and alternative possible paths. Second, the information is often complex and unfamiliar. Third, in the name of

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transparency and completeness of information, the consent documents are often lengthy: in my own oncology practice they are regularly twenty or more pages, single-spaced. The process of “informed consent” sometimes feels like a process of institutional protection. After the consent form is signed and therapy proceeds, everyone waits to see what the outcome will be. Everyone waits, and waits, and waits. Impact is revealed in time, eventually leading to another moment of pronouncement in which uncertainty is reduced, for better or worse. Uncertainty is reduced when the scan shows no evidence of cancer, or the catheterization shows no further narrowing of the arteries of the heart. Uncertainty is reduced, or even removed, when the test reveals that the disease progressed despite the best treatment available. This kind of turning point ends the new average everydayness to which we have become accustomed within the institution of medicine. It is a moment of transition, review, and anticipation. It is a moment when the news for which we have been waiting with hope, or dread, or resignation turns our story toward whatever may come. It is the moment of success or the moment of failure, revealing whether the story is happy or sad. It is the culmination of events that began when someone was thrown into disease, and that continued through the diversions, crises, adventures, and surprises of the new average everydayness established by the protocols, recommendations, interventions, and struggles within the relationship between the patient, the doctor, and the institution of medicine. If this turning point were the end of the story, it would be a light that shines on everything that came before, coloring it in the direction of triumph or tragedy. But it is not the end of the story, because after a new reality has emerged (“You are cured,” or “You will be overcome by your disease”) the patient still must do something with that new reality, and the doctor is still on the journey with the patient. The pronouncement of the outcome is a turning point in the story that leads to a new question: What now? When a disease is cured, people are nonetheless changed by the experience of disease and treatment. They return to jobs, loved ones, and homes, but their world is transformed. Even the familiar can seem strange and unfamiliar.

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When disease progresses despite the doctor’s best efforts, patients still have life remaining and they must decide what it means to live with this new clarity about death’s inevitability. Death has always been inevitable, of course, but now the patient knows the likely cause of death, and the timeline no longer has the vagueness of average life expectancy. Such clarity is philosophically provocative and important. It can be distressing, it can be an opportunity for insight, it can be both. As a life-threatening disease progresses, sometimes the question arises, Why bother doing anything? That question is always relevant in our lives since death is always inevitable. But it appears with new force when we can no longer sustain our denial of death. The next questions are these: If an act does not matter now, why did it ever matter? If an act mattered in the past, why would it not matter now? We have no options other than to live life until life is finished. Even suicide is an act we perform while we live: it is something we can do with our day. The practice of medicine as being in time shines a light on the human condition. It shines a light on the most important philosophical questions we can ask in a well-lived life, because every variation on our experience of dis-ease is collected in the caldron of medicine. What people experience urgently, repeatedly, and in a concentrated form in the practice of medicine, just is the human condition. The overt appearance of disease simply makes this obvious and explicit. This is why the practice of medicine is a fundamentally philosophical project, in the least abstract way possible. It is a form of practical syllogism. The conclusion of the syllogism is not a proposition. The conclusion is the shape of an actual life, lived by someone who has no other life to live. It is the life of a person who must do the philosophical and spiritual work of facing reality, whether that means trying to return to a past pattern of activity, creating a legacy since time is short, becoming attentive and learning to be grateful in a new way, or else committing suicide. And when the journey is long or difficult, patients and doctors form relationships that go beyond corporate contracts or negotiations about rights and responsibilities. These relationships often exemplify the power and value of shared experiences and the impact of those experiences on the lives of people involved. This means that the practice of medicine as being in time, like many of our deepest philosophical projects, is communal. It is a practice profoundly concerned with the nature of love.

V. The Clearing The practice of medicine as being in time is an act accomplished among people who show up in a particular way, for a particular reason, in a particular place—the clearing.17 No one merely shows up. People who inhabit the clearing show up as this or that, with roles, needs, hopes, fears, goals. This is especially true when the people who show up have not yet developed a relationship with each other, appearing almost entirely as rolebound characters in a place with an overt purpose and rules. Two prominent roles are those of patient and doctor. But the practice is influenced in an important way by people who inhabit other roles—the nurse, the parking attendant, the administrator. The receptionist is often the first person seen by a patient who has been thrown into disease and who is seeking help. Likewise, the housekeeper is a person who enters hospital rooms every day, and who tends to waste and sometimes-embarrassing messes, often in the presence of a patient suffering from illness and its treatment. There is a profound intimacy involved in the work of a housekeeper who cleans up after a patient has accidentally urinated on the floor or has thrown up in the sink because of the unfamiliar and debilitating disease. Over time, relationships among people within the practice of medicine can become more complex, as stories from other parts of life intersect with the experience at hand. Beyond the particulars specific to the people who show up in the practice, the practice itself has a cumulative influence on everyone who shows up. When a space is cleared, something is removed. The space is cleared for some purpose. This is philosophically interesting because it bears on questions of value, ontology, aesthetics, epistemology, and power. It is also philosophically interesting because it creates an absence where something once was. This absence often becomes the unnoticed background

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The German word Lichtung means a clearing of the sort we come across in a forest. Heidegger adopts the image as a place in which any idea or thing can appear either by showing itself or by otherwise being unconcealed. It makes the disclosure of beings possible, including our access to our own being: the clearing grants us access to those beings that we ourselves are not, as well as the being that we ourselves are. We have direct knowledge of the entities of the world that appear in the clearing, but we can only know the clearing itself indirectly.

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hum, and the quiet genealogy of the absence conceals assumptions in the open. Whatever has been cleared away to make the space has been cleared away for a reason. Clearing away what used to be in the space might be an unjust act, causing more harm than good. Or it might open the opportunity for a more successful replacement, the way an old building that has served its purpose is torn down to make room for a new one. It might usurp the place of the old for reasons attached to mere power, even if the new thing placed in the clearing is objectively worse that the old thing. Or perhaps it is not so simple: perhaps the new thing is superior only from the perspective of a different surrounding system of power incarnating values that do not fit well with the old system. The clearing within which the contemporary practice of medicine arose was a philosophical clearing created when the principles developed in the enlightenment led thinkers such as Francis Bacon to reject the idea that one of the most important roles a doctor has is to recognize when someone is overcome by disease so that person can prepare well for death. In the clearing, these enlightenment thinkers applied the new-found successes of science to human disease in order to cure it. But Francis Bacon, who swept away the old approach to human disease, also lived in a culture with a religious frame that said something important about what it is to be human. When this was finally pulled away, only the biology remained. The space for the contemporary corporate practice of medicine was cleared for a specific kind of response to the experience of humans thrown into disease. The story about the clearing of space often elides the history of physical space. It ignores the ways the new structures have been designed to evoke the dispositions necessary for the corporate practice of forprofit medicine. The cleared space has replaced the philosophical frame in which the practice of medicine once occurred. Clearing and replacing the physical structures and the philosophical structures were complementary acts. Both were necessary for the emergence of the overarching power that determines how the new clearing is populated—the corporate power that transformed the practice of medicine. Clearing takes time. Repopulating the clearing takes time. Clearing a physical space to build a different kind of physical space is a sign of a philosophical clearing and rebuilding, an incarnation of thoughts and choices. Thought precedes the physical construction of new spaces in the clearing, but once they are built, the physical structures shape thought and

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feeling in the same way cathedrals both follow from and shape a certain way of existing in a mysterious and uncertain universe. When a person is thrown into disease, with all the fear, anxiety, and bewilderment that accompany the experience, vulnerability to the effects of the shape of physical space increases. Physical spaces arranged in the clearing are intended to shape the inward human spaces that are made newly malleable by the anxiety accompanying disease. Physical space is a philosophical and spiritual force. The arrangement of physical space in the clearing is not morally neutral. To understand the institutions in which the contemporary practice of medicine occurs, one must pay attention to what corporate entities are expressing through their arrangement of physical spaces. Hospitals have their peculiar ontological status because they are the places where we are born, where our terrifying diseases are treated, and where we navigate the transition from being alive to being dead (whatever being dead is). Their ontological status is analogous to that of holy places—cathedrals, mosques, synagogues, burial mounds. Sacred spaces pull us toward contemplation and religious feeling. Spaces built for the experience of the holy, the noumenal, or the mysterious are set apart. Because they are set apart, their ontological status cannot be described in material terms without remainder. Within holy spaces, certain areas are especially holy. These spaces are accessible only to certain people for reasons that are not always obvious. This is part of the nature of the sacred space taken as a whole. Hospitals, likewise, have spaces that are restricted to people who wear special costumes signifying authority. The rest of us know the spaces have important purposes. However opaque these purposes might be, we trust the people wearing the costumes. The arrangement of space provokes and shapes our inward experiences. Walk into any small, rural, community hospital. Notice the lobby, the chairs, the potted plants, the linoleum flooring, and the ways the nurses’ stations and hallways are arranged. Then walk into a new urban hospital that is part of a corporate health network and notice the lobby, the chairs, the ways areas are marked and secured electronically, and the decorations, art, and portraits of past Chief Executive Officers after whom various spaces are named. The spaces are profoundly different. Paying close attention to the two kinds of spaces is a philosophically illuminating act.

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The practice of medicine as being in time requires a clearing as surely as the corporate practice of for-profit medicine requires one. It requires a clearing imbued with a sense of the importance of the vocation—its value, its priority, its weight among other human projects. There must be a sense of being part of something on which much depends. This heightens attentiveness, anxiety, and awe inside the space, especially for patients who have been thrown into disease and who need help. The difference between the experience of patients and that of people who work for the institution is consolidated by visual markers such as identification badges for providers, wrist bands for patients, and differences in clothing—scrubs or white coats for providers, and thin gowns for patients. The identical gowns given to patients mark their status. Even when patients wear their own clothing to walk in the hospital, they often put the gown over their clothes. Doctors who do not wear white coats or scrubs will often wear a stethoscope or an identification badge on a lanyard to mark themselves. The experience of belonging to the institution in a certain non-patient way extends to cafeteria workers, parking attendants, and housekeepers. Volunteers, who are very helpful to patients and visitors, often wear special vests or badges. The reasons for volunteering at a hospital are themselves revealing. Some people have been patients, and they return as volunteers to experience the institution in a different way. Some people are fascinated by sick patients and their families, and they wish to serve in proximity to them. Some wish to go to medical school or nursing school, and they are acclimating to their own goals or strengthening their resumes. The order of the various robes marking gradations of status within the clearing contributes to the feeling of the space. There is also a kind of strangeness to it. Within the clearing we emerge into the world for the first time through birth and we leave the world through death. We have parts of our bodies cut off. We walk out to our cars in the parking deck while our loved one’s body is taken to the morgue. But we also decide whether we want chicken, pizza, or overpriced salad for lunch in hospital cafeteria. The whole range of human experience is contained within the clearing. If we are not cloaked with protective layers of disguise, ornament, and authority, the sense of how strange everything is can be disorienting. We do not choose the conditions of birth, death, trauma, and illness. They are examples of thrownness as part of the human condition.

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Why did this happen? That is a common question amidst the realities contained, constituted, revealed, or veiled within the clearing. The question is never easy to answer, but part of being human is to wonder what the answer is. If the answers seem impossible to settle, which they are, or if the questions are frightening, which they are, we can try to avoid them during the stages of our so-called normal lives. But the unavoidability of the questions in the face of disease contributes to the sense that something strange and important happens within the institutions where medicine is practiced. The strangeness, and its juxtaposition with normal activity such as parking and eating, brings profound human questions into the conscious inward space usually occupied only by “normal” activities. This puts socalled normal activities into a physical and mental context in which they can also seem strange. At the same time, when eating, parking, and seeing reassuring smiles are juxtaposed with the strangest parts of human existence, even diseases that threaten life can seem less strange. The physical structures grow up in the clearing. The aesthetic dimensions of these structures both shape and are shaped by the purposes of the clearing, its whatness.18. The aesthetics of the institution influence what is possible for the practice of medicine as being in time. On a large scale, the hierarchy of powers is incarnate in the structures that show up in the clearing, revealing what is important and what is not, who is important and who is not. On a smaller scale the aesthetics of the structures we build influence the practice simply because human behavior alters in response to colors, prolonged eye contact, privacy, and features of rooms such as the height of the ceiling, the solidity of doors, the lighting, and the openness or hiddenness of staff work spaces. A single-bed room creates a different set of practices than an open ward. A modest lobby that feels like a small, roadside hotel creates different experiences of anticipation than a lobby with a vaulted ceiling and large pieces of art or portraits of corporate leaders. The conversations regarding the practice of medicine are different in open work spaces than they are in work spaces concealed behind closed doors. The arrangement of hidden spaces in basements is likewise philosophically important. Morgues are usually in the basement of a hospital. 18

“Whatness” is called quiddity in scholastic philosophy. Whatness describes properties a thing shares with others of its kind. Quiddity, or whatness, answers the question, What is it? In scholastic philosophy, the general notion of whatness was contrasted with the haecceity or thisness of a thing—the characteristic of an individual that caused it to be this individual, and no other.

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The basements of hospitals are often where equipment repair shops, storage areas, and garbage processing facilities are located. Hospital basements have a starkly different feeling from lobbies and wards. It is similar to the backstage rigging in a theater, with an undisguised functional aesthetic and with no sense of covering-over anything. Unadorned reality shows up in basements. The proximity of morgues and waste disposal facilities in basements is worth noticing. There are other ways a morgue might be designed and placed in the clearing. Our decision to place morgues in basements hints at something poignant about what morgues mean to us. The presence of locks on some doors and the absence of locks on other doors alters the experience of becoming a patient within the structures placed in the clearing. The presence of locks to avoid theft of medicine, supplies, or information is a part of the order. The absence of locks on the doors to patient rooms is likewise an expression of an asymmetrical order of power, which requires unidirectional access to patients at all times by the medical staff, ostensibly in benevolent service to patients. The absence of locks is one example of the Hobbesian trade we make when we become patients, exchanging certain freedoms for certain forms of security. There are few places where we do not have locks on doors for privacy or security. There are few places where unspoken rules allow other people (nurses, doctors, medical students, housekeepers) to enter with only a cursory knock (if that), and without waiting for explicit permission to enter. The presence of locks in some places, the absence of locks in other places, and the freedom with which certain people can enter spaces while other people are barred, is an arrangement of power that can make a patient feel vulnerable, destabilized, and exposed. Often such unrestricted open access to patients by medical providers is defended (not always unreasonably) as necessary for the safety of sick patients. Irrespective of the cogency of such arguments, the moral responsibility for respect must be mindfully embraced in these artificial settings that can so easily demean, humiliate, and dishonor people who are already facing crisis. The physical arrangement of things contributes to the order of the functions, activities, and sub-purposes of different spaces within the clearing. But a second form of order is created through policies, procedural manuals adapted to the structures in the clearing, memos, and instruction given to managers of various types who have authority over subsections of the institution. Eventually administrative hierarchies accrue solidity by

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having histories much longer than those of new physical structures or new people hired by the institution. The order consolidates over time as it is internalized by institutional employees—doctors, yes, but perhaps more importantly non-clinicians who are oriented toward the institution qua institution. These administrative exigencies gain independence from the fundamental mission-driven activities and goals comprising the practice of medicine. The order becomes identified as the way we do things here, a mark of belonging or not belonging. It is often defended as necessary for the safe and efficient practice of medicine. The value and rationality of the order eventually seem obvious and self-evident to those who have internalized the order, but it can seem foreign, hostile, or unwarranted to patients and staff who are new to the institution. Most institutional employees experience the order as tolerable or even invisible, until it is resisted, disobeyed, or otherwise crossed. The independent existence of the order becomes most evident when it is at apparent cross-purposes with the practice of medicine and the good of the patients. This is where the Department of Risk Management, working alongside the Department of Public Relations, meets some of its most important challenges. The fundamental language of this administrative order is the language of economics, which has an increasingly insidious relationship to the order within the clearing and its impact on the practice of medicine. This force is so powerful and ubiquitous that it provokes questions regarding the ontology19 of money. Money is often thought of as an innocuous means of exchange, nothing more than a convenient way to store and transfer value so we do not have to lug around chickens or hand-made quilts to trade for food, medicine, and other necessities. This is a quaint and sometimes useful fiction. It is a good way to introduce children to the ways work is translated into the value stored in money, which can be saved and used to purchase things unrelated to one’s own particular form of labor. But the simplistic image is a ridiculous way to talk about the truth of money’s role, power, and force in contemporary culture, especially in the philosophically dense, economically lucrative, miracle-advertising culture of medicine. 19

Ontology is the philosophical study of being, addressing questions about what kinds of entities can exist, what kind do exist, how these entities are ordered or grouped, and how we gain access to knowledge about them. Heidegger had the intriguing idea that only through phenomenology can we gain access to ontology. The being of entities is revealed in their phenomenological conception.

