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CHAPTER 1

PART ONE

Physicians Must Be Altruistic

PHYSICIANS must be compassionate and empathetic in caring for patients, and must be trustworthy and truthful in all their professional dealings. They must bring to the study and practice of medicine those character traits, attitudes, and values that underpin ethical and beneficent medical care. They must understand the history of medicine, the nature of medicine's social compact, the ethical precepts of the medical profession, and their obligations under law. At all times they must act with integrity, honesty, and respect for patients' privacy, and respect for the dignity of patients as persons. In all of their interactions with patients, they must seek to understand the meaning of the patients' stories in the context of the patients' beliefs and family and cultural values. They must avoid being judgmental when the patients' beliefs and values conflict with their own. They must continue to care for dying patients even when the disease-specific therapy is no longer available or desired.

Rosalind Warren

OUTPATIENT

In this wry opening selection, a middle-aged hypnotist named Luisa, suspecting that she might have bronchitis, goes to the doctor for a checkup. When the examination is both "dehumanizing and demoralizing," Luisa decides to use her profession to teach her doctor a thing or two about "ethical and beneficent" care.

ROSALIND WARREN is an attorney living in Philadelphia. She has had stories published in Crosscurrents, Fantasy and Science Fiction, and Seventeen.

The waiting room is crowded. Mothers watch fidgety children, couples sit together on drab sofas, adult children talk in soothing voices to elderly parents. Everyone in the waiting room has someone with them. Luisa has come alone.

"New patient?" the receptionist asks. Luisa nods.

The receptionist hands her a clipboard that holds a form. "You'll have to fill this out," she says. When Luisa returns it a few moments later, the receptionist looks it over. "You haven't filled in your occupation," she says.

"Hypnotist," says Luisa.

"Oh?" The receptionist meets Luisa's eyes. They're unusual eyes. Clear blue, almost violet. They often remind people of deep bodies of water.

"It's the family business," says Luisa. "Both my parents were hypnotists. As were two of my grandparents."

"How lovely," says the receptionist.

"The doctor will see me right away," says Luisa, still looking into the receptionist's eyes. She enunciates each word slowly and carefully.

"But we call people in the order they arrive."

"I arrived first," says Luisa.

"You arrived first," agrees the receptionist.

Luisa has barely glanced at Life magazine's special Winter Olympics issue when a nurse calls her name. She follows the nurse down a corridor to a small examining room. The nurse hands her the usual skimpy garment, telling Luisa to remove her clothes and put it on. When the nurse leaves, Luisa strips, puts the thing on, and sits down on the edge of the examination table. It's cool. Almost immediately she has goose bumps.

Luisa doesn't look great in the drab shapeless garment, but she looks better than most. She is of an indeterminate age. Certainly past forty. She would probably be described as "well preserved." She is tall and strong-looking and has longish red hair. Not beautiful but striking. The nurse comes back in and smiles when she notices that Luisa's fingernails and toenails are painted cherryblossom pink.

"Stand on the scale," she instructs. Luisa gets on the scale, and the nurse adjusts the indicator back and forth, minutely, until it finally rests on 130.

"One hundred thirty," she says.

Luisa turns to look at her. "What about my eyes?" she asks.

"Hmmm?" the nurse says, writing. She looks up and meets Luisa's eyes. "Oh!" she says. She gazes at Luisa for a moment. "They're such a nice color," she says.

"Really?" asks Luisa. "Tell the truth."

"They're a little weird."

"Scary?" asks Luisa.

"Nope." The nurse smiles. "I like them."

Luisa smiles. "I weigh one fifty-seven," she says. The nurse glances down at her clipboard and frowns. She erases the 130 and writes 157.

"But I carry it well," says Luisa. "Don't I?"

"You certainly do," says the nurse. "Now I have to take your blood pressure." She straps the arm band on, pumps it up, and looks at it. "One hundred ten over sixty," she says.

"One twenty over seventy," Luisa says. The nurse gazes at her blankly. "I'm sorry," says Luisa. "But these silly games are quite harmless, and they're crucial if I'm to stay in practice. I'll stop if it disturbs you."

The nurse smiles. "It doesn't disturb me." She writes 120 over 70 on Luisa's chart. "I think it's interesting."

"What happens now?" Luisa asks.

"You wait for Dr. Heller."

"I probably don't even need Dr. Heller," says Luisa. "I'm ninety percent sure I've got bronchitis. Everyone in my family has bronchitis. Everyone on my block has bronchitis. But I can't just write myself out a prescription for antibiotics, can I?"