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Money is power. Hoarding money is the will to power. Money can be used to make good things happen. But can also be ravenously accumulated for its own sake, a battery storing power in absurd amounts beyond anything a person, family, or community could ever need. To think of money as something the individual “consumer” uses to buy necessities is to miss the point about hoarding money as will to power. Money has a being of its own, which is revealed through its force in the world—notably in the ways it shapes projects and institutions, and impacts the philosophical dimensions of value, priority, meaning, utility, and tolerance for injustice in exchange for other goods. Medical systems manifest this will to power when they choose to expand their profit margin even if it hurts people. This is often done under the false cover of fiscal responsibility and security. But we must not forget that wealth is increasingly concentrated in the hands of the few, some of whom have accumulated wealth equivalent to that of a small nation. This level of wealth constitutes a world-altering power in which “consumers” are no longer relevant because “individuals” are no longer relevant. The only relevant factors are “big data” and “populations” that can be moved in aggregate as a game among players who control powers such as Google, Facebook, Amazon, and the inferno of Dark Money. Against the backdrop of such power, a wife losing her husband of fifty years because they could not afford medical care seems small and insignificant. It is not. The reality of love between those two people, the mystery of the threshold of death, and the courage required for them to juxtapose a lifetime of joy with impending separation makes the entire financial industry look like a big, stupid, earthbound meteor that is “powerful” only in the sense that it will cause massive destruction, but utterly impotent in its ability to generate a single unselfish good, gross in the bluntness of its transformation of beauty into financial spreadsheets, and evil in a sense no meteor could ever be since meteors are not capable of intention or moral insight, unlike purveyors of capitalistic totalitarianism. A second language of the administrative order within the clearing is the language of law. Like money, the force of law reveals an ontological weight that goes far beyond definitions or idealized frames. Law is not the same as ethics, nor is it the same as justice. This distinction is exemplified

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in the history of legally-institutionalized racism in the United States, leading to the devastating systematic imprisonment of young black men. Disagreements regarding abortion, the death penalty, and taxation’s role in distributive justice likewise reveal the difference between law and ethics. Within the practice of medicine, the central placeholder for the influence of law is the concept of lawsuits for medical malpractice, which has led to the ubiquitous and profitable need for malpractice insurance. The established standard of care is often the basis for judging whether or not malpractice has occurred. But the basis for initiating a lawsuit has little to do with the established standard of care. The motivation is often grief at a loss that is unexpected either because of a misunderstanding of what was reasonably possible, or else because a true error occurred. Expectations are sometimes unrealistic because of the medical system’s optimistic portrayal of itself and its capacities. But whatever the motivation for a particular lawsuit might be, the institution’s posture toward the law is almost always defensive. Administrators and lawyers work from a principle of fear despite the reality that lawsuits are relatively rare compared to the number of challenging events that occur in the uncertain world of medical practice. The desire to avoid lawsuits can shape practice in ways that make little sense biologically, philosophically, or spiritually. A third language of the administrative order within the clearing is the language of risk management. Every patient wishes to avoid unnecessary risk. When risk is attached to the possibility of benefit, a good decision for an individual requires that benefits be weighed against risks. The same is true for institutions where medical and surgical procedures are performed with no guarantee of success, and with the possibility of harm or death as a consequence. Risk is an unavoidable dimension of the work, and one that is rightly addressed and minimized when possible. But risk management is guided by fears that go far beyond anticipated procedural risks or legal concerns. It is too often concerned with avoiding any institutional risk that is not justified by the profit that might result from the risk. The phrase risk management connotes a kind of control over events that is inconsistent with a rational concept of risk. Risk refers to unwanted consequences that occur despite our best efforts, or else because our efforts were not our best, which is an independent risk in an enterprise involving fallible humans susceptible to fatigue and inattention. What can be managed to some extent are foreseeable sources of risk that are avoidable with

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planning, along with the ways in which we respond to a patient’s experience of unwanted outcomes. A better, though inelegant, name for the department would be Avoidable-Risk Management. But that name still falls short because all risk is avoidable if we stop doing medical and surgical procedures. Even if the name is extended to Risk Benefit Analysis and Avoidable Risk Management When Benefit Justifies Risk, the question remains, Risk to Whom? Like money and law, the management of risk can become its own force, motivated by its own narrow goals. This can create a conflict between benefit to a patient and risk to an institution. Once an administrative order gains authority to distribute power within an institution, it needs a mode of surveillance and control to maintain the order and the power. This requirement was answered in a revolutionary way by the Electronic Medical Record. The EMR is a tool that is evolving and that will continue to evolve. The EMR will not go away. It can only change. The ostensible benefits of the EMR are many. It allows rapid access to patient records across institutions that are far from each other. Within an institution it allows quick access to old records, without the unwieldy process of bringing multiple paper files from a storage area to a hospital ward. It decreases the risk of adverse drug interactions and incorrect medication dosing. In the future it might evolve with machine learning to support better diagnosis, more efficient use of medical tests, and more effective clinician learning. It makes new kinds of large-scale clinical research possible. Unfortunately, the EMR in its early development (the first 20 years) was experienced negatively by many clinicians. It seemed designed to optimize billing practices for increased profit, and to monitor the timeliness of mundane tasks such as documentation, which increasingly dominates the days and evenings and weekends of doctors and nurses. It did not seem designed to improve the way doctors and nurses serve patients. It has disrupted doctor-patient encounters by forcing doctors to face a computer screen for much of the visit. This is driven in part by institutional demands that notes be written quickly, which means they must either be written during the patient visit, or else in the evenings after work. The effect has been devastating in medical training: residents spend up to half their time on the EMR. Corporate priorities led to the diabolical form of the current EMR, and there are good reasons to question the corporate motives that will

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shape future versions of the EMR: the independence of the administrative order from the practice of medicine as being in time, the consolidation of corporate priorities in the distribution of power within the clearing, and the dominance of the languages of finance, law, and risk management all coincide with the corporate takeover of the institutions that house the practice of medicine. This corporate takeover, coupled with advances in machine learning, is leading toward fundamental changes in the practice of medicine that could take two very different forms, one utopian and the other dystopian. In the utopian version, the experiences of patients and doctors become more meaningful, more helpful, more humane. Evolution of the EMR reduces the time spent on documentation. Machine learning/AI leads to faster, more accurate diagnosis and treatment, allowing time for deeper discussions about a patient’s story, hopes, fears, and goals. As machine learning/AI evolves, the training of doctors might evolve, allowing computers to do what they do best so that minds can do what minds do best. Medical schools might be able to redesign curricula in ways that value systems-thinking over memorization. Students might find expectations shifting to the mastery of problem-solving that is logical, while effectively incorporating a patient’s whole reality into the decision-making process through training in communication, storytelling, the principles of improvisational response to the unexpected, mindfulness, and other skills drawn from the humanities and arts. Science and technology, rather than determining the nature of medicine, might become the means to ends assessed through the core doctoring skills of listening, paying attention, reaching imaginatively into unfamiliar worlds, and learning to heal through the practice of presence commonly called attending. In the dystopian version, the corporate transformation of the institution that houses the practice of medicine combines with advances in machine learning/AI to produce new efficiencies so that doctors (or their surrogates) can see more patients in less time, decreasing the number of doctors an institution needs, while improving the institution’s profit margin. This not only worsens the most harmful and unjust aspects of sin in the history of the practice of medicine, but it does so under the disingenuous cover of aiding the vulnerable. Horrific consequences become possible in service to economic priorities, with no mechanism for assigning responsibility, nor for stopping the horror.

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Imagine a nationwide corporate drugstore chain with stores in every small, rural town in America. This corporation establishes small pharmacy-clinics in each store. The pseudo-clinics do simple blood pressure checks, glucose tests, flu shots, and so forth while the infrastructure is established and the in-store clinics are normalized through advertising. Next, imagine a powerful search engine that is refined and refocused specifically to produce a differential diagnosis from patterns of health-related queries such as descriptions of symptoms, family medical history, family social history, family economic history, past internet searches, public posts related to the body or disease, and so forth. Meanwhile, a massive online distributor of products other people have created develops packages of tests and treatments to match likely diagnoses. These packages can be purchased online because of recent changes congress passed after a 10-billiondollar contribution to various vague things that interest various powerful people for various reasons. The packages differ in price based on a bronzesilver-gold rating system. Customer services, including advice from real doctors chosen from among the best in India and in several African countries, are available for an addition per-usage fee. The advising physicians are under the authority of a famous doctor who was hired as CEO of the medical venture. It is not hard to imagine getting your differential diagnoses on GoogleMed, your tests at the ubiquitous CVS-pharmacy-clinic, and your treatment package through AmazonMed, with customer question-answering services outsourced to doctors in developing countries, because these doctors make more with a computer working for the Google-CVSAmazon medical partnership than they could ever make caring for the poor in their own country. Over time, the evolving neural network develops automated treatment recommendations based on collective data, statistics, trends in Medicare spending, and algorithms derived from politically motivated shifts in policies. XAI—Explainable Artificial Intelligence—capable of giving an account of the reasons for its decisions, is difficult to develop, which means that the system works without short-term accountability: results of decisions within neural networks do not become apparent for many years, if ever. This means the system can offer recommendations to the rural poor that lower life expectancy by a few years, resulting in huge economic savings that can be repurposed, perhaps in the form of tax reductions for the wealthy. The system is advertised as achieving “the greatest good for the greatest number of people,” drawing on vast reservoirs of data to bring

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about the collective good most efficiently. Meanwhile, corporate profit margins grow larger while corporate liability and risk go down. The system decreases the costs of Medicare and Medicaid, sparing the wealthy any increase in taxes. This dystopian evil fits perfectly with the corporate goal of hoarding money-as-power. Something like this will be hard to avoid. Welcome to the future of medicine. It is already happening.

VI. History as a Problem Anything that exists in time has a history that is inseparable from the truth of the thing.20 Embodied existence cannot be understood apart from the history of the embodied being. A deep practice likewise has a history, apart from which the practice cannot be understood. The practice of medicine as being in time must consider the problem of history, because history is inseparable from the very concept of practicing in time. The history of a body or a practice is a problem, because the past cannot be directly observed. It exists only in memory, in the impact of past events on present events, and in enduring artifacts originating in the past. The problem of history is not insurmountable in the practice of medicine, unless a doctor dismisses the importance of history, or does not understand how to approach it. Because history cannot be observed, the skills required for the exploration and interpretation of history are memory, imagination, and storytelling. Memory can be individual, or it can be communal, as long as a community has a means for passing on stories about its own history. For an historian who was not present at the past events, and who is not part of the community identified with the events, the history can only be accessed through imaginative reach. The capacity for imaginative reach depends on curiosity, patience, mindfulness, and a willingness to listen with humility and attention. It also requires access to stories held in individual or collective memory, along with interpretive accounts of the meaning of a story or artifact. Such access, in turn, usually requires an act of trust on the part of the storytellers. If efficiency means collecting the greatest number of discrete facts in the shortest amount of time, then memory, imagination, and storytelling are not efficient modes of data collection. If verifiability of discrete facts 20

Human beings (in Heidegger’s language, Dasein) are constituted by past experience in the world, whether or not we are conscious of being shaped by the past. But we are also oriented in our being toward the future. Because of this, our future possibilities and potentialities are delineated in terms of past experiences that set the boundaries for future hopes and dreams. The idea of the past has an urgency because it is constitutive of what it is for us to be. Although we exist primordially in the present, the past is not dead and buried. It is very alive. Our own consciousness of our being is shaped by what we have done and what has happened to us, just as much as by what we hope, intend, or plan.

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is required, these modes of inquiry seem even less efficient: verification is generally dependent on direct observation, systematic reproducibility, and measurability, none of which apply to memory, imagination, and storytelling. Within the contemporary practice of medicine, one sometimes hears the maxim, If it can’t be measured, it isn’t real. This maxim is unfortunate for several reasons. First, if history is not strictly measurable, but is nonetheless important, the maxim excludes important sources of information relevant to the practice of medicine. Second, because the truth of the maxim cannot be measured, its own criterion for truth undermines its meaningfulness. Third, because the maxim can offer no measurementbased reasons for excluding non-measurable things from meaningful reality, it can only exclude them by blunt assertion, an act of mere power. Fourth, the practice of asserting philosophical maxims without reasons is bad philosophical practice, and possibly philosophical sin: a community that embraces such a maxim calls into question its own reliability as a community of reason. The memory of an individual is fallible, in the sense that something one remembers is not necessarily what actually happened. The collective memory of a community, or the memories of multiple individuals who recollect the same event, can augment the veracity of a memory in the case of agreement, or else offer alternative versions that illuminate a memory in the face of disagreement. Sometimes no one is available to corroborate a person’s memories of an event. In that case, the correspondence of memories to events as they actually happened depends on the condition of a person’s memory and their willingness to tell the truth. The correspondence of a memory to things as they actually happened is often important in the practice of medicine. The most basic form of engagement with memory in the practice of medicine is known as taking the patient’s history. Taking the patient’s history begins with the least complicated details such as age, current medications, allergies, and past illnesses and treatments. Accurate historical details of this kind can be a matter of life or death when, for example, someone has a history of anaphylaxis with a medication. But the correspondence between memory and historical accuracy is not always the most important thing. Sometimes a person’s experience of the meaning of an event is more important than details about the event itself. Meaning is meaningful anytime it is meaningful to someone: a person’s experience of meaning is legitimately meaningful,

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even if it is related to a false memory, a misperception, or a misunderstanding. The memories of other individuals, or of a person’s community, can illuminate an individual’s own memories in ways that are relevant to the practice of medicine. Our communities are the reservoir of memory for us when we become forgetful or lost. We watch over each other’s time and we collect stories that clarify each other’s memories. We do this not merely for the sake of accuracy, but also for the sake of meaning, reminding each other of the roles past events play in our present experience and our decisions for the future. Even the simple histories collected by every medical student refer to experiences of people from the patient’s community. Family history identifies diseases other people have had, including people who died before the patient was born. These histories demonstrate the meaning and relevance of biological features of embodiment over time within the story of a community. Dispositions, vulnerabilities, and surprising behaviors loop in and out of stories, revealing the difference between lived time and the linear measurement of mere biological duration, or the metrics of socioeconomic change expressed as various discrete, statistically analyzable demographic units—money, property, employment, education. When we lose our memories, we need others to help us fill in the gaps. When we are confused or in doubt about our own recollections, we need witnesses from within a shared experience of time to rescue us from oblivion, lostness, and atemporality. We need witnesses from the past to speak a yes, a no, or an amen into difficult encounters with disease that threaten our relationships with our bodies, our communities, and lived time. Insofar as memory—individual, family, community, or otherwise— reaches into a past that is different from the historian’s own past, the content of memory can only be grasped through an act of imagination that reaches into a world other than one’s own. The significance of events, characters, and roles populating that world can only be revealed through the memories of people other than the historian. Practice is necessary for the development of this kind of imaginative nimbleness. There are many forms of practice that help. Paying attention to unexpected or elided parts of my own world can stretch my imagination, while enriching my own life and experience. Reading novels, which wears a practice William Osler recommended to his own residents, can exercise the imagination, teaching the mind to inhabit unfamiliar worlds portrayed

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by novelists. But the most important way a doctor’s imaginative reach and flexibility grow is through the long practice of listening with humble attentiveness to the memories, perceptions, and ideas of others, related through storytelling in the clinic or hospital room. When the door to the hospital or clinic room is closed, and the doctor sits down and begins listening to a patient, a book is opened and the first line is read, followed by a second line, and a third. Along the way a version of the patient’s world is built in the imagination of the doctor. This helps a patient because it is a gesture of respect toward the patient, and because it provides a foundation for good decision making. The doctor also grows by learning true stories about the world. Unfortunately, such thinking is all too rare in the practice of medicine? Why this is this so hard? What is wrong with medicine? What is the core problem? One possibility is medical school, the machine that trains physicians. It is difficult to stop perpetuating the thing. We form physicians poorly in medical school, and we continue the same formation process in residencies and fellowships. Senior residents form junior residents and medical students in the same way they were formed. The process is consolidated and there is no way out. A diagnosis can lead to ideas about how to fix the problem, but this problem is anything but simple. It permeates the way the imaginations of doctors are formed, what the culture expects of doctors, and what doctors expect of themselves. The problem will not be solved by focusing only on the actions of individual doctors and institutions. Any genuinely meaningful solution will likely originate outside the contemporary corporate edifice of medicine, relying on a completely different set of resources. We must also consider the ways in which medicine has become a larger and more pervasive kind of power, and the ways in which that power shapes policy and cultural imagination. Consider, for example, the history of organ transplantation. We now define death in a way that is very specific and that involves one organ—the brain. But the concept of brain-death is very new. In the past, families sat at the bedside of a loved one, and the person was considered dead only when the heart stopped. How did we change the location of death? How did we conclude that a person whose heart is still working is dead? We redefined death in terms of an individual’s powers—cognition, the capacity to interact and communicate, and the ability to pursue goals and flourish. Without a brain, no one can do those things. If we define the conditions necessary for

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permanent functional incapacity as “death,” perhaps it is okay if we use their organs. We would never take organs from a living person. But if we define death as “brain-death,” we will only be taking the organs from dead people. For most of human history, communities have known what death is. But it turns out they were mistaken because they were ignorant of the facts. Fortunately, we are scientifically advanced, so we can declare people dead even though their hearts are still beating. The problem is that the assumptions behind this way of thinking are not made explicit. One assumption is that the goal of medicine of medicine is to keep a person’s molecules moving, and moving in the right direction. But if we are going to change the definition of death in a way that still leaves organ harvesting as an ethically acceptable option, we have to say what a person is so that we know whose molecule-movements should concern us. If being a person means something along the lines of thinking, feeling, and acting in light of goals, the definition of death does seem to shift: it is difficult to argue that a person is alive if there is no person to whom we can meaningfully refer. But aside from the assumptions of naturalistic reductionism and the value of profit-hoarding, medicine has no coherent philosophical frame for saying what a person is or is not, nor what death is or is not. Definitions must simply be asserted by the institutions. Institutional, moral, and educational incoherence regarding the ends of medicine causes moral damage in doctors who occupy the gap between the ostensible goals of healing people and relieving their suffering, and the actual motives of corporate medical institutions. The same is true for patients who have been shaped by the advertised promises of those institutions. When we only draw on familiar, comfortable ideas and tools to address these problems, the solution is subsumed by the same system that created the problem in the first place. A true solution will require another type of imagination. Many failures in the practice of medicine—missed diagnoses, poor communication, unworkable treatment plans, broken trust—are fundamentally failures of imagination, or failures of corresponding attributes such as curiosity, mindfulness, and love. These are philosophical failures in which the wrong kinds of knowledge are given priority and misunderstandings about the purpose of the practice of medicine are integrated into the core of the institution’s identity. The tendency toward the temporallythin, disembodied abstractions dominant in gnostic medicine can obscure the most basic aspects of a patient’s experience of disease accessible only

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through memory (illuminating what is valuable in a life, but at risk of being lost), imagination (allowing strangers—patient and practitioner—to grasp each other’s world), and storytelling (through which most non-biological information is conveyed). Institutionalized failure of this kind can also be construed as the systematic success of corporate medicine’s goal of eliminating all inefficiencies in its pursuit of profit. Attention to memory, imagination, and storytelling requires time, which decreases the number of patients who can be seen (and billed) in a workday. Profits go down since doctors cannot bill for listening to stories at the same level as they do for procedural interventions or medical manipulation of rogue biology. Increasingly, these forms of failure are synergistic. The practice of medicine connects with an individual patient’s own history though memory, imagination, and storytelling. Beyond this there is a larger sense of history that is relevant to every level of the philosophical analysis of the practice of medicine as being in time. This larger history shapes the stories and characters of both patients and clinicians, and it shapes the institutions within which medicine is practiced. This history is made of different kinds of time. It is made of time stolen from people who have had their story mingled with a history of slavery and who have experienced the slow battle to be seen as fully human, the slow accumulation of rights and recognition, and the excessive effort required to secure even the basic necessities of life. It is made of the time required to work in order to pay medical bills that are artificially high because of a history of power that favors the insurance companies and the pharmaceutical industry. It is made of the time required for us to wait on the institution’s permission for us to enter restricted spaces. The larger history includes the forces that have produced the moral abominations of wealth disparity, inadequate insurance coverage for millions of people, and the terror of being undervalued because of ethnicity or poverty. The larger history is one that has presumed to define death in ways that seem ambiguous and curiously motivated. In this larger sense of history, the primary challenge is not discovering the details historical reality: it is finding courage and integrity to acknowledge and redress the often-painful injustices revealed by that history. True acknowledgment is difficult and complex. History can be hidden by being assimilated-through-showcasing inside the structures of an unchanging, inherently unjust system (as when a racist institution