"No," says the nurse. "You can't."

"What's Dr. Heller like?" Luisa asks.

"He's very nice."

"Tell the truth."

"He's a complete jerk," says the nurse. Then she looks startled, and they both burst out laughing.

"But he's a very competent doctor," the nurse says. "He can diagnose your bronchitis as well as the next doc."

"Thanks for putting up with me," says Luisa. "You will feel happy for the rest of the day. You will walk around thinking life is a piece of cake."

"I certainly look forward to that," says the nurse.

Luisa snaps her fingers. The nurse blinks, then moves quickly to the door. "Dr. Heller will be right with you," she says as she leaves. She has left the clipboard with Luisa's chart on the table, and Luisa quickly changes her weight and blood pressure to the correct numbers.

Time passes. Ten minutes. Twenty minutes. Nothing happens. The nurse had left her with the impression that the doctor would be right in. Clearly, he won't be. There is nothing to distract her. She should have brought her magazine with her. She imagines parading out into the waiting room dressed as she is to retrieve her copy of Life. She decides against it.

She looks around the room. It's a generic examination room. No windows. No pictures or photos. Nothing interesting or unusual to hold her attention. Luisa hasn't much interest in things, anyway. Things rarely hold surprises; people do.

Another twenty minutes pass. Luisa is beginning to think they've forgotten all about her. She's starting to feel woozy. It angers her. Sitting here half dressed is the last thing she needs. She knows that in examining rooms up and down this hallway sick people sit in skimpy hospital garments waiting for the doctor. It's more convenient for him this way. She tries to calm herself. This treatment isn't life-threatening, she tells herself. It may be dehumanizing and demoralizing, but it won't kill you. They only do it this way because they can get away with it.

Finally the door opens and a big man in a white coat breezes in. He's in his mid-thirties, large and bearded. He looks like a lumberjack. His blue eyes are intelligent but not particularly kind. He moves in a rush.

"Well, Luisa," he says loudly, glancing down at the clipboard, "I'm Dr. Heller. What's the trouble?"

"Sorry to keep you waiting," says Luisa.

"Hmmm?" he says, scanning her chart.

"I said I was sorry to keep you waiting."

He looks up at her. "Symptoms?" he asks.

"Fever," she says. "Sore throat. Bad cough. I think I have bronchitis."

"I'm the doctor," he says, making notations on her chart. He places his stethoscope on her back. "Cough!" he barks.

Luisa coughs as he moves his stethoscope about on her back and then her chest. His movements are all precise and quick, and his touch is firm and cold. He looks into the distance, concentrating. He doesn't look at her.

"It began two weeks ago," Luisa says. "I woke up with a bad sore throat. Three days later I began running a slight fever." She stops. He isn't listening.

"How much pain have you caused your patients by not listening to them?" she asks quietly.

"Hmmm?" He takes a thermometer from a drawer. "Open," he says, angling the thermometer toward her mouth. Luisa pushes it away.

"Listen to me!" she says.

He stops and looks at her, his eyes dark and angry. Their eyes meet. It's a struggle. But Luisa is angry.

"You will slow down and give me a good, thorough examination," she says finally. "You will take your time, pay attention, and explain the reason for each procedure. You will listen to me when I speak. Not only am I older than you and deserving of your respect for no other reason, but I live in this body. I may know something about it that can help you."

The doctor gazes at her, unblinking.

"I'm not just a body with an illness," says Luisa. "I'm a person. You care about my feelings."

"I care about your feelings," he says. He sounds doubtful.

But he continues the examination at a much slower, kinder pace, and Luisa is surprised at how good he is. His cold hands even seem to warm up slightly. But it's clear that he's fighting the impulse to race through the exam and get on to the next patient.

"Why are you in such a hurry?" she asks.

"I have so many patients. I hate to keep them waiting."

"You don't care about that. Tell the truth."

"You've got a fabulous body," he says. "I love older women with big breasts."

"Not about that," she laughs. "Why are you in such a hurry?" "This way I stay in control."

"What if you aren't in control?"

"I have to be in control."

"Why?"

"I'm the doctor."

"And you're the doctor because you have to stay in control," says Luisa. "Right?"

"Yes," he says. "I do like your eyes. They're ..."

"What?"

"Calming."

He finishes the examination. "You have bronchitis," he says. "I'm writing you a prescription for 500 mg of ampicillin."