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celebrates Martin Luther King Day with placards, cupcakes, and an interactive event led by several black employees, while ignoring the economic inequality experienced by their outsourced, mostly black Environmental Service Workers). Awakening to the suffering of others is painful, especially when we realize how much of the foundation for our own security and flourishing depends on a system that is inherently unjust to others. Such pain is worse if there is no clear remedy for the devastation that results from long injustice. When there is a just remedy that is difficult, but cowardice or selfishness interferes with our pursuit of it, the pain of acknowledging the truth intensifies further. In a world of distraction, where the truth of a reported fact is viewed as fluid and unreliable, the force of stories from history is diluted. To escape both the pain of the truth and the pain of the remedy, the history of injustice can simply be denied. If no story can be trusted, any story can be embraced as one’s own. In the absence of a reliably true story, we tell ourselves that we cannot be faulted for doing the best we can. We choose a story based on whatever criteria we can live with. Even if a story is not morally optimal, it might still be morally acceptable to us. Self-interest, avoidance of pain, resistance to change, tenacious prejudice, or the desire to increase our power and agency can all motivate acceptance of untrue stories. If we ever achieve enough moral honesty to acknowledge historical injustices, we still must consider the ongoing impact of these injustices on the practice of medicine. Pain is inescapable as we address injustice. We might try to escape the pain by pointing to prima facia goods that emerged from the injustices. Worry over the loss of those good things can tempt us to resentment or dishonesty about the past. But meaningful reparations of material goods, educational and vocational opportunities, and offices linked to authority cannot occur without a redistribution of wealth, opportunity, and power. When institutionalized injustice leads to inequity, the solution demands more than an appeal to individual conviction, courage, and commitment. The institutions themselves must change. Institutions invariably try to escape change though vague referrals to unsuccessful past attempts at change and other similar strategies. It is easy to appear serious, cautious, and responsible by asserting that we should not simply “throw money” at the problems. It is easy to assert a hypothetical concern that more damage than good will come from disruptive institutional changes. It is easy to

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deflect responsibility for change when an institution benefits from past injustices, especially if the injustice started before the institution existed. These deflecting strategies are so powerful that sometimes revolution seems like the only force sufficient to silence the noise of excuse-making so we can move on to genuine solutions. Institutionalized racism is one example of how responsibility for an injustice can be diluted in a large institution, while the injustice continues to be insidious in its effects. When this happens, those who advocate for change can have trouble focusing their strategy and gathering the force of outrage into a sustainable and compelling voice. This is especially true within an institution such as medicine, which produces so much net good, and which is needed by those who would also change it. Even when we achieve clarity about the ongoing impact of past and present injustices, we still have the problem of translating our insight into a plan that can be implemented. The social determinants of health are a direct result of the material reality of injustice, and the practice of medicine as being in time is an incoherent project without continual reference to these forces. Even when a doctor is focused exclusively on the current moment with a patient, the local and temporally-focused practice of medicine will ultimately fail if it does not engage these larger questions. The same is true for institutional administrators who think about concrete practices such as whom to hire, which new buildings are necessary, and which non-revenue-generating programs still merit support. For example, in a city with a long history of racial and economic injustice, social workers have the expertise required to address challenges such as transportation to a hospital, trust in the care offered by the hospital, transition back home, and the gathering of resources in the community to allow continued healing. Social workers are not highly paid and they do not generally charge for their services in a hospital, so they represent a net loss of revenue to an institution if no other factors are considered. Because of this, corporate medicine’s institutional priorities have led to the decimation of many social work departments. They have been repurposed to shorten hospital stays for the sake of increasing revenue in an age of bundled Medicare and insurance payments. This is a philosophical sin. Individuals can advocate locally, but until the leaders of an institution have a conversion-experience, evil will inevitably grow under the guise of fiscal responsibility. Once we arrive at a plan to address these problems of history, we still have the challenge of actually carrying out the plan. This is the point at

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which corporate powers can become most apparent, not only through passive bureaucratic obstruction, but also through active dismantling of resources aimed at overcoming injustices and through political actions that undermine access to healthcare for the very people most injured by historical injustices. The decimation and repurposing of social work departments is one example, but there are many others. Reducing the time and flexibility allowed for clinic visits can distract us from the relevance of history and injustice for the care of individual patients in a clinical setting. The practice of placing minorities in publicity photos for an institution can relieve the pressure of accounting for ongoing injustices in hiring practices and in the distribution of resources and power. A culture of fear mutes individuals who would face genuine threats if they actively tried to change the culture or spoke out against injustices. Such fear is easier to sustain when jobs are low-paying, health insurance is attached to employment rather than being available through a national health service, and dissent is treated as contrary to the so-called shared values of the corporate institution. The true obstacles to institutional change do not reside in the public parts of institutional leadership, but rather in the hidden parts where financial, legal, and institutional risk departments do their work, relying on a range of tepid self-referential justifications for their opacity. The problem of history can be transformed into the problem of narrative control. This approach removes the problematic parts of history through rhetorical strategies, diversion, and narrative revision. These are all strategies for managing the accumulated effects of past actions over time, stretching longer than a single life, a single generation, or even a single form of civilization. The effects of institutionalized injustice shape the world in ways that reach far beyond the limits of the beginning and end of an individual life. Re-narration strategies are not overtly framed in such terms, because that framing would run counter to the goals of public-image management. Institutions can project the appearance of being concerned with injustice rooted in history. They can use advertising strategies, modest public statements of apology, and carefully-crafted expressions of their determination to right-the-wrongs and to make-things-better, while changing none of the scaffolding upon which the institution is built. They can create a crisis and encourage everyone committed to the corporate good to set the past aside and rally around the urgent need. Financial crisis is one excellent opportunity to divert attention from injustice and inequity while the

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institution’s goals remain unchanged. The crisis is not used to address the fundamental problems of history, but rather to maintain or strengthen the corporate institution’s core priority—profit. In some political environments, such as the one that led to the election of Donald Trump as president of the United States, the problem of history can be addressed by simply changing the facts of history, because, in the words of Pilate, What is truth? Large-scale narrative revision impacts local practices such as medicine by compelling individuals to retell their own local stories in a way that reflects corporate priorities. Individuals become not “a thousand points of light,” but a thousand mirrors reflecting the corporate narrative. Sometimes this arises from a sense of helplessness to do otherwise: the problems seem too big for any one person to solve. Only corporate powers are large enough to address such enormous problems. But one condition for corporate involvement is a change in the narrative that provides a sense of relief from responsibility. In the United States, for example, the problem of history is inextricably tied to the history of systemic racism. But even as racism is increasingly addressed in open forums, there are some groups of people whose response to this is to feel marginalized and forgotten, and other groups who feel unjustly blamed for the problem of history. In the 2016 presidential election, impoverished white men comprised one such a group to whom Donald Trump’s rhetoric appealed. This breeds resentment among members of these groups, which makes them more vulnerable to political manipulation. Narratives are revised in ways that provide various forms of temporary relief, even when the motives for political manipulation are at odds with genuine strategies for improving conditions. If a corporate structure is sufficiently powerful, it can organize itself under the cover of a worthy mission. In the case of medicine, the worthy mission is to cure people and prevent them from being dead. This mission is then used to reframe expressions of indignation about institutional injustice as vaguely threatening or borderline-illegal, disrupting the good work of the institution. The wide-scale distribution of revised narratives occurs through television to some extent. But it occurs even more powerfully and insidiously through the algorithms of search engines and interactions with social media that alter the stories we tell about ourselves, others, and the world. When this happens at a culture-wide level, and the criteria determining the inside and outside of a culture are manipulated, complex issues that have

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a long history can be over-simplified and distilled into a few characteristics that define us, and a few characteristics that define them. Words that are laudable on their surface are turned into the banners under which injustice is perpetuated: security, fiscal responsibility, freedom, capitalism, and individual autonomy are a few that are common and effective. Defining such boundaries and borders on a large scale is the rhetorical task of fear-based nationalism. The physical boundaries of a nation provide one clear locus for attention. Another effective strategy for producing division is to cross-link fear with features of individuals that are discrete, definable, and susceptible to caricature—features such as skin color, religion, and country of origin. Large-scale distribution of a revised narrative must also be linked to the power of economics. One example of this is the military-industrial complex, in which war can be perpetrated using clear distinctions of race, religion, and geo-political identity, morally motivated by defense of family, homeland, faith, freedom, and “our way of life.” The practice of medicine—given its proximity to the possibility of death, its relevance to everyone, and the percentage of the Gross Domestic Product devoted to it— provides another complex space in which the power of revised narratives can be wielded effectively by corporations to increase profit. Taken as a whole, this is a form of capitalistic totalitarianism working under banners such as “democracy,” “the free market,” and “rugged individualism.” It has consolidated journalism, social media, television, and the ways in which access to political power is obtained. Resisting the narrative is an act of rebellion against the order. It is often labeled as unpatriotic or even traitorous. Such labels are very effective for grouping people into categories of them rather than us. Because one of the banners under which these forces do their work is the vague notion of democratic freedom, some level of dissent must be permitted, and the allowance of some dissent lends credibility to the corporations’ tolerance of “differing voices.” Dissent must be managed, but there are so many different opinions that they tend to cancel each other out and to be diluted in the deluge of information, much of which is made suspect by being called “fake news.” Within these political, financial, media, and rhetorical forces, all of which are finally rooted in the priorities of corporations, the practice of medicine as being in time still occurs when the doctor walks into the

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patient’s room, closes the door, and asks something as simple, beautiful, humble, and unpretentious as, How can I help today?

VII. Hiddenness and the Symptoms of Disease The practice of medicine as being in time draws upon memory, imagination, storytelling, and a partnership between a person who is a doctor and a person who has been thrown into disease. Against the backdrop of the problem of history, how can patients and doctors flourish in the difficult circumstances of illness, suffering, or impending death? At least part of the answer depends on what happens in the clinic or hospital room when the door is closed, and one human being says to another human being, “How can I help you today?” Or, “Tell me about yourself.” Or, “I heard you recently received some difficult news. Would you be willing to talk about it in your own words?” There are far more lifechanging first lines in clinic and hospital rooms than there are first lines in novels. Beginnings matter to doctors and patients both, because they matter to human beings. They are usually spoken in everyday language. Inside these rooms, an ancient human reality can still be reverenced, irrespective of the corporate realities outside the room. Maintaining the integrity of this ancient reality requires intention on the part of the doctor and patient. Recovering these skills requires a radical form of recollection intimately related to the value of time. Practicing in this way can be difficult in the profit-oriented world of corporate medical institutions. Closing the door in the clinic or the hospital is an important ritual involving much more than merely a protection of privacy rights. It is a way to acknowledge a holy trust. It is a way to be gentle with a person struggling with the hiddenness of disease, and the possibility of uncovering the source and meaning of disease. It provides the space and time a person needs to overcome isolation, shame, or fear. Fear is a force that can motivate philosophical reflection, courage, repentance, and discovery. Fear is also a power that can be used to manipulate people, sell services, and increase profit. Clarity in the privacy of the clinic or hospital room can protect against the fear-and-greed-driven philosophical sins to which corporate business models are vulnerable. Clarity about the hidden dimensions of disease is one way to face fear, though the pace of discovery must fit the patient rather than a clinic time slot. 101

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Attention to the pace of discovery can lead to a partnership of trust, a sense that even when other forces impinge on the practice of medicine, both doctor and patient will try to achieve genuine flourishing. It can lead to more accurate naming of important human concerns—hopes, fears, things that might be gained, and things at risk of being lost. Whatever the nature of the institution within which the practice of medicine occurs, the clinic or hospital room is a sacred place of disclosure, just as the confessional and other places of genuine human intimacy are sacred. What happens in the room when the door is closed can remind the doctor about the true nature of medicine, why it matters, and why the personal cost that comes with the practice is a worthwhile trade for the privilege of doctoring. We cannot escape looking at things from some point of view. That is part of having limits—our eyes are a couple of centimeters wide, ours ears cannot hear things bats hear, our noses do not experience the olfactory world a beagle enjoys. We are limited, and our point of view in this huge universe is noticeably bounded. Sometimes we crave a view from nowhere—a view that is not conditioned or limited or susceptible to our biases and prejudices. The effort to find such a view often leads us toward the lowest common denominator. This can appear to be a gesture of respect in a pluralistic society. But this strategy eliminates almost everything that matters to anyone. None of us has a generic story. I have never heard a generic story I would want to claim as my own. Even at the level of physical existence in the world, the view of a forest from a satellite’s perspective is not as satisfying to me as leaning against a favorite tree in a favorite forest with a favorite friend. The practice of medicine as being in time cannot be abstracted from the particulars. Doctors must learn to notice particulars and to value them at least as much as generalizable knowledge. To integrate this skill into the practice of medicine as an act of love, the doctor must commit to being surprised by others and to discovering what other people want to share. It requires curiosity and humility. It requires good humor—a willingness to recognize that the doctor’s own little treasures might be fool’s gold. It also requires simple courtesy and good manners. A doctor who enters the theater of the room as a skeptic will get nowhere, even though such a doctor might still serve as a valuable technician. The practice of medicine sometimes postures as a science that is more concerned with biological generalizations than with particulars unique to

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an individual. This is understandable, but it is a mistake that can diminish the practice and harm people. Thinking like a doctor is different than thinking like a scientist. Though doctors certainly apply science when helping patients with problems, their thinking is often closer to the kind of thinking we see in the humanities. Thomas Kuhn’s controversial book, The Structure of Scientific Revolution, described the ways normal scientists usually think in their laboratories, working within scientific paradigms to incrementally advance the field. Kuhn’s description was not a denigration of normal science. Being a scientist requires commitment to the local science learned through earning a degree, winning grants for a lab, and writing articles that are accepted by the leading journals in the field. It requires a kind of faith in the process. Signing up to be a biology major in college does not make a person a biologist. A student is accepted into biology graduate school only if their grades and recommendations are great. That means they had to devour the information taught to them, and they must have acted in a way that made their professors want to write letters of high praise. They write their dissertations based on views of the world in which their senior mentors have been invested for decades. They succeed if their work advances the models and projects valued in their mentors’ labs. No one in the lab is looking for wildly new and radical challenges to the paradigm. One of the most productive scientists I have met during my career as an oncologist told me that he never does an experiment in which he does not already know the outcome. Sometimes he is surprised. But he chooses a project because he thinks he knows where it will lead. No ghosts will ever show up. If they do show up, they will be labeled as “outliers.” But that is how one achieves discovery in normal science, through commitment to the process in order to achieve generalizable knowledge about the natural world. Medicine has its own paradigms and it has a body of generalizable knowledge achieved through scientific investigation. But there are many variables among patients that make the neat application of generalizable knowledge complicated and imprecise. Symptoms of disease can be sudden and intense, or they can be vague, chronic, only possibly present. The pace at which a disease evolves affects many other parts of doctoring. The way symptoms of disease show up says something about the biological nature of the disease. But it also affects the patient’s experience of disease, which in turn can affect the course of the disease and its response to treatment.

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When a disease progresses rapidly, it demands efficient modes of investigation, assessment, and decision making that resemble a response to a biological machine rather than a full and mature response to a human being experiencing disease. Pattern recognition and action based on algorithms built from the best evidence and approached systematically using checklists can save a savable life. But this is not how most diseases behave. A disease that appears slowly leaves room for action based on more thorough conversation about goals, about other dimensions of the patient’s experience, and about what a patient might expect based on the behavior of the disease over time. Some doctors prefer to focus on rapidly-presenting, life-threatening disease. Others prefer working in the setting of indolent disease. Both are needed. Patients likewise can vary in their responses to sudden threat, as compared to the uncertainties often associated with disease that presents slowly. Doctors are taught that “symptoms” are how the patient describes the experience of disease, and “signs” are observable manifestations of disease. The language of signs is very different from the language of symptoms. Signs are often described in convoluted Latinate (but often poetic) language that is the price of admission into the inner circle of the practice. But symptoms of disease are described in language closer to a storyteller’s description of the story’s setting and environment—It was a dark and stormy night. Accidental metaphor, simile, and syndactyly are common in the strange genre called the description of symptoms. The same is true for the doctor’s attempt to interpret the symptoms back to the patient, which requires high-level nimbleness with language. Metaphorical story-telling language in medicine is motivated by something common to all discovery that uses language to name things in the world: it is the only way we can ascribe value to thought and feeling through naming. It is how we show things to other people, or mark things and places that matter in the life of an individual or a community. Metaphors and other forms of analogy engage our imaginations in the process of learning to see, to understand, and to order the world and the relationships among things in the world. Patients use forms of analogy drawn from what is familiar to them in order to express the unfamiliar experience of disease, and to make sense of it for themselves, their families, and their doctors. Doctors use forms of analogy to organize their knowledge, and to teach patients and each other. Medicine has hundreds

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of metaphors relating phenomenological21 aspects of disease to the familiar vocabulary of food, flora, fauna, foods, and various celestial bodies. Hydatidiform moles—an abnormal pregnancy in which fluid-filled vesicles distend the chorionic villi of the placenta—are grape-like. The metaphorical description of stools is often disturbingly culinary—rice water, pea soup, anchovy sauce, or red currant jelly. Forms of analogy that connect the unfamiliar to the familiar are varied and often culturally specific. Symptoms are rooted in the body and in the relationship between the body and the environment. Once-easy interactions become newly troublesome. The body’s experience of symptoms can be mitigated, if the advertisements are to be believed. Once the symptoms have been given concrete descriptions and names, vagueness and helplessness retreat. Now there is something that not only can be treated, but perhaps ought to be treated, maybe urgently ... Ask your doctor if it’s right for you. Television commercials interpret our bodies to us, often in manipulative ways that increase fear. They make our bodies newly vulnerable and in need of things only the pharmaceutical company can offer. By all means, please ask your doctor if it is right for you, but understand that the pharmaceutical company has probably already talked to your doctor, citing industry-funded studies with statistically-significant outcomes suggesting that it is indeed right for you. Manipulative advertising can distract from the deeper meaning of symptoms, which always have an important relationship to the lived experience of embodiment, whether or not a particular symptom actually points to some biological pathology. There may be people who manage their bodies like machines, tinkering until the machines quit, observing with detachment the failing of sinews, tubes, and joints. For such people, the endless creation of new ways to tinker fits well with the culture of technowhiz tool-and-toy manufacturers. But for most people who have enjoyed some measure of harmony among the limits of lived embodied experience, symptoms indicate a threat to harmony as disease approaches, carrying them closer to the unmusical limit of death.

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Phenomenology expresses a maxim that is consonant with the approach many physicians embrace: to the things themselves. It is a methodological conception about how we come to understand the whatness of a thing as it shows up to us (in contrast to most sciences, which conceive of their ideal objects of study as being independent of how things appear to consciousness). Any entity that shows itself in itself can be the focus of phenomenological investigation.

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Because the body itself has a definable location and limit, symptoms also have a location: they are somewhere inside me. But beyond that, the location of symptoms can be bafflingly vague. Vagueness of location is part of why disease is experienced as a threat, like hearing a strange noise coming from somewhere in the house. It can be unnerving and frightening. We are compelled to search for what made the noise, what caused the disturbance. But we are afraid of what we might find. We might even pretend that we did not notice anything. But when it happens again, we have to pay attention despite our fears, perhaps going to a doctor, to a knowledgeable friend, or to the internet. If we decide to go to a doctor, our choice of doctor matters. Vagueness and distress motivate us to ask questions, and we want our doctors to care about finding the answers. But the rules governing the length of visits in the world of corporate medicine often keep the conversation short. Instead, multiple tests and images are ordered. This provides something constructive for the patient to do when there is not enough time to talk. It also eases the doctor’s mind when a vague symptom might be disease X or Y or Z, however unlikely, but there is no time to ask clarifying questions. Unfortunately, using medical tests and imaging to fish for answers in the face of vague symptoms is often a waste of time and money in the absence of a well-crafted conversation. But when the culture does not make room for conversation and partnership, doctors often feel they have no option besides ordering more tests. If a doctor initially recommends watching a vague symptom, but the patient turns out to have a serious and threatening disease, the doctor might bear a sense of failure and self-doubt. If the signs and symptoms were missed or misinterpreted because of institutional demands for shorter clinic visits, the doctor can experience moral injury and resentment, since the doctor carries the responsibility for the “failure” rather than the institution. Eventually many doctors give up and refuse to carry the burdens of uncertainty. They shift toward the defensive practice of medicine, which usually implies the doctor’s self-protection from liability and emotional weight, not defense of the patient. This diminishes the practice for everyone, except corporate financial departments analyzing quarterly earnings. We can do better. Doctors and patients need time to talk. Guided conversation, which takes years to master, is often the most important diagnostic tool the doctor has. It can also be an important means of treatment and healing. The

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symptoms of a disease occur within the geography of the body. Patients have unique maps of this geography in their minds, with annotations linked to personal memories, family history, and stories about the world that provide clues to the meaning of symptoms. A doctor must be capable of considerable imaginative reach to understand a person’s annotated map of their own body. But imaginative engagement of this sort can illuminate the significance of a symptom in a way no laboratory test can. A person’s imagined topography may not map onto images provided by advanced radiological technology, but it can provide invaluable insight into the patient’s experience. It becomes a lexicon the doctor can use to interpret and translate information and ideas for a patient in a meaningful way. To hear, understand, and imagine a mythical topography, the doctor must listen with a sense of respect for the patient and regard for the order— the mytho-logic—inside the mapped world the patient reveals. Everything with a familiar place inside the mythic topography of a body will also have some relation to the alien force of disease. A doctor who understands this can use metaphors, similes, and analogies to diminish chaos and to restore a sense of order in a disrupted topography. This work of interpretation can be comforting to a patient and remedy some of the dis-ease. Mythic topographies of the body (including medicine’s own) are also often communally held: interpretations of the body, though adapted to an individual, are inseparable from communal history, culture, and language. This work of imagination, interpretation, and translation is a difficult art to learn. It requires skill, patience, and practice. Observing and describing the outward behavior of lovers is much easier than finding language that expresses their inward emotions and shared experiences. Likewise, it is much easier to describe biological facts revealed through blood tests, biopsies, radiological studies, and physical exams than to grasp the full meaning and significance of the symptoms that comprise a person’s experience of disease. The mythical topography that emerges through the imaginative and metaphorical work of interpreting symptoms sometimes diverges from the doctor’s sense of the relevant biological facts. This divergence is part of the hiddenness of disease. It suggests that there is more to the story and that the telling should continue. Even when the doctor’s collection of biological facts seems fairly complete and reliable, discordance between biological description and the patient’s account of symptoms is a reason for continued interest and curiosity.

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A lack of interest and curiosity in the face of such discordance constitutes a failure to practice good medicine. The failure may be a failure of character or virtue. It may be a failure of basic compassion. It may be a failure of imagination or intellect. It may be an institutional failure related to profit-motivated limits set on the time allowed for a clinical encounter. Whatever the reasons for such failures, they diminish the practice of medicine and they must be addressed and corrected. Discordance between biological investigation and the patient’s language of symptoms indicates that the origin of dis-ease is still hidden. Diagnosis requires disclosure, and the integrity of any pronouncement of diagnosis depends on the completeness of the disclosure. This in turn requires attention to the reality of disease as it manifests within a patient’s experience taken as a whole. In the clinical setting, a patient’s interpretation of the meaning of a disease can drastically alter the patient’s course. If someone in the family has died from a disease, that part of history might determine the effectiveness of a given therapy—not merely because of genetically determined factors, but because the patient loses hope, and hopelessness can worsen disease or even lead to death. If a disease is interpreted as punishment for certain actions, the conviction that the suffering is deserved can change the outcome. This is why a good doctor cannot ignore the meaning of symptoms construed in this rich and complex sense. Even when the symptoms and the biological evaluation map onto one another, the meaning of the symptoms can still remain hidden. Meaning is not a biological category. Within a laboratory setting, if all conditions are held constant except one variable, and if problems associated with auxiliary hypotheses are bracketed, and if methodological reductionism is embraced in order to execute the experiment, perhaps questions of meaning can be ignored without any obvious impact on the experiment itself. But the clinical setting is vastly different from the laboratory setting. Doctors might wear lab coats and see patients through the filters of discrete biological data, but that changes nothing about variation from patient to patient. Immeasurable and hidden variables abound, not only within the bodies of the patients, but within the details of their secret behaviors and within the private environments they call home. When a patient goes to the doctor, but hides a symptom or the meaning of a symptom or both, the doctor must treat the patient’s desire for hiddenness as reasonable from within the patient’s whole worldview. To do otherwise is disrespectful, making it less

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likely that the doctor will ever recognize and address the patient’s true concerns. There are many reasons someone might go to the doctor, ostensibly to be evaluated for dis-ease, but hide the very symptoms that prompted the visit. One common reason is that we hide the full meaning of symptoms from ourselves when we are afraid. Imagine a man with vague abdominal pain who recently lost his wife to cancer, and who recalls the vague abdominal pain that initially led to her diagnosis. The unexpected sensation brings back the full force of his grief. It is more than he can bear. But as he researches causes of abdominal pain, he discovers a less frightening cause—say, a report that people with streptococcal throat infections sometimes have abdominal pain. And in fact, he has noticed some scratchiness in his throat. So, he visits the doctor with the complaint of sore throat, but never mentions abdominal pain. The doctor performs a throat swab, and the man turns out to have a positive streptococcal test. Despite the frequency of false-positives associated with the test, the man is relieved as he leaves the clinic with the antibiotic prescription. Now he can focus all his energy on his grief for the loss of his wife, rather than worrying over some tummy ache. If the abdominal pain turns out to have been caused by pancreatic cancer that spreads because of a delay in surgical resection, this does not make the patient’s act of hiding unreasonable. Given the circumstance of his grief, his decisions were understandable. A decision or action does not have to be optimally rational to be reasonable. Symptoms unattached to any specific diagnosis can create imaginative spaces within which agonizing fears can reside. Vague sensations with murky causes can interrupt our routines and heighten our awareness of contingency, vulnerability, and mortality. Such things might be more than a person can bear without further spiritual growth, community support, or reevaluation of life’s priorities and goals. For someone who has no resources to face the potentially terrifying significance of symptoms, avoidance of overwhelming existential distress by any means necessary is not unreasonable. Perhaps the only way a person can get out of bed and take care of obligations is through denial or distraction. A person who only sees one strategy for responding to a threat is not irrational for using it. It is irrational, however, to expect a patient to use an unavailable alternative strategy. Time passes inexorably and this certainly has implications for disease progression. Symptoms can point to diseases that are curable in early

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stages, but incurable in later stages. Because of this, part of good doctoring is to help patients find ways to endure what seems unendurable. This kind of helpful act requires respect for a patient’s experience, rather than contempt for their initial strategies. If a disease requires a risky intervention, a frightened patient might find it easier just to hide suggestive symptoms. If a disease threatens function or even life, hiding symptoms in order to escape the doctor’s office with a pronouncement of good health might bring temporary relief. Only respectful and imaginative attentiveness can disclose the significance of hidden symptoms that appear in the patient’s subtlest forms of expression, and only compassion can show a doctor the way to help a patient face a difficult new reality. If a symptom points to a disease that causes shame, a person might keep it hidden to avoid that shame. Shame-motivated hiddenness is often complex. Some diseases are associated with cultural shame. Some diseases are linked to various forms of “weakness” that can be perceived as shameful by the patient. Sexually transmitted diseases can cause shame by being associated with moral failure and a lack of self-control. Diseases that interrupt neural regulation of the bowels or the bladder can lead to the shame of incontinence, with soiled clothes and unpleasant odors. Disfiguring diseases can cause shame about one’s body, leading to isolation that is a source of both agony and relief. Doctors who wish to help patients disclose symptoms that might cause shame must understand the reasons for shame. In order to imagine another person’s experience of shame, doctors must understand what is at risk for the patient, what is threatened by shame. Unfortunately, medical training is often a process in which weakness of any kind is despised, and in which considerable shame is inflicted on doctors. “Pimping” is a common form of teaching in medical school. It is a caricature of the Socratic method in which students are asked questions drawn from the finite knowledge base of the attending physician until the limit of the student’s knowledge is reached and the student must admit ignorance. At that point the student is shamed for having inadequate knowledge. Fatigue, fear, uncertainty, and bewilderment are other despised forms of weakness that shame doctors. They learn to hide these things from patients, each other, and even themselves. They develop a dysfunctional relationship with their own weakness and shame, which interferes with their emotional and spiritual growth, and their ability to tell the truth. This harms the doctor as a person, which inevitably affects the

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doctor’s ability to care for patients. Patients can sense this. When they do, they lose trust. Mistrust of the doctor, or of the institution within which the practice of medicine occurs, is another important cause of hiddenness. Trust is required for a patient to reveal a symptom suggesting a disease that might lead to shame, procedural risk, or potential loss of function or life. The patient can only trust a doctor who reliably, skillfully, and respectfully interprets symptoms in light of the patient’s lived reality, including the patient’s fears, hopes, and stories about the truth of the world. Trust requires a sense that a doctor has the patient’s well-being in mind and is willing to consult the patient regarding what constitutes the good in a life before recommending an intervention that comes with risk. A patient can only trust a doctor who will not accentuate shame, break confidence, or force a patient into difficult conversations faster than the patient can assimilate information. In the absence of trust, hiding a symptom can be a rationally motivated act. Uncovering hiddenness requires a partnership between a patient and a doctor. Otherwise it is a form of assault. The contemporary practice of medicine is deeply influenced by a corporate understanding of time, equating time’s value with money. Severe time limits are artificially imposed on the encounters within which the doctor-patient relationship is fostered. Under the pressure of these contrived time limits, doctors sometimes become impatient when a person visits the clinic because of some concern and then hides the very symptoms that would disclose the disease. Impatience can lead to various forms of coercion in an attempt to efficiently elicit the hidden information. Coercion diminishes trust, creates defensiveness, and motivates continued hiddenness. When emotional intensity, time constraints, and a power differential between a patient and a doctor deform the simple humanity of a clinical encounter, the result is not only mutual frustration, but also mutual blame. Overcoming these obstacles to trust within the constraints of a corporate system requires something more like performance art than protocol, management, or science. Coercing a person to reveal something hidden, including the hidden symptoms that brought the person to the clinic in the first place, is an act of disrespect and perhaps a kind of violence. Experienced doctors know there are circumstances in which coaxing patients to overcome their reluctance to disclose something hidden is an act of

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healing, wisdom, and compassion. But insight into these circumstances requires long and artful practice motivated by love. All of life occurs in relationship to hiddenness. The journey of disclosing what is hidden is not only the task of science, which investigates the natural world, but also the task of philosophy, storytelling, and any human act capable of revealing truth. The practice of medicine is one in which all hiddenness is relevant and all manner of disclosure is relevant, because the focus is not merely an object (the body) but rather a subject (the embodied person) who is the nexus of all thought, feeling, action, experience, and meaning relevant to human existence. Given the true scope of the practice of medicine, which never reaches the end of learning about humanity, hiddenness should be embraced as an intrinsic part of the practice, rather than something surprising, or worse, despised. Almost anyone can learn discrete biological facts about the human body. As creative as scientific discovery is, most of the biological aspects of the practice of medicine involve pattern recognition and an ability to think through material and efficient causes related to these patterns. This is a wonderful skill, to be sure, and it takes many years to learn. But mastering biological facts or a set of techniques is not the most difficult part of the practice of medicine as being in time. The most difficult part of becoming a doctor is learning the slow art of disclosure, in which people who have been thrown into disease, and who are anxious and uncertain, begin to uncover tender, hidden things about themselves. The art of disclosure is not simply about efficiently diagnosing disease and planning practical interventions. The art addresses the deepest parts of being human on the threshold of mystery. When a person is thrown into disease, the human condition—with its fragility, contingency, vulnerability, and mortality—is brought into the light. For the sake of their patients and for the sake of their own humanity, doctors must not miss this part of their vocation. Disclosure of hiddenness in the practice of medicine as being in time is the art of becoming aware of limits and the meaning of limits in a life well-lived.

VIII. Curiosity, Falling, and That Which Shows Itself in Itself The varieties of hiddenness and the art of disclosure are integral to the practice of medicine in its full scope, a practice fundamentally focused on the mortal, embodied subject as the nexus of human meaning. Three philosophical concepts illuminate the relationship of hiddenness to the practice of good medicine—curiosity, falling, and that which shows itself in itself. Curiosity orients the doctor and the patient toward hiddenness with a benevolence that values what is hidden and the reasons it is hidden. It is one important condition for the disclosure of what is hidden. Hiddenness implies uncertainty about what will be disclosed, how it will be disclosed, and what the effects of the disclosure will be. Because of this, patients and doctors must be willing to fall22 into what is hidden, knowing that the meaning of what is disclosed and the effects of the disclosure are not under their control. Aside from logical tautologies, we know nothing with certainty. Once we relinquish our need for Cartesian certainty, we can embrace a sort of philosophical faith that the work of disclosure can bring us closer to reality through knowledge of that which shows itself in itself.23

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Falling: Within the bland conformism of average everydayness, we still make choices that reflect our understanding of who we are. But we generally conform to the herd— the force of whatever or whoever shows up around us. Heidegger calls this falling. Falling in with the herd is not necessarily bad: it creates part of our background of shared intelligibility. But it also leads to distraction and forgetfulness. We can only regain authenticity by finding a way to escape falling through a personal transformation. This transformation depends on certain fundamental insights that arise in our lives. One jolting source of insight is the experience of intense anxiety in which our familiar world, which is our foundation for security, suddenly collapses and everything loses significance for us. In this experience, we meet ourselves as individuals. We begin to learn things about the ourselves, others, and the world that we could never have learned without first falling in with the herd, and then experiencing the awakening that comes through anxiety. That Which Shows Itself in Itself: Phenomenology allows us to investigate being, while minimizing distortions from past metaphysical concepts. Phenomenology is guided by the maxim, To the things themselves. As we learn to see, we realize that phenomena are self-showing, even if the meaning of being remains hidden. The work of phenomenology is to let that which shows itself be seen in the way it shows itself. Disclosure implies concealment, and the ways in which things conceal themselves belong to their essence as phenomenon. The method of phenomenology allows us to interpret this concealment

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This kind of knowing is a basic act, depending only on the actual encounter with that which shows itself in itself. Saint Augustine’s favorite example of this was the love of God. Another example is commonly reported by people at the end of life who describe being aware of peace and unity, understanding those words only as placeholders for something more real than words can contain. These philosophical concepts are far more likely to show up in a humanities seminar than in the medical school curriculum. This reveals something important about the philosophical assumptions undergirding medical schools. William Carlos Williams, who embraced the maxim “To the things themselves” as his poetic principle, said that medicine and writing were the same thing for him. His insight into the similarities between the place of imagination in the practice of medicine and its place in the act of writing gestures toward the kind of thinking required to grasp these philosophical concepts and their relationship to hiddenness in the good practice of medicine. A smart ninth grader can probably follow the basic reasoning undergirding therapeutic protocols for cancer treatments. A teenager who is very good at gaming might be able to become passably competent at robotic surgery, given enough practice games prior to the actual operation. But a great doctor must learn to imagine the worlds of complex strangers filled with love and hate, fears and needs, gods and demons, and then partner with these strangers to make some of the most difficult decisions a person can make, in some of the most disorienting and stressful conditions a person can face. Medicine is dense with story. Antoine Chekhov was a master observer of the strangeness and wonder that show up in the clinic and in hospital rooms, and the similarity between the stories encountered there and the wide-ranging worlds of great novels. One privilege of medicine is the chance to witness the ways in which the world diverges from the assumptions, worldviews, and experiences native to the doctor’s own life. Imagination allows doctors to expand beyond their own horizons, to grow into new worlds, and to open themselves to unexpected possibilities that come in the disclosure of hiddenness. But when such things as arbitrary time limits for visits and demands for excessively time-consuming and to approach things as they are in their showing of themselves to us. We learn to see ourselves, other people, and the world as they actually show up in consciousness.

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documentation interrupt the relationship between doctors and patients, imagination suffers and the mind is abstracted from the richness of lived reality, to the detriment of both doctor and patient. When patients are put into gowns and their sense of place, person, power, and agency are diminished, dismissed, and despised until all that is left is an abstract corporate agenda and the thin gruel of biological language, too much is lost. Too much is lost for everyone involved. Doctors and patients begin to experience a distressing form of inauthenticity. When the particulars are shorn from the both doctor and patient, genuine healing is much more difficult. Some people, both patients and doctors, prefer this abstracted experience because it is more efficient. But skimming the surface instead of plunging into the depths is a drab way to live a life. It flattens beauty and makes the world monochromatic. Doctors begin to lose their aesthetic sense of beauty, form, and harmony. They become dull to the consonance between the beauty of function and the beauty in the face of a 90-year old woman who comes in clutching the picture of her recently deceased husband. Over time imagination atrophies and doctors become the kind of people who can remain placid, professional, and aloof in the presence of pain, suffering, fear, grief, and anxiety. When doctors reach a place where nothing moves them, something at the core of their humanity has died. The practice of mindfulness—showing up fully—can help a doctor or patient reawaken their ability to see beauty when it appears, even in the middle of illness, suffering, and death. It is a simple lesson that can transform how doctors experience their strange and wonderful vocation serving people in their clinic or hospital: Show up completely and listen quietly for a few minutes while the miraculous human being in front of you tells you who they are and how you can help them. Curiosity is an invitation into what is not known. The unknown can be something we crave to explore. It can be something we do not even know how to name. We know how to explore the natural world through science. We know how to explore our own feelings sometimes. We know how to explore our thoughts. We might be able to explore the thoughts and feelings of others. We do not uniformly know how to explore the divine, if there is such a reality. We have forms of anxiety that have no clear object and that we are unsure how to explore. We can explore our identity—sexual, spiritual, vocational, intellectual, emotional. Some aspects are more transparent than others, some are more surprising than others, and some

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seem to have no distinct shape or clarity even though they feel indispensable. Exploring identity also forms identity. Our efforts to understand ourselves are fundamental to our orientation toward many other areas of curiosity in the world we encounter. Some aspects of our identity, such as our sexual orientation, gender identity, and the consequences of our sexual choices are intimately related to our bodies, including the lived experience of our bodies we bring into the practice of medicine as being in time. Because the fluidity of our own vulnerable experience of identity is shaped and disclosed over time, a kind of tenderness, mindfulness, and gentleness are required for our exploration of the unknown to be an act of love. Curiosity requires courage. We can be afraid of the unknown without being dominated by our fear. If fear dominates when once-familiar parts of our world—our homes, our bodies, our priorities, our ideas—suddenly seems strangely unfamiliar, we are tempted to draw back from risk and to track along well-worn ruts, instead of asking difficult questions that might help us think differently. When fear dominates us, we feel paralyzed in our own choices, which makes us more vulnerable to the decisions, goals, and priorities of others. This is not necessarily bad if we are truly unable to act. But it is unfortunate if it interferes with our own discovery of the truth of ourselves, or the truth of the world as we experience it. Institutions respond in fear when the unknown looms, and they try to preempt the unknown by creating policies, protocols, and new layers of administrative oversight. In the arena of corporate medicine, biology, technology, risk avoidance, and legal defensiveness are the dominant forces that decide our actions when we allow fear to prevent us from deepening our engagement with the unknown. The juggernaut of medical and procedural intervention can carry us to places that make little sense in our lives, causing us to suffer, and removing opportunities to do things we might have chosen with less fear. We lose the ability to think creatively in the face of uncertainty, which might feel like a kind of relief, but which is also sad. Fear is often a form of premature knowing that is at cross-purposes with the openness of curiosity. In a sense, an unknown thing cannot be an object of fear because we do not even know what it is. We can only be afraid of the unknownness of the unknown thing. As the unknown thing is incrementally disclosed, whatever fear persists is at least connected to reality. Of course, if every possibility is frightening, our fear is connected to

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reality even when we do not know which possibility will become actual. This happens in the practice of medicine when patients who do not believe in miracles have incurable illness or irreparable trauma. If there are truly no good possibilities (such as divine intervention making everything better), reality can be frightening even if the particulars are still unknown. In any case, when the unknown is truly unknown, fear must be rooted in something else, fired by something besides the reality of future events. The fear might be a response to having no control over future events. It might be a response to the limits of human knowledge, or to the contingency and vulnerability disclosed by facing the unknown, or to past experiences of harm when something that was unknown became known. Whatever the origin of our fear of the unknown, and however important fear is in certain circumstances, the fear itself is not a category of knowledge, and it is difficult to address until its object, or its lack of an object, is clarified. We sometimes become more afraid as the unknown is disclosed through curiosity. But commitment to knowing what is unknown requires that we accept our lack of control over the knowing. We fall into a kind of knowing that answers our curiosity, even though we know the disclosure might bring difficult challenges into our lives. Real things can feel overwhelming, too hard, too much for a person to bear. In the face of an impending loss, we sometimes feel like reality can only be endured by retreating from it. Retreat can make some circumstances in the world tolerable: we just pack our bags and walk away from the difficult thing. But when the threat or fearsome reality resides in our own bodies of minds, there is no retreat, no escape. Fear and curiosity work together when the fear reveals something about the nature, character, and contour of the emerging reality. Courage can grow stronger as we endure uncertainty and our lack of control over the transience of things. As we fall into knowledge of an as-yet unknown reality, we may or may not achieve courage. But this too is an aspect of the unknown that can provoke our curiosity and our interest in what is happening to us. Perhaps the exemplar of this is the lived experience of impending death. Falling into the unknown occurs in time. It has the unidirectional aspect of time. One who has fallen cannot fail to have fallen. One who knows cannot fail to have known. Because falling occurs in time, there is a beginning, a middle with many variations, and a sense of moving toward the end. The practice of medicine as being in time engages embodied mortals

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through the entire arc of falling. The arc is continuous. But just as our sense of time as having parts is a useful fiction, our way of talking about the falling that has begun, that continues, and that is moving toward an end is a fiction that is necessary for the mystery to fit our human-sized capacity to engage with life and death. We can experience the end of falling as an end if the arc brings us to awareness, acceptance, and mindful transformation. Even if we never fully know the unknown, our experience of the arc of falling into the unknown can be transformed by reframing the nature of the unknown. One way to reframe the unknown is to reframe the known. We can learn to see the “known” in a new way that makes the known strange: we come to see that the unknown always resides at the heart of what we take as known. Becoming aware of the fundamental strangeness of the familiar can give us the courage to embrace the unknown. The experience of falling is continuous with the entire adventure of being alive. Awareness of the strangeness that has always been our constant companion can teach us to trust even in the midst of uncertainty. Falling reveals important things about the reality of being human. It reveals contingency, risk, spiritual malleability, and the inherent limits constitutive of embodied existence, without which falling is not possible. It also reveals the limits of the feelings associated with falling. We do not fear boundlessly, hurt infinitely, or fall forever. When we become aware of the limits of fear, pain, and falling, our experiences of fear, pain, and falling change: we see them as unambiguously finite. Limited embodied creatures cannot endure something that seems endless. But endlessness is a fiction, no matter where it seems to show up in the perceptions of a finite creature. We are only capable of registering finite fear, pain, and disorientation from falling. We are creatures who live in time. Memory allows us to pull past experiences into the present moment, and imagination allows us to pull future possible experiences into the present moment. Because of this, we can make experience inside a moment more difficult than it might be without memory and imagination. But we can only experience what fits in a moment. Every past moment and every future moment, like the present moment, can only hold a finite actual experience. The practice of medicine as being in time addresses suffering by engaging with the relationships between memory, lived experience, and imagination—which is to say past, present, and future.

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Falling can be enlivening. It can lead to the kind of awakening for which much might be reasonably traded. We can feel a surprising freedom when the vague and frightening certainty of future death is replaced by the diagnosis of a definite disease that will probably be the cause of our death. The suffering we experience from long fear of some dark thing often decreases once the darkness is upon us and we must face it directly rather than merely worrying over its arrival. Falling can bring dread if we continue to grasp for anything that might prevent the falling. But it can also bring a sense of robust peace when we finally let go, after struggling against something we cannot control or avoid. We can imagine many fears—fear of poverty, fear of being alone, fear of failure, fear of debility. Our worry over these things can feel like falling into darkness and dread. But these fears can also be mitigated when we listen to witnesses who have already experienced the feared thing. If we can relinquish our attachment to the object or occasion of dread, our dread of falling can lighten. For some, non-attachment becomes a form of spiritual growth or maturity. Even if we do not want to relinquish our attachment, the fall can bring about a revaluation of our fear, illuminating the object of our fear and the experience of falling. A person who is thrown into disease often meets very specific objects of fear—cancer, pain, disruption of so-called normal life—along with vague, difficult-to-name objects of dread. The practice of medicine as being in time occurs in the midst of these kinds of experiences, all of which follow from the temporal limits of embodied mortal creatures. Good doctoring requires mature awareness of these human experiences lived in relation to passing time. Some kinds of knowledge only come through the actual experience of falling. They cannot be handed on through language. Attempts to translate such experiences into stories can provide guidance, comfort, and relief from the sense of isolation. But a story about knowledge that comes from the experience of falling is not itself the knowledge. There is no substitute for the experience itself. Many of these kinds of experiences show up in the practice of medicine as being in time, because experiences that occur within my body are different than stories about similar experiences that occur outside my body—in your body, for example. When disease threatens my body, it threatens the entire world-as-I-experience-it. No matter how much I know about a disease, and no matter how many stories I have heard from other people who have been through the experience, what I

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come to know when the disease is inside my body will be different from hearing a story about someone else’s experience. For everyone, including doctors who care for thousands of people facing disease, knowing the threat of disease inside one’s own body is always a form of falling. Falling is not a result of one’s own agency. It is beyond one’s control. The falling associated with the bewilderment of disease-in-my-body is unique because it leads me to knowledge of what it is for the entire world-I-experience to be threatened in some way. The threat is pervasive. Perhaps the disease will take away my sense of sight, which will change the whole world for me. Perhaps it will make me immobile so that I cannot move from one part of the world to another. Or perhaps I will lose everything through death. The world-in-itself feels stable and reliably there. But the experience of falling brought about by disease-in-my-body reveals that the only world I have is the world-as-I-experience-it. This knowledge is disorienting if I have never thought about it until the moment disease threatens my world. Even though stories cannot substitute for the experience of falling, nor prevent the fall, they do have a place in preparing us for the moment when the experience is upon us. Stories can make us less disoriented, they can help us feel less alone, and they can offer us the kind of peace that comes from a wise and good guide. Falling is not intended. It is not a consequence of our own agency. It happens to us and it is beyond our control. We are overcome. But as an act of consciousness, we can intend openness to the unknown. In the midst of falling, the disposition of my consciousness that follows from my own intention can make me more capable of seeing, feeling, and paying attention. Falling can be noticed, just as other kinds of experiential knowledge can be noticed. We can see blue and we can notice that we are seeing blue. We can experience pain and we can notice that we are experiencing pain. Having an experience is different from noticing that one is having an experience. That said, my experience of something can be changed by noticing that I am having the experience. If I fall from an airplane the falling is still falling, whether I am able to pay attention or can only experience chaos in my consciousness. But if I can pay attention to my experience of the fall, and choose to do so, the experience of falling is affected. When a disease progresses despite medicine’s best attempt to cure it, patients can experience a kind of falling that is known through the experience of falling. The

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falling itself is unchanged by noticing it, but noticing can change the experience of falling by mitigating panic, for example, so that the falling is experienced merely as falling, which can allow other experiences to occur in the patient’s limited time, rather than having them crowded out by feelings of chaos and panic. Non-attachment can allow us to see falling as that which shows itself as itself. Panic, anxiety, and fear can reveal certain dimensions of falling, including the value of what is threatened. But there is a way to observe the pure nature of the falling-as-falling, for better or worse. The value of nonattachment can be explored in the middle of experiencing disease-as-falling. Part of exploring the experience of falling is to ask whether the panic, anxiety, and fear are humanly worth more than dispassionate experiences of the falling. Consider the category of falling we call dying. Even before we know what an experience of dying is, we can know that we will die. Knowing this allows us to ask questions about what we hope for in the experience of dying, with full awareness that dying is a kind of falling we cannot control. We know our decisions depend on self-knowledge and imagination rather than direct experience of the falling itself, because we only die once. We can meaningfully ask whether panic in the face of death is valuable and necessary for the disclosure of something real and important in human experience. Or we can mitigate panic through mindful, philosophical preparation. None of this is a substitute for the experience of falling, but it can reasonably be construed as preparation, which has an old place in the history of human thought—the idea of philosophy as preparation for death. Through curiosity we control of the direction of our conscious intention, which is a kind of control over what we come to know about anything, including the experience of falling. But we cannot control our surprise when the falling first dawns. Surprise is part of experiencing a thing that shows itself as itself. It is something that comes upon us, not something we intend and hold through the power of our curious gaze when it dawns. If we have used imagination, and especially philosophical imagination, to orient ourselves toward the varieties of uncontrollable falling in the world, once the experience of falling is upon us we can turn our intending minds toward it more readily, with wonder as a bright and hopeful form of curiosity in a mysterious world. This philosophical preparation allows us to control some part of our own participation in the falling, not in the sense that we control the falling,

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but in the sense that we come to know the falling as actual falling that is beyond our control, and to fully experience this part of life. We can pay attention to something real that occurs in the uncontrollable experience of falling and that is only accessible to the one who is falling. The unity that results from philosophical preparation allows the falling to be an experience we call ours, leading to knowledge and insight about falling, about ourselves, and about ourselves-as-falling. Even if the falling is a falling toward death, which is the end of the world as we experience it, we can in some sense remain intact, integrated, and whole throughout the uncontrollable experience. This can be an affirmation of the goodness of life. The experience of falling reveals something we can hope to know better—falling itself. Falling continues to be itself-as-itself even when it is an object of curiosity and wonder. Wishing to know more is a shift in disposition that results from the falling. It does not change the falling itself, but it does change the experience of falling in a way that is a kind of maturity and growth. This deepens our capacity for awareness, insight, imagination, memory, and hope. There is long philosophical and scientific concern about whether or not anything that is itself-in-itself can be experienced in a direct and pure way, or whether the very presence of someone who is having the experience changes it. The world comes to us through our senses, and our access to the world-as-it-is-in-itself is partial at best because of the limits of our senses. But the experience of falling is different from sense-experience of the world. It is uncontrollable and clearly not constructed from our own will or design. Nonetheless, the experience of the falling is part of the reality of falling itself, because the meaning of falling can only inhere in a consciousness. In the case of biologically-grounded experiences of being thrown into disease, and realizing from within disease that one is falling toward death, the falling itself is not a biological phenomenon: it is a phenomenon of meaning, related to consequences that have value because the things threatened are valuable to the one who is falling. In such cases, because our experience is constitutive of the reality, we have direct access to it. The experience of dying is an important example of this. Non-attachment allows us to become curious about our falling as it shows itself-in-itself. Non-attachment is a kind of being in time that releases the accumulation of time, without denying our own temporal and finite nature. It is a way of paying attention to the crusted forms that grow over time from episodes of falling, anxiety, and fear. It is not a lack of care,

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but rather a way of learning to care without grasping. Non-attachment as a mode of love and gratitude is interrupted by the bodily metaphors of grasping and holding. Some things are known with a kind of tactile-dependent thought that comes to know the shapes in the world through the act of holding. This is an important way of learning about the world. But forms are not the same as shapes, and the formal world cannot be held in this way. The formal world is seen through the appearances in the embodied world. Bodies can be held, but the reality that is embodied cannot be physically held. It is only known through the imaginatively nimble mind imbued with the uncanny sense that something lies beyond the touchable world. The formal world is transcendent. It is the meaning of what is touchable in the world. This is the imminent-transcendent that inhabits the mundane, embodied world, and that draws us into the meaning of the embodied world by drawing us past it. To see this, we have to practice for a long time, intentionally, with openness and humility. Non-attachment is how one who is falling remains present and grows in knowledge, not by means of control, but by a different form of clearing in which a person is present and transparent, becoming the knowing. This is an inward shift in our way of seeing. The shift is a philosophical act that does not alter the embodied world in any way. It leaves all the embodied world exactly the same. It changes nothing about the ways we interact with the world through science and technology, or interact with each other through language, mingled senses, and invitations to come close. It is simply a change in the light by which we see everything that is, without altering a single atom in the world. The shift is an intentional act of a consciousness. Non-attachment is an achievement that frees consciousness from being defined by environmental stimulation, distraction, or preservation. Whatever death is, it is unique among the realities toward which we can fall. The entire world as we experience it is at stake. Perhaps our existence is at stake. Because of this, the peculiar experience of falling toward death can reveal astonishing dimensions of consciousness in a unique and important way. The desire not to miss this opportunity for growth and insight is deeply rational, and it is an affirmation of the value of this strange life that ends in the way it ends.

IX. Idle Talk and Interrogated Questions The practice of medicine as being in time is difficult to master. It requires a philosophical conversion that is inseparable from a doctor’s own experience of embodied life. Because most of a doctor’s waking life is spent at work, philosophical style at work impacts the doctor’s character outside of work. The practice is an adventure in spiritual and philosophical disruption that can go well or can go badly. Clarity comes and goes, often based on something as simple as a better or worse night’s sleep. Its elusiveness can lead to premature skepticism and a return to old practices that are familiar, measurable, and reliably helpful in many cases. Of course, sometimes skepticism is accompanied by welcome relief: we cannot endure a constant state of falling, uncertainty, and conversion. But our occasional need for relief from philosophical weight is different from a desire to escape the obligation to pursue reality and truth. Doctor’s need a philosophical conversion that shifts them away from reducing people to their molecular events, because the good practice of medicine is oriented toward whole persons. To practice in a way that elides a person through a philosophical reduction of the person to non-person events is spiritually damaging to the patient, but it is also spiritually damaging to the doctor. It is spiritually damaging to the doctor because it is a long practice based on a false view of reality—false, or else obstinately partial in the face of overwhelming evidence that there is more to the story. The doctor’s own personhood provides accessible, illuminating, and obvious evidence that there is more to the story. It is also spiritually damaging because it desecrates the trust a patient brings to the doctor in the context of vulnerability, exposure, crisis, and need. Medicine’s background assumption of naturalistic reductionism, along with the force of corporate medicine’s obsession with efficiency as a means to profit, make the sustained practice of such philosophically converted conviction difficult. Backsliding is easy and common. Of course, even in the practice of medicine as being in time, many practical tasks must be done algorithmically as a form of mere-doing, like tying one’s shoe laces or brushing one’s teeth. The body is describable biologically. Once the body’s mechanisms are understood, medical, molecular, and surgical interventions can normalize rogue biology. Knowing 125

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how to normalize biology is useful in service to goals that go far beyond biology. Machines do not have goals in the way embodied persons have goals, so the biology of the body can never exhaust the reality of the body. But when a biological malfunction is a machine-like malfunction, patients can die if we fail to treat them with the same careful, well-reasoned approach we take to repairing our valuable machines. Attention to such things is not only consistent with the practice of medicine as being in time—it is crucial. In between falling into the unknown, making high-stakes decisions, and experiencing other philosophically important events, our lives are filled with mundane acts that sustain us. In a religious liturgical year there are holy seasons and seasons of ordinary time. The work of ordinary time is different than the work of holy seasons. Ordinary time is also holy and its work is necessary. Our conduct in ordinary time impacts the high holy days and seasons. Ordinary time is meant as preparation for the holy seasons. In it we live ordinary life, and we do so in the light of the holy season that has ended and the holy season that is approaching. Human beings are rhythmic from the womb where the systole and diastole of the mother’s heart give the first shaping rhythm of contracting and relaxing, which are equally necessary for life. The rhythm continues through the constant, alternating patterns of breathing in and out, waking and sleeping, and playing in the ocean’s waves. Embodied human existence is dynamic, varying within a larger pattern where regularity is indispensable for life. Without such variation within ordered regularity, bodies disintegrate, minds become chaotic, and people become fatigued, disoriented, and lost. We cannot always live in crisis, though we must accept tension in a world that demands our response as it changes. Holy days and ordinary time within a liturgical year mirror the variation-within-order we need. Stretches of ordinary time are important for the seasons of transition and philosophical change in the practice of medicine as being in time. Doctors must tend to small things, showing deep regard for their importance. This is a task of ordinary time for the doctor who is paying attention to the philosophical meaning of time as the fundamental limit in human life. Much of medicine is about attending to small worries, small questions, small adjustments, and preventative care. None of these are generally experienced as disease. But because the body and mind are at the center of the practice, even these small, slow-paced, mundane experiences provide

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a chance for other thoughts or concerns to rise to the surface in the time of calm, instead of waiting until a time of crisis. This is why the ritual of examination is important: it requires the art of reading the truth in the room, which guide variations in the examination based on the needs and responses of a patient. As things are noticed during the physical exam, opportunities for unspoken concerns open up in the calm. A patient’s comments and physical response to touch can reveal openings in which a question might be asked that is meaningful or respectfully provocative. The practice of medicine is always oriented toward being in time, if only because the inevitability of death is the backdrop for even the most mundane concern about the mortal body. Without the larger context of uncertainty, the unknown, and questions of philosophical significance, we experience ordinary time as mere duration, more of the same. This is the time of corporate medicine in which the length of a visit is predetermined, and the documentation and billing are given a dominant place in the encounter. For both the patient and the doctor, the experience is determined by the presence or absence of a deliberate philosophical orientation toward the significance of ordinary time. The corporate medical structures can isolate and degrade ordinary time when they allow no place for the sacred and have no desire for holiness to break through. Whether holiness is construed as an actual ontological reality that subsists and endures, or else as a placeholder for an experience that is important but difficult to name, concepts such as the holy are not among corporate priorities that devolve into concerns about profit. Concerns about holiness may actually detract from corporate priorities. They might detract by reducing efficiency. But they might also detract by changing the tenor of the task at hand—especially in the face of a philosophically dense question such as What are doing? Crisis raises our awareness of the sacred. Experiences on the threshold of loss or mortality shine light on the beauty of ordinary time, opening our eyes to the holiness that quietly resides there. Meaningful speech in the context of ordinary time as sacred time can degrade with the desecration of ordinary time. Degraded speech is idle talk. It does not move toward an end. It does not move the heart. It can dull the mind and emotions, and diminish our sense of the realities that are lit up only when ordinary time is regarded as sacred. Without room for the full experience of embodied existence and the experience of being thrown into disease, we are bewildered by falling toward something we do not understand.

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The degradation of language narrows our ability to respond to the unexpected, which diminishes the integrity of practice. Degraded speech is common in the practice of medicine, though culpability for such speech is difficult to assign because of the very pervasiveness of its practice, which shapes the culture of education and the institutions in which the practice of medicine occurs. No form of speech is inherently bad. On the contrary, as part of the total language of medicine, most forms of speech are good and necessary. But it becomes degraded when it presumes to be a complete form of speech, claiming to comprise everything important for the practice. Good forms of speech that are degraded by claims to be more comprehensive than they are include the dominant languages of biology, finance, risk, and law. The speech is degraded because reality is much more complex than any of these languages. It is degraded by presumptions that elide important dimensions of embodied existence. Idle talk is not philosophical sin unless it is a result of obstinate cynicism, skepticism, or cowardice. Idle talk can be a form of rest in some circumstances and avoidance of hard things in other circumstances. The energy required to focus on difficult topics is not sustainable for long periods of time, especially in the context of the often-exhausting experience of disease. Limiting conversation to topics that fit into one of the dominant languages—as when doctors talk only about variations in lab results or small details of a daily plan—can allow mundane relief for a patient who has been thrown into disease and who is enduring significant threats. Languages such as those of biology and technology are relevant and important. They constitute idle talk only when they distract or divert from moments in which deeper framing truths about reality need to be addressed in order to use those languages in a way that fits the goals, purposes, needs, and worldview of the patient. Approaching the most difficult things requires preparation, a kind of readiness to face the uncertainty of loss and the mystery of death. Many people have not spent time facing such things. The experience of being thrown into disease sometimes brings patients face-to-face with fragility, mortality, or loss for the first time. For such patients, idle talk can provide a way to pace conversations about difficult things. It can be a plea for more time, a sign that the patient needs more room to adjust to being thrown into disease. Listening for signals that a patient is asking for time to adjust is an act of respect. It is a recognition of the significance of disease for a

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person, including the tension between a person’s ability to acknowledge disease and the ineluctably linear progression of biology. Part of the experience of disease is the tension between the incremental progression of biological disease in time and our variable consciousness of time passing. Even idle talk that reviews discrete biological facts with no reference to the significance of the facts can nonetheless build toward a nearly inevitable recognition of biological progression in time. Sometimes this leads to a shift in the kind of discussions a person is willing to have. But it can also divert from the truth and increase the awkwardness of idle talk on a significant threshold. Without understanding the dynamics between biological time and a patient’s perception of the arc of disease over time, a doctor cannot be the kind of teacher the patient needs—a philosophical guide and witness to the mystery, strangeness, and significance of the transitions we call experiences of disease. Idle talk among practitioners can be sin if it treats holy things related to patients’ lives, bodies, and experiences in a glib or disrespectful way. A holy thing is set apart. It lends significance to some part of life that is worthy of veneration, reverence, or at least respect. Even when a holy thing is sequestered, it organizes other things around it, revealing their place and priority in our lives. Within a life, one’s holy things may or may not have specifically religious significance, but they do function as signposts, markers of significance in a life. The holy might be associated with a physical place in which one prays in the face of mystery, uncertainty, or adversity. It might be associated with practices such as meditation or philosophical reflection, which bring one to a place of insight, decisiveness, or courage. It might appear as the scaffolding of a world view oriented toward the divine to understand what is most valuable. The category of holiness is outside the languages of biology, finance, risk, and law, but these can still be organized within a larger language of holiness as long as they do not claim to exhaust the significance of the practice. Discussions about how to respond to changes in biology are often necessary and good. But a discussion becomes idle talk by excluding other forms of conversation between patients and doctors, especially when the biology alone cannot reveal the next right thing to do. In contemporary corporate medical institutions, this is the most common way in which languages of holiness, meaning, or purpose are marginalized. They can also be elided because of a patient’s fears or a doctor’s discomfort. Doctors are

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often uncomfortable simply because they lack the skill and insight necessary for richer forms of conversation and decision making. The biology might be compelling, but both the patient and the doctor will be lost if they retreat into the idle talk of bracketed, biological language, while avoiding the languages of wisdom and storytelling in which our fears, hopes, and spiritual-philosophical concerns are expressed. In contemporary corporate institutions—especially in high-stakes, highprofit settings such as intensive care units—this kind of lostness is common. The best of our biological knowledge turns into idle talk when it is sequestered from holy, philosophical, meaning-oriented forms of speech. The complex and sophisticated use of multiple languages in high-stakes settings, surrounded by powerful profit-driven corporate forces, requires the same attention, courage, and commitment needed to master any other long art. Doctors and patients say things, but they also ask each other questions. The quality of an inquiry—scientific, philosophical, or otherwise— depends on the quality of the question. A good question is motivated by a good goal, formulated in language fitting to the object of inquiry and constructed in a way that opens our minds, relationships, and conversations to something we recognize as significant but do not yet understand. Learning to form a good question takes time. It takes time because it requires insight into the experience and goals of another person. It requires nimbleness with language so that questions can be adapted to the history, needs, and priorities of a particular person in a particular situation. Doctors need wise and experienced teachers, along with a lot of practice, to learn how to form good questions in the middle of realities as difficult as human suffering, loss, and death. They must work hard if they want to learn how to hear an answer in a way that meaningfully guides decisions, or that hints at better ways to ask the question. The patient and the doctor must be partners to form questions that address significant realities in language fitting to a particular person in a particular situation. The art of asking of questions in the practice of medicine can be diminished by standardized forms, questionnaires, and lists of prompts that make doctors dull while they try to check all the required boxes to maximize billing, avoid legal vulnerability, and manage institutional risk. This is tragic. Many of the technical details in the practice of medicine are the kinds of things that might eventually be done more efficiently through a combination of artificial intelligence and robotics. But many years are

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needed to teach a doctor to listen for the hints, clues, and insights needed to shape a question and to ask it at a fitting time, reiterating or rephrasing it when necessary. Answers follow questions. To arrive at answers that contribute to genuine discovery for an individual patient, the doctor must pay attention to the long art of asking questions. In the profit-driven corporate world of contemporary medicine, patients must help doctors find the courage, patience, humility, and love required to persist in learning the art of asking questions and caring about the answers to the questions. The questions patients and doctors ask each other reveal their priorities. They also reveal the scope of insight the questioner has already achieved. Just as there is no such thing as a generalizable patient, all doctors begin in a particular situation based on their own experiences, failures, and values, along with the background information to which they have access. In the age of the Electronic Medical Record, a large amount of information is available. Information is often shared between institutions that have the same software systems. Access to this information can be useful. It can focus questions when time is short, and shape questions quickly in a relevant way when a situation is urgent or emergent. This usefulness depends on the accuracy of the information in the EMR. Unfortunately, the information in the EMR is not always accurate, in part because it is entered by people who may not be good at asking questions or listening to answers. Contemporary demands for documentation of everything as proof of its reality is overwhelming. It is time-consuming and often driven as much by billing and legal concerns as it is by optimal patient care. Information— good or bad, true or false—is frequently cut-and-pasted into new notes without reviewing it with the patient. People are often surprised by the content of their record. As useful as prior information can be and as unavoidable as assumptions and agendas are, doctors will ask better questions if they temporarily bracket the information from EMR and spend some time listening to actual patient. In the practice of medicine, the privilege of asking questions is as sacred as examining a patient’s body. Questions are a way of reaching out toward the minds of other people, and perceiving the structures of the worlds stored in their memories. We use questions to reach toward the content and disposition of another person’s imagination. Questions feel for the contours of invisible things that cannot be interrogated with blood tests,

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x-rays, or stethoscopes. The artfully used question is the portal into the mystery and meaning of another person’s story. We all show up physically. Our bodies have shapes, postures, and wounds. Expressions on our faces can reveal, conceal, or reveal by trying to conceal feelings, thoughts, and dispositions that are themselves invisible. Our words, sentences, and silences do the same. With or without an overtly interrogative grammatical form, our questions reach for unknown and un-seeable parts of other people, meaning their experiences of their own bodies, minds, and souls. The privilege of asking questions is sacred because it is a request to enter spaces that are tender, holy, and often difficult for a person. This is why genuine trust is always the condition for asking questions in a way that respects another person, rather being an act of assault. The act of forming or inviting a question is a sacred act, and the manner in which we approach the act matters. The very structure of a question is inextricably tied to a moment of invitation. We can refuse to answer questions unless we are being coerced. Within the practice of medicine there are forms of coercion that can remove the sense of invitation, participation, and respect necessary for the artfully enacted oscillation between questions and answers. Shame is a morally violating coercive force that is common enough to merit our mindful attention in order to avoid it. Because patients are often ill and in need of help, there is a power differential inherent to the relationships between patients and doctors. Illness can compromise a patient’s clarity, strength, courage, and resolve. Humility in meaningful service implies an awareness of being a guest in the life of another person for whom these questions and answers are intimately tied to risk and vulnerability. A question asked from the vantage point of humility opens room for partnership even in the face of power differences, anxiety, and fear that accompany the experience of disease. Doctors must steward the privilege of access with moral integrity. This requires that they interrogate their own questions, their manner of asking questions, and their approach to inviting questions. Every doctor who has the authority to ask questions will eventually become a patient who participates by answering questions. Attending to our shared humanity is fundamental to the practice of medicine. It constitutes one of the most basic ways in which the practice is preserved as a safe place in which we can ask our core questions of meaning and face some of our most tenacious fears.

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Understanding the significance of asking and answering questions is at the heart of the practice of medicine as being in time. These questions and answers allow the practice to be a holy space in which we test our views of meaning in the universe, and in which we learn to serve, to love, to tell the truth, and to be fully human. In our questions and answers we come to understand the function of language, the power of metaphor, and the place and shape of meaning in a good life. Learning the art of questions and answers is how we engage in genuine discovery, whether we are trying to understand the biology of disease, or to understand the larger human experience of being thrown into disease, with everything such experience implies for an embodied mortal creature who is afraid and in need.

X. Judgment, Assertion, and Ambiguity The change measured by clocks, by biological rhythms, and by our perceptions and feelings as we are thrown into disease and our lives are disrupted are all relevant to the practice of medicine as being in time. Time is the condition for the unfolding of events. As a matter of pure binary logic, time leads inexorably toward one or the other of two mutually exclusive possibilities. The cancer is either cured or not cured. The leg is either amputated or not. A person either lives or dies. Though decisions are always made against the background of the eventual certainty following from binary logic, we cannot avoid uncertainty in decision making before the outcome occurs. The practice of medicine as being in time comprises many significant moments of decision making. Good practice includes the work of knowing what can be known, seeing what can be seen, hearing what can be heard, and imagining both the fullness of an as yet unknown future and the fullness of an unfamiliar story that is the inward context of another person’s embodied experience. When this work has been done, the practice of medicine proceeds, moving forward in time through judgment, assertion, and ambiguity. The place of these three concepts in the practice follows directly from the art of questions and answers. Judgments are made in light of our awareness of true things in a room and the significance of these things. Assertions are always made as-if our judgments are correct: they are the best we can do in the face of uncertainty. Ambiguity, which is so common in the practice of medicine, demands nimbleness, humility, honesty, and patience, because things might become clearer in the future. The confidence of our assertions can sometimes seem at odds with the ambiguity of a situation. Divergence between confidence and ambiguity can undermine trust, but when the ambiguity is unresolvable, the confident assertion can also bolster waning resolve if we must act urgently. Deciding whether to acknowledge or mute ambiguity is a matter of prudence. Sometimes enduring ambiguity without naming it explicitly is an act of courage for a doctor who is trying to find the best path while helping a patient to navigate fear. Judgment is a transition event. It is a move from the act of gathering information in the clearing to the acts of deciding and pronouncing, which 135

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changes a person’s world. Judgments derive from and shape our views of the world and our conclusions about the meanings of events. It culminates in a sense that the time has come. Judgment is an acknowledgement of the limits of time and the value those limits impose on our choices of how to occupy time. Biology progresses according to laws of efficient causality. It is altered by interventions that make use of efficient causality in medias res. Biology does not pause, waiting for a judgment to be made about its nature, or about the changes we hope to make in its trajectory. This is one of the fundamental senses in which medicine is a practice that is inseparable from being in time. Biology works inside a linear form of time grounded in the most basic kind of change that occurs in a series of causally linked events. This linear form of time is conceptually fundamental to the nature of the practice of medicine, insofar as the object of the practice is the human body. But it is also important because of how deeply it contrasts with the human experience of lived time. Our experience of this contrast illuminates our freedom and the limits of our freedom. It also reveals the urgency of our pragmatic expressions of meaning following from the timelimited choices we make about our priorities, values, and commitments. The order of biological time forms the banks within which the time of lived experience flows, revealing the inescapability of judging a situation, since refusing to make a decision is always to make a decision. Doctors are expected to make judgments. It is part of their role. The way we assign roles that include the authority of judgment indicates the importance we ascribe to that power. People to whom the role is given must have certain qualifications and character traits. Depending on the kind of judgment assigned to a role, the people who fill the roles must to go to law school, medical school, divinity school, or mechanic school. We look for honesty, courage, endurance, and integrity—traits that allow us to trust someone else to make judgments for us, perhaps because we do not have the needed knowledge, or because we are not legally allowed to make the judgment for ourselves, or else because we are scared and cannot see all the relevant details. We hold people accountable when they occupy roles attached to the expectation and authority to judge. We do not want them merely to make judgments: we want them to make good judgments. This includes having a kind of wisdom regarding what constitutes the goodness of a judgment. The goodness of the judgment might be determined in relation to a body

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of precedent, as in law. It might depend on a body of knowledge as in mechanics or the biological aspects of medicine. It can also relate to goals, requiring imagination and the ability to listen well. The completeness of what is gathered in the clearing and the skill with which these gathered fragments are connected into a meaningful whole affect the quality of a judgment. Every case must be evaluated against the background of precedent, factual knowledge, and the formal expectations we associate with such roles. In the practice of medicine, this certainly includes biological information that provides insight into the causes of physical distress or dysfunction. But beyond relevant biological facts, many particular aspects of a person are important for judgment. The other people who are part of a person’s experience, story, and support are important sources of information and insights that shape good judgment. Prudence is the virtue most closely associated with the ability to gather and connect relevant pieces of information. Prudence in the practice of medicine is something like seeing the truth in a situation, or seeing the truth of a room through attention, mindfulness, imagination, improvisational nimbleness, curiosity, patience, and love. Making a judgment in the face of uncertainty involves important risks—risks to the patient, risks to the doctor, and risks to the institution in which the practice of medicine occurs. The most pronounced risks are those faced by the patient, in whose body the consequences of the judgment play out. The patient must come to intimate terms with time’s limit and with their own contingency. Important dimensions of their experience as embodied creatures are threatened by disease, but also by risks inherent in interventions for disease. Medical error is a leading cause of death, and misguided advice unconnected to the truth of a patient is a leading cause of suffering without genuine benefit and loss of meaningful time at the end of life. Because uncertainty is always part of a judgment, if the outcome is poor, unexpected, or undesired, regret about a judgment is common. Those who make judgments in the practice of medicine carry the consequences of their judgments with them. When things do not go well doctors face their own limits, the limits of their practice, and the grief of another person’s suffering. If practices for coping with such grief and loss are not incorporated into the work, the burden can lead to moral distress, fear, or coping methods that serve neither doctor nor patient well.

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Based upon judgments, doctors make assertions. Assertions lead to actions, which in turn materialize some possibilities and eliminate other possibilities. They lead to a state of affairs that is more certain than the judgment upon which the assertion was based. Judgment is tentative because of unavoidable uncertainty, but assertion has the feeling of being definitive, because it defines the reality that will follow the transition from judgment to action. Action is binary because something either happens or it does not, but possible outcomes are not symmetrical. If something happens it cannot be made not-to-have-happened. If something does not happen, it still might happen in the future, unless circumstances change and it becomes impossible. Not doing something allows time to pass, during which we might still do the action as long as it is still possible. If we choose not to intubate a patient, we might still intubate the patient in the future. But if the patient suddenly dies because we did not intubate, not acting becomes an action that cannot be revised. We cannot intend to act unless we assent, and we cannot assent unless we judge. If we wait to make a judgment, we are waiting to act, and this is an action of the something-not-happening type. The progression of a biological process occurs in time fitting to efficient causality. If our judgment is delayed by uncertainty about final causality or purpose, the biological progression does not wait for us to achieve clarity. When the manifestations of efficient causality and those of final causality diverge, we can feel a sense of urgency or even panic. Assertions are pictures of the way things are, and the way things can and should be. They are a source of motivation to move from how things are now to how they can and should be in the future. To make an assertion reliably, we must organize the elements of our judgment in a way that is clear, capable of being articulated, and actionable. Assertion requires the capacity to place judgment and its consequences into language. The language must bridge the technical and scientific aspects of the judgment with the truth of whatever emerges though the particulars of an individual’s story. It must be accessible to everyone who will participate in the action— the patient, the family, and the members of the medical team. Assertion gathers judgments together and yields a practical conclusion that leads to a new action, or else stops an ongoing action. The doctor’s skill determines how well judgments are gathered together and plans of action are formed, but the persuasiveness of the assertion also depends on how a doctor uses authority and language to make it. Authority can be a function of one’s

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history, credentials, or institutional position. Effective assertion is an act of leadership that requires trust, confidence, and insight into the ways one’s words and manners are perceived, and the impact of these on the emotions of other people. Assertions can be instruments of service, instruments of silencing, or even instruments of violence. In all cases, assertions are acts of power— real power, or else the desire for power in the face of perceived or actual powerlessness. Assertion can include statements about how we think things ought to be, or how we wish them to be. Such statements are poignant because they express our sense that however difficult the next decisions will be, and whatever the consequences of our actions, we wish we were not in the situation. The judgments, assertions, and actions that arise from a difficult situation are not themselves the cause of the situation, and they do not imply a desire to be in the situation. Ideally, assertions place everyone on the same side and they identify the unfortunate situation as the common object of our concern. But when assertions are made by someone who is tonedeaf to the complexities of relevant non-biological realities of patients and families, the assertions can silence the truth of the room. This is especially true if the one making the assertion is perceived as having power, whether that perception comes from institutional structures, from a sense that the urgency of a situation somehow makes mutual respect optional, or from arrogant assumptions made by the doctor. We want to think of the confidence and of an assertion following from the reliability of the judgment. We hope for some correspondence between the force of an assertion and the firmness of the judgment upon which the assertion is based. But the force of an assertion is often determined by more than the quality of the judgment and the expertise of the one making the judgment and the assertion. Its force can also be determined by the personality of the one making the assertion, or by the perceived urgency of the situation. In all cases the force is something we feel at the nexus of biological progression in time, and the expansion and contraction of lived time as it is experienced in the context of disease. In the midst of these many dimensions of force some things remain changeable. For example, the doctor and the patient can pay mindful attention to each other’s perceptions of reality and work to find a language that adequately expresses the shared parts of their reality, however ambiguous interpretations and conclusions might seem.

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Ambiguity is always present in the practice of medicine. In the same way that theories are always underdetermined by data, judgments are always underdetermined by what is gathered in the clearing and assertions are always underdetermined by the adequacy of judgments. We cannot know with certainty that the information on which we base our judgments is true or complete. Even if our judgment is well-informed, synthesizing the parts of reality we discover in an optimal way, we still cannot be sure that our assertions will lead to the best course of action. Ambiguity is always present in the practice of medicine because ambiguity is always present in human action. Time is limited, and however much we wish to continue to gather information in the clearing to diminish ambiguity, time is a background hum that continues to increase in volume, pressing both the doctor and the patient toward a decision about how to act. Because ambiguity is inevitable, learning to live with ambiguity is an important part of the spiritual dimension of the practice of medicine as being in time. Learning to practice medicine among ambiguities is a skill that draws on many aspects of a doctor’s character. We can only learn how to tarry with ambiguity if we are willing to let go of some things, such as our resistance to uncertainty. When Descartes carried out his great experiment in doubt, he introduced an impossible criterion for indubitable knowledge, for certainty. He doubted everything that could be doubted, until he arrived at something he could not doubt—the fact that he was doubting. Because doubting is a form of thought, he could not doubt thinking. Because thinking requires a thinker, he could not doubt the existence of someone thinking—in his case, himself. This is how he arrived at the formula cogito ergo sum—I think, therefore I am. But that is all he established, because his mechanism for recovering any other aspect of known reality is dubious. Nonetheless, many clinicians still lean on a cartesian version of certainty as the ideal standard for knowledge. That standard leads to enormous difficulty for doctors and enormous suffering for patients. This version of certainty must be relinquished. Practices of mindfulness, patience, and truth-telling can help doctors and patients accept the limitations of knowledge without becoming paralyzed. Our sense of what constitutes community in the practice of medicine as being in time can be enriched if we recognize the impact of ambiguity in a patient’s experience, the courage required to act despite ambiguity, and awareness that everyone involved in the practice of medicine experiences the pervasive presence of ambiguity. We surely know that we are all

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in this together. None of us can escape ambiguity, nor can we escape the necessity of making important decisions in the face of ambiguity. If we grieve at having to make important decisions without certainty, we can at least share our grief and fear. The necessity of facing risk when a situation is unavoidably ambiguous affects the doctor and the patient in different ways. But doctors and patients can work together to better understand what is difficult for each other in their respective roles. And of course, doctors only temporarily occupy their vocational roles: eventually every doctor assumes the role of patient. Doctors and patients can build a partnership by acknowledging that ambiguity is difficult, but common to everyone. Because ambiguity results in part from how partial our knowledge of the world is, acknowledging ambiguity can motivate humility that allows many different perspectives and insights to be expressed. Having many voices in the clearing strengthens the sense that our knowledge is as complete as possible, that our assertions are as reality-based as possible, and that the actions following from judgments and assertions are the best we could have chosen given the resources we had at the moment of decision. Admiration for the choice to act in the face of ambiguity can sow respect among participants. These are simple points. But attention to simple points can make big differences. The practice of medicine is ill. We need some rudimentary training and a few small, early wins.

XI. Buried Over The practice of medicine as being in time occurs in a space where some of the most important human events occur. But it can be buried over and its true nature hidden from view. It can be hidden from the patients and from the families. It can be hidden from the doctors. Burying over the true nature of the practice of medicine is an act of philosophical significance. It points to a communal effort to tell a partial story about embodied human existence in the face of uncertainty and fear. Even our truest stories are only approximations of some part of reality. Though burying over can truncate parts of a story, it does not necessarily make the story worse than other stories: it depends on the purpose of the story and the reason for the burying over. Sometimes we cannot endure hearing every true part of a difficult thing, or least not all at once. Burying over one part of a story might make other true parts of a story bearable. Burying over is an act that may or may not be overtly intended. If it is intended—whether on the part of a patient, a family, or a doctor— there is almost always an element of performance, with a kind of honed restraint, as actors modulate their expressions on stage to achieve a certain effect. The structure of hiddenness is a tenuous structure, and situations in which burying over plays an important role are delicate. Care must be taken to avoid inadvertent exposure of truths that cannot yet be endured. Burying over can be a form of defense against perceived threat. Disease threatens both the body and the equanimity of the patient. Burying over will not change the threat to the body, but it can alleviate the threat to equanimity, at least for a time. If threat to the body is not urgent, there might be no harm in delaying a decision about treatment, especially when treatment is not the only reasonable choice for a person. Defense against threats to equanimity can be necessary while a person adjusts to a new reality into which they have been thrown. Burying over can be an act of defense against the harm one’s family might experience in the face of loss. Patients often protect their families from the full truth about a serious disease, just as families and doctors are sometimes inclined to bury over details or difficult aspects of truth in order to protect a patient who is afraid. This can temporarily preserve not only a person’s equanimity, but also a person’s ability to work, focus, or care for 143

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others. When disease is unchangeable and death inevitable, a family might ask how to avoid assaulting other good things in the patient’s life—their loves, joys, hobbies, or work. One reasonable answer to this question is to bury over. Even if the strategy is not effective or lasting, the desire to avoid additional threats to good things in a patient’s life is at least interpretable as an act of love and care. But there are also situations in which burying over the truth leads to harm. In such cases it is closer to an act of cowardice on the part of patients, families, and doctors. When disease has a biological basis that is changeable, burying over can lead to delays in treatment and missed opportunities to be released from disease. We are not solitary individuals. We are embedded in families, friendships, work places, and communities. Other people can be impacted by how we negotiate the reality of disease. Beyond the biological consequences of burying over important things, a conspiracy of silence can ensue in which one person wishes to avoid facing a reality while another wishes to talk about it, and this can lead to isolation and a loss of trust. When doctors bury over a part of the truth, ostensibly for the sake of protecting a patient in some vague way, they are sometimes motivated by their own fear or discomfort at the prospect of telling the whole truth. This is a sign that a doctor needs to do the hard work of facing the threat of personal vulnerabilities provoked by a patient’s disease. Burying over can be motivated by discomfort with the grief, anger, and disorientation to which doctors often bear witness. But such uneasiness can eventually lead doctors to disclose, and perhaps overcome, their own cowardice or fear. Burying over can be an act of corporate greed as temporal human fears of aging and death are turned into advertising strategies. When television ads tell viewers to ask their doctors if a certain treatment is right for them, the corporations are using fear to make money. Side-effects are rapidly rehearsed, or else half-sung in a soft, concerned, comforting voice. The ads create the sense that this medicine provides an answer your doctor might not have considered. The imagery is either irrelevant to the ostensible condition treated, or else it is the pharmaceutical company’s ideal portrayal of lives filled with happiness, laughter, adventure, and love. “Ask your doctor if happiness, laughter, adventure, and love are right for you … Umbilicophilomab.” Institutional mottos often include the words hope, saving, cure. The hope to which these mottos refer has no explicit object. But it does imply

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a hope that our institution can succeed where other institutions have failed to fix, cure, or save you. It does not refer to the hope that our institution will remain steadfast and present, helping you to embrace loss and mortality as time inexorably passes by, once you are thrown into the stark reality of your own limits and those of medicine. Corporate burying over uses an implied promise that our institution can keep you from being buried over. No wonder corporations are interested in medicine: few businesses can advertise using the statement, “Buy our product and we can keep you from being dead.” Burying over can be a sign of lostness. When we are lost, we do not know where we are, we do not know which way to turn, we do not know what to do next. When we are lost, we need help, we need direction, we need a guide. If someone seems to know the territory, we are more likely to listen to them when we feel lost. If a stranger seems to know the territory, we freely and gratefully give them authority in our lives. If lostness is the only alternative to trust, we will ignore the oddness of placing authority in the hands of a stranger with a badge, a white coat, and a confident demeanor. We accept things in the state of lostness that we would not accept in the middle of so-called normal life. But unlike the geographical details of a national park or a foreign city, some of the realities that are a daily part of the practice of medicine cannot be known by anyone. We cannot know the future. We cannot know that risks will be avoided. We cannot know the consequences of our choices until they occur. We cannot know what death is. We bury over the unknowable when someone appears as a guide who is not-lost, even if the appearance of not being lost derives from institutional position or arrogant and unreflective self-confidence rather than genuine knowledge or insight. But even if we are all lost, being lost together is easier to endure than being lost alone. Burying over can be a form of grief. Grief reveals that burying over is not oblivion, but is rather a unique form of awareness. Though burying over is a kind of denial on its surface, grief reveals that burying over is unsuccessful at keeping the buried thing from re-emerging. Burying over discloses how much we wish the buried thing was not real. Grief reveals that burying over cannot permanently hide things, and it intensifies the reality that we want the buried thing to remain buried, the way covering our naked bodies with a tiny piece of cloth exposes our discomfort at being naked in some circumstances. A person who buries over something as a

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form of grief is calling out for tenderness, for a prudent recognition of burying over as one way of saying how sad or afraid a person is. We sometimes choose painful consequences for the sake of another hoped-for good thing—infertility, for example, as a consequence of potentially curative chemotherapy for cancer. Burying over of the loss of fertility allows breathing room, time to grieve. Such burying over is a way of grieving that allows the grief to be real, while also allowing a person to act, rather than to be paralyzed. It can even allow a person to be grateful for the good, rather than merely confused by grief at the loss. Doctors must recognize the good in the act of burying over in order to respond well to patients when they ask for room to breathe. Doctors must also understand where burying over can harm—especially when the harm comes from their own lack of insight, fear, or exhaustion. The language of burying over is strange to many doctors, and because of the strangeness, topics of this sort are often ignored in training and practice. But we must be patient with strange language when we are talking about strange things. Burying over can be an act of faith—naming something that is not yet real, but that might be real if, say, a miracle occurs. It can be liturgically revealing in a way that points beyond data, including astonishingly persuasive data such as the presence of a dead body at a funeral. Within a religious framework (whether or not it is a theistic religious framework) liturgical acts of burying over ascribe meaning to certain things by calling the buried thing mysterious, and giving it back to mystery through the process of burying over metaphorically and literally. Liturgical acts assert authority over the unknown by assigning the state of being-buried-over to a thing, relieving the thing of its power, or at least situating its power in a way that is consistent with other powers and verities. Liturgical burying over can be a communal gesture of forgetting, leaving something behind. Burying over can also be a liturgical gesture of not forgetting, granting the buried-over-thing an ongoing place in communal memory. The formalized structures of liturgy in burying over gives guidance to the lost. They can give guidance about what needs to be buried over, and how to carry out the burying-over. Liturgical responses and approaches to burying over can be thought about communally in times of calm, and revised as wisdom grows. Burying over can be an act of respect for the fear of another person who is frightened at the thought of being buried over. It can allow the time

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a person needs to excavate something alien and unfamiliar, but real and true. Fear can be paralyzing, and burying over can be a way of reclaiming time that is unpopulated by paralyzing fear. When someone is thrown into disease, other fears that have been buried over can begin to surface. Relational work, such as the need to be forgiven or the need to forgive, can emerge with urgency after being buried over the years. It can relieve the paralyzing terror of something like dying, at least for a time, while a person excavates other important buried things in the cauldron of disease and impending death. Keen spiritual and philosophical insight are needed to wisely navigate the temporary choice to bury over the outcomes of incurable disease in order to attend to other buried-over realities from the past in a way that adds to a person’s flourishing. The existence of these multiple dimensions of a person’s life and truth must be recognized before a doctor can be a helpful guide or partner in these difficult seasons of life. Doctors regularly face the inexorable progression of biological processes in time. They know that biological progression imposes limits over which we have little or no control. But they must understand more than biological limit if they want to be wise guides when a patient has a pressing need to address various buried-but-emerging dimensions of a complex life. In urgent circumstances, some things might not be able to be addressed because of a lack of time. Priorities must be established, and only a doctor who understands the practice of medicine as being in time can be genuinely helpful in these situations. Burying over can be a theatrical performance with a purpose. Some communities expect a kind of burying over as an act of bravado. Others expect it as an act of delicacy and sensitivity. Sometimes a person or community fully acknowledges the implications of an incurable disease and, having done the work, they want to enjoy a stretch of time that more closely resembles whatever they call normal. A family or community can then give a gift to their loved one who is sick, suffering, or dying by filling their days with things they most enjoy. Collective healing can also occur when a community prescribes burying over as a gesture of mercy or respect: sometimes we simply have to let go of past things, however important they might be, so we can focus our limited time and attention on the most important things. In such cases, burying over becomes a communal performance that consolidates the community’s identity as it stands against the thing they are releasing, underscoring the place of the buried-

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over thing in the larger context of what the community holds most valuable. Claiming the buried thing as buried-indeed can be a profound act of grace, relieving the sick or dying person of great suffering through forgiveness. Burying over is fitting in the care of the dead. When a body is dead we bury over it so that it can decay without harming members of the community who have not yet died. The same is true for a community or institution that has died. Such burying over is a way of remembering, while also moving on from life lived in relation to this person (or community or institution) to life lived without them. It allows a future that continues to have some relation to the dead that is in time, but that does not obstruct new possibilities: the dead are present as having been. Burying over the dead is a way of keeping them present without denying that they are dead. It creates a memory-place for the dead and for the meaning of death. The dead remind us of the past parts of the story about how we came to be who we are, where we are, in the way that we are. By burying over the dead, we are also reminded of our own future, and the future of every community and institution. Burying over as a way of caring for the dead reminds us of what being dead is and how different it is from being alive. We are creatures who cannot escape mortal embodiment and the movement of time. Noticing the difference between being dead and being alive can heighten our sense of life, which otherwise can be dulled by forgetfulness. Burying over the dead can be an expression of profound gratitude for life. Burying over can be an act of accepting the limits inherent to the lives of creatures like us. We cannot change the reality of death. Burying over acknowledges the corpse as a corpse: we do not act this way toward living things. Accepting that a corpse is a corpse in the act of burying over can be part of the process of achieving peace. The peace does not have to include gratefulness, since we can come to peace with something we desperately wish had never happened. But if the peace discovered in acceptance extends to reality as a whole, we might discover deeper gratitude for the small beautiful things and people we meet. We learn to see small forms of good that we might otherwise have missed. We are often limited in what we can bear in the moment, and we are limited in how long we can bear suffering and loss. Burying over can be a way of saying we need to rest a while before moving ahead because our emotional, spiritual, or physical energy is limited. Sometimes we must buffer the power reality has over imagination by turning to a fiction for a

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time. As long as the buried over thing remains buried over by this fiction, we can rest and heal. We can prepare for a return to the unavoidable, because the burying over will eventually fail, and the buried thing will reemerge, forcing us to face it. Burying over is limited as the sole strategy for enduring. Other spiritual and philosophical strategies are needed. The thought of being buried over is terrifying. Burying over and loneliness are kin to each other. Burying over leaves us with many unanswered questions. It is one way we tarry with the unanswerable. Sometimes this is welcomed. Sometimes it is merely endured. There are many ways we can respond to the limits of our knowledge. Unanswerable questions can be buried over to avoid wasting time on such things. We will never get an answer, so there must be a better use for our limited time. Or we might bury over unanswerable questions because it is agony to live with them when the stakes are high. So many of our questions are about death and about the future in general. We can publicly bury over such questions as a way to keep them private. The burying over is a public act. But within our own minds we rehearse the burial and sit with the thing we publicly buried. Private tarrying with unanswerable questions can lead to a state of wonder. It can lead to peace and humility. It can also lead to a sense of isolation, loneliness, and fear in solitude. When we see that burying over an unanswerable question is a sign of just how unanswerable some questions are, we still learn something about the truth of the human condition. We can choose to embrace that truth or not. If we choose to embrace it, we might realize that the burying over has done its work, and we can bring the buried thing back into the open.

XII. The End The ambiguity of the word end is fitting to the practice of medicine as being in time. The discovery of one’s reason-to-be in the midst of disease, the goals that arise from and express the value of a life, and the temporal limit we call death all converge in medicine when the practice is understood for what it truly is. The end of a life is its purpose and its finish. The end of a life is its purpose in light of its finish, its finish in light of its purpose. Every limit encountered in the practice of medicine is a limit conditioned by time. The finish of a life dissolves a person’s relationship to time as lived in this embodied life. Whatever a person’s measure of the meaning and value of a life might be, time is the one measure shared by every life. The end, as life’s finish, gives passing time one kind of significance. The end, as life’s purpose, gives time another kind of significance: time is the currency we trade for the acts that constitute the legacy of a life. The practice of medicine as being in time attends to embodied people who are shaped by time. Decisions are determined both by our purposes and by the limits of our bodies’ duration. Patients and doctors must approach decisions with this larger view, rather than through the myopic view of naturalistic reduction. The practice of medicine must also articulate its own end in fairness and transparency to those who have given over their trust. This articulation of ends has two senses. The practice has a purpose, though the purpose can be obscured, diminished, warped, or replaced. Its goal, its end, its telos depends on the worldview inside of which it is practiced. Its end might be something close to the care of mortal, embodied persons in their encounter with the reality of being embodied. Its end might also be linked to vaguely populated concepts of progress disguising a more fundamental desire for money and power. The end of the practice of medicine can be articulated in terms of its own limits, meaning not only its fallibility and the incompleteness of its knowledge, but also the limits of its own purpose. For example, when a patient dies, the care of the dead body is handed over to others outside the practice of medicine. The same is true for ongoing care of the family and community who loved the person who died. The practice reaches an end, 151

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because of the limits of its purpose, whenever someone wants to do something to their body that falls outside the goals of medicine—committing suicide, for example. When resources are scarce, a practice defined only in terms of procedural or pharmaceutical intervention reaches a more pragmatic kind of end, which can also push the practice of medicine to become truer by redefining, or recovering, a sense of its deeper purpose. Knowing the true ends of the practice of medicine as being in time can avoid much suffering among both patients and doctors. Decisions in medicine only make sense for people when they are made in relation to ends as goals. Our transience, contingency, and mortality often become most clear to us in the experience of being thrown into disease. When we are forced to face the nature of our limits, we can achieve clarity about our end in terms of our sense of purpose as we continue to spend our time day by day, hour by hour, moment by moment. Even as we approach death, talking about dying means we are not dead, which means we are alive, which means we still have time to spend. We should spend that time purposefully. This may have nothing to do with productivity. In light of our end, spending time purposefully might mean finally sitting in silence, doing nothing at all beyond paying attention, breathing in and breathing out. Decisions made as though the body is nothing more than a biological machine can only accidently coincide with our true sense of purpose. If mere duration is a person’s primary goal, viewing the body as a machine and making decisions based on biology makes sense. But if a person’s goals and their sense of their own ends are at cross-purposes with interventions required to maintain biological duration, these ends have priority over biological goals. This is related to something that is often mentioned in clinical settings, but rarely articulated fully—the concept of autonomy. In contemporary medicine where the body can far outlive purposeful consciousness, the practical impact of so-called autonomy and the role of a person’s stated goals or ends can be complex, both because they must be interpreted and because they can be challenged. The practice of medicine as being in time is ordered by narrative structures. It has the beginning-middle-end form of a story because its purpose and work are inextricably tied not only to bodies that have an arc from birth to death, but also because the practice is tied to spiritual, conscious people whose purposes, goals, and ends arise from within their story and are articulated through their story. The practice of medicine itself also

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has its own history, which is a story that can be told in many ways. The way this story is told affects the practice of medicine as being in time. It affects both doctors and patients, often in different ways depending on how patients’ stories relate to the stories doctors tell about themselves. There is a long story about the changes in medicine wrought by its turn toward, and incorporation of, the scientific method. This story is often told in triumphalist terms that elide the moral, intellectual, and spiritual lapses and harms that have accompanied the history. At the same time, many great advances have occurred that restore function, prevent disease, lengthen life, and relieve suffering, and this despite the variables among patients and the variations in the skills of investigators and doctors that make medicine’s claims to scientific rigor dubious. The story includes an economic history, a political history, and a social history, all of which are filled with morally devastating deceptions, injustices, inequities, and failures. Understanding the central place of stories in the practice of medicine is necessary for the practice to be good. Understanding the story-form answers to the questions about how we got here, is likewise necessary for the practice to be good. On a smaller level, a visit, a procedure, or a course of treatment has an end. The arc is always toward the end as completion—in order to move on to something else. The meaning of the end is inseparable from the reality of death when there is no possibility of resolving disease. The meaning of death becomes the end once we accept that everything remaining in our life is conditioned by that final, impending event. In one sense, for a mortal embodied creature, everything relates to the end as death, because death is the limit of time, which motivates us to populate our limited time with acts that are worth the time we trade for them. But day to day, our acts can be carried out with no overt consciousness of mortality as the limitedness of time. The practice of medicine can orient itself toward the recovery of function or the removal of obstacles to goals. These can be experienced in a narrow field of time that brackets and excludes the approach of death. Nonetheless, all obstacles and functional limits addressed by the practice of medicine derive their character and significance from their relationship to mortal embodiedness. Because of this, even when the practice of medicine is oriented toward some small, immediate, local goal, it is also always related to the end defined by death. This is why the practice of medicine as being in time is a philosophically potent nexus of human ends that comprise a well lived life.

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The practice of medicine as being in time is the study of limit. It is a cauldron in which questions of human purpose are always relevant, whether they become clearer or more bewildering. The practice of medicine does not create the meaning or the absence of meaning. It is attention to the presence or absence of meaning in light of our unavoidable limits. Attention is mindfulness, a kind of intention in which meaning or its absence is brought into focus. The motive for attention to meaning or its absence might be an immediate need for concrete decision making or a desire to act in a certain way. When we focus attention on the ways meaning or its lack is clarified for the sake of decision making, we learn more about the ordering role that meaning or its absence has in a life. Attention to the reality of limits is the central philosophical force of the practice of medicine. It is the clarifying power that leads to focus and concentration. A lack of attention to the reality of limits dissipates our focus and dilutes mindfulness. The practice of medicine as being in time studies limits in time— biological limits in time, as well as vocational, relational, and spiritual limits in time. This is the foundation of the philosophical power and identity of the practice. The idea of an end is the idea of a limit, which is the condition for form. Form determines the possibilities available to a thing. The limit of form is the condition for beauty. Beauty and suffering meet in the ambiguity of the end. We suffer when we meet limits, whether these are limits of function that prevent the fulfillment of desire, or the limits of our ability to stave off the dissolution of the flesh when alien forces invade and throw us into dis-ease. And yet we can only see a thing that has limits, a thing that has a form. The form of a thing is defined by its limits, and beauty can only appear through form. The limit of a thing is the end of a thing, in the sense of both its telos and the boundaries of its form. The practice of medicine as being in time is a study of limit, a study of form, and a study of the beauty that appears through form. It is also a study of the suffering that comes from the limits of form that also limit function. Its purpose is oriented toward ends in every sense of the word. Without mindful attention to limit, form, beauty, suffering, and ends, the practice of medicine as being in time loses its own form, limit, and end. The practice becomes lost. Death as the end of life is also the end of our knowledge. We do not know what death is. In principle, to say there is nothing after death is to assert the least provable statement possible. A much more scientifically sound idea is that death is not the end of the story. The data we have

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supporting any conclusion about what happens at death are the thousands of cases in which people have met the criteria for death, or come very close, and vividly experienced something they take to be heaven, the divine, people who already died, or some other variation on an afterlife. These witnesses may or may not be mistaken in their interpretation of the data. But the data itself, derived from experience and observation, is not empirically contestable in principle, no matter what speculative things might be said about the putative mechanisms undergirding the experience. There is zero evidence supporting the alternative interpretation—namely that there is no afterlife, and that the interpretations of the data suggesting otherwise are mistaken. In principle, we can never have data supporting the absence of an afterlife, because this would require that an observer die, experience annihilation, and report back. If there is no evidence to the contrary, the interpretations of the data offered by the people who actually had the experiences are prima facia reasonable. This means that skepticism regarding the afterlife can never be more than an assumption with no data to support it. More than this, one can only embrace skepticism by making such assumptions in the face of data that constitutes prima facia evidence for an afterlife. We can embrace an afterlife in light of the data we have, or we can offer compelling reasons to be agnostic, but we cannot assert that there is no afterlife except by making a brute assumption with zero evidence. When the end comes, it often feels uncanny. It can seem impossible even as it inexorably occurs. If we think of being dead as not being at all, the approach of death can be discordant and bewildering to our awake, integrated, memory-filled, loving, longing consciousness that still feels like a singular entity to us. When a piece of music reaches the end, its ending feels fitting, even if we wish the experience of the music was not over. A good ending gives a sense of completeness. But if the music suddenly stops in the middle of the piece, before the chords and themes resolve, the effect is very different. Something feels unfinished. The unresolved parts of the music hang uncomfortably in the minds of the listeners. The difference between the experience of music and the experience of impending death is that the score interrupted by death is our very life. We are the music. When death approaches in a way that feels misplaced, early, or abrupt, we are profoundly disturbed. We sense that something is wrong. But the sense of something being wrong requires a sense of what right would be. This leads us to an important question: Why would we expect

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things to be a certain way called right? And even if we do not think of death as the end of our existence, but rather a transition in the form or state or experience of being, the end is still uncanny. The experience of death is unprecedented for us. It is always mysterious, and for many people it is frightening. The meaning of our end raises questions about the meaning of suicide, both for a person considering suicide, and for a doctor caring for someone who wishes to die in this way. We cannot change the mysterious and uncanny nature of death’s threshold through investigation or experimentation. We only learn about dying by dying. But up to the point where we no longer have experience, we can assert control over the time of our death. Sometimes we rely on medicine to delay the time of death, whether we mean by “death” the end of meaningful conscious experience, or the end of mere biological activity in the thing we call our bodies. If we come to a point where we have no means to delay the end, we still have some control in the sense that we can make it happen sooner, and on our terms, through planned suicide. This possibility can bring comfort to people who are frightened of pain or the loss of control at the end of life. Some people are afraid of losing control over bodily functions, leading to embarrassment or shame. Others are afraid of losing control over the mind as it forgets, or hallucinates, or becomes disoriented. Still others are afraid of having to turn over control to other people when they can no longer move, or feed themselves, or change their own diapers. The practice of medicine as being in time requires a kind of wisdom regarding these fears, including wisdom about its own role in suicide as a remedy for these fears. The idea of death can be comforting for many different reasons, each dependent upon the meaning of the end understood as the goal and purpose of being human. Death is not always bewildering or disorienting to people surrounding a dying person, nor to the one who is actually dying. For those who do not believe that death is the end of existence, the approach of death can feel like an adventure, a journey into something new. For those who have come to terms with their own mortality, and who have embraced death as a reality that is expected and fitting, it can be orchestrated as an end that is more like the ending of a piece of music. This acceptance—this living orientation toward the end that integrates death into the arc of life— is itself a kind of philosophical control. Socrates said that philosophy is preparation for death. He might have meant that philosophy gives us courage to embrace the inevitable with

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equanimity and intentional resolve. He might have meant that philosophy is the practice of letting go. Or he might have meant that philosophy is a way of living truly, living continually in the light of this uncanny and unavoidable limit that constitutes the condition, circumstance, and form of what is called the story of a life. This is a mature form of control because it does not depend on changing the unchangeable, but rather depends on accepting what cannot be changed and living in relationship to reality, whatever it may be, in a way that alters the control death has over our experience of life. This is a form of truth-telling, remaining open to reality and living with the grain of the universe that is our only home. The practice of medicine as being in time includes continual movement toward this more philosophical version of agency for mortal, embodied, conscious people. As a pediatric oncologist, I have helped many people near the end of life. The experience has changed me as a person. Before I became a doctor, I had never seen anyone die. I had a lot to learn. Now I cannot count the number of dying people I have been with. Death used to feel like a vague future possibility. Now I live my life in light of my awareness of death. I think that is a good thing. My dying patients help me to live a truer life, to delight in small wonders, and to grieve places where I hurt others. Patients who are at the end of life often tell me about things they have loved or regretted in their lives, and things they wish they had time to do. I cannot be at the bedside of such a patient and not see the choices and opportunities in my own life differently. Denial is tenacious, but the regular experience of death is one way to overcome inattention and forgetfulness. It is a way into gratitude for all the beauty that shows up every single day. As I have changed, so has my experience of dying people. I have learned to be present and to listen to the needs of the person in front of me. Sometimes they need silence. Surprisingly often, the patient and the patient’s family need to laugh. Until I had the privilege of being with dying people, I had no idea how common laughter is in the middle of sorrow. Everyone should be able to learn about dying as a part of life. Death is one of the only things about the future we all share, but we almost never see it. The hiddenness of death is unfortunate. So many people die in the hospital where the rules are, “Don’t go behind this door. Don’t touch this. Know your place.” That is shifting because of hospice and palliative care. Hospitals must become more hospitable. Medicine does not own dying. Human beings preside over the holy mystery of dying.

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We like to think we can fix all sickness. The optimism is stunning, and our success at fixing problems has made it easier to embrace the illusion that we can also control death. We cling to this illusion to the bitter end. By doing so we often make the end bitter indeed. We should ask ourselves why we want to rid ourselves of death. Do we really never want to die? It understandable that a first answer will refer to the people we love, the work we enjoy, the goals we wish to accomplish. These are lists of wonderful human-sized desires, hopes, and dreams. But such lists of good things miss the explicit acknowledgement of one deep reason we never want to die—the mere terror of death simply because it is death. That terror is so powerful and so difficult to talk about that it often quietly determines many of our decisions. We are surprised when our 90-year-old mother dies because we have not been able to talk about death with her or with each other. Instead of dying in the space where she was married and raised children, where she suffered and expressed suffering, where she displayed courage, where she overcame things, where she cooked meals and entertained and worshipped, she dies in an intensive care unit surrounded by people in lab coats who talk about her in terms of the biological changes they are tinkering with and trying to fix. She dies sedated on a ventilator, instead of experiencing this final mystery in the same space and community where she lived the rest of her story. There are simple ways doctors can do better, modeling a different way of being with people in the hospital. Doctors do not have to wear white coats. They can remind patients that they are more than their diseases. They can view themselves as guests in the lives of patients, listening for the ways to help that make sense from within a patient’s own story. They can deliberately use ordinary language. Patients want experienced guides who will offer their best judgment, but they also want a doctor who will listen to their thoughts, hopes, and fears in the course of making decisions. Sometimes patients want a doctor to be more directive. This is also fine as long as it fits a patient’s life and needs. The practice of medicine as being in time is fundamentally about ends—limits, goals, the telos of a life, completion, finishing, death, stopping. In this way, it is fundamentally a philosophical discipline, the practice of philosophical discovery, and an example of a practical syllogism ending in action, which in turn leads to reflection and insight. The practice of medicine is a form of service to people within the domains of embodied

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fragility, birth, dying, and the experience of the diseases into which we are sometimes thrown. The arena of this practice has a responsibility to attend to the experiences of those who show up. Doctors’ responsibilities are in proportion to the trust they are given and the authority they wield. Questions of ontology, beauty, form, value, morality, mystery, purpose, and the nature of a good life arise in the context of the practice of medicine, not primarily from the perspective of biological knowledge and manipulation, but from the perspective of a person’s story. This includes the arc of a person’s life story. It also includes the story we tell about the universe in which we live, and which bears on the way we frame the meaning of our personal stories. All of this is philosophically important. It is also philosophically urgent, because the fundamental limit that determines the shape of all other limits in human experience is the limit of time. Time is the condition for all human experience. But for any embodied mortal creature, at any point in life, time is running out. Because we care so deeply about the way we start our lives, the way we live our lives, and the way we die, the focus that most fundamentally defines the good practice of medicine is being in time.

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