"What would make you listen to your patients?" she asks. "What would make you care?"

"Nothing," he says. He is writing the prescription. "Take this four times daily with plenty of water." He hands it to her and turns toward the door.

"Wait," she says.

He stops. "Take your clothes off," she says. He turns around and stares into her eyes. He begins to unbutton his shirt.

As he removes his clothing, Luisa puts hers back on. By the time he's naked, she's fully clothed. He stands there looking very pale. He has goose bumps. She hands him the hospital garment. He puts it on.

"You will sit here and wait," she says, "until the nurse comes looking for you. You'll see what it's like."

He sits down on the edge of the examination table and sighs.

She pauses at the door. "When the nurse comes, you'll forget about me."

"I'll forget about you." He sounds happy about that.

"But you'll never forget the next half hour."

As Luisa leaves the room, she sees the nurse heading toward her with a clipboard. "Dr. Heller is in the examining room," she tells the nurse. "He asked not to be disturbed for at least a half hour. But he wanted you to explain to the patients who are waiting that there'll be a delay. And to apologize."

"That's new," says the nurse.

"That's right," says Luisa. She meets the nurse's eyes. "Have an interesting day," she says.

Albert Schweitzer

from FIRST SERMON ON REVERENCE FOR LIFE

In an era marked by celebrity-driven fund-raising, Albert Schweitzer's name has become synonymous with sustained humanitarian effort on behalf of others — effort that eschews the limelight for a practical ethics based on help and love. Awarded the Nobel Peace Prize in 1952, Schweitzer is best known for his journeys to Africa, where he practiced medicine and established hospitals; Schweitzer also held degrees in philosophy and theology. In his own time, Schweitzer was regularly featured in magazines like Time and Life. Today Schweitzer's legacy is less familiar, and, by modern standards, aspects of his life are viewed as suspect by some: his patronizing, if not racist, attitudes toward some of his African patients and the moodiness those who went to work with him sometimes encountered. Perhaps this is all the more reason today to consider the words of one who understood himself only too well, who wrote about his own limits and who struggled to connect thought, word, and deed in his writing and in his service to others.

This excerpt is taken from the first of twelve sermons Schweitzer preached between February and April 1919 in Strasbourg, France, at Saint Nicolai Church. In this sermon Schweitzer first defined his well-known phrase "reverence for life." The subtitle of the sermon is "What Does It Mean to Be Good?"

ALBERT SCHWEITZER'S (1875–1965) Sermons on Reverence for Life were compiled into a book, translated by David Larrimore Holland, titled A Place for Revelation. Schweitzer's 1947 anthology The Spiritual Life has recently been reissued.

Desire for knowledge! You may seek to explore everything around you, you may push to the farthest limits of human knowledge, but in the end you will always strike upon something that is unfathomable. It is called life. And this mystery is so inexplicable that it renders the difference between knowledge and ignorance completely relative.

What difference is there between the scholar who observes the smallest and least expected signs of life under a microscope and the old peasant, who can scarcely read and write, when he stands in his garden in the spring and contemplates the blossoms bursting open on the branches of his tree? Both are confronted with the riddle of life! The one can describe it more thoroughly than the other, but for both it is equally inscrutable. All knowledge is finally knowledge of life. All realization is astonishment at this riddle of life — reverence for life in its infinite, yet ever new, manifestations. For what does it mean for something to come into being, live, and pass away? How amazing that it renews itself in other existences, passes away again, comes into being once more, and so on and so forth, from infinity to infinity? We can do all things and we can do nothing, for in all our wisdom we are not able to create life. Rather, what we create is dead!

Life means strength, will coming from the abyss and sinking into it again. Life means feeling, sensitivity, suffering. And if you are absorbed in life, if you see with perceptive eyes into this enormous animated chaos of creation, it suddenly seizes you with vertigo. In everything you recognize yourself again. The beetle that lies dead in your path — it was something that lived, that struggled for its existence like you, that rejoiced in the sun like you, that knew anxiety and pain like you. And now it is nothing more than decomposing material — as you, too, shall be sooner or later.

You walk outside and it is snowing. Carelessly you shake the snow from your sleeves. It attracts your attention: a snowflake glistens on your hand. You cannot help looking at it, whether you wish to or not. It glistens in its wonderful design; then it quivers, and the delicate needles of which it consists contract. It is no more; it has melted, dead in your hand. The flake, which fell upon your hand from infinite space, which glistened there, quivered, and died — that is you. Wherever you see life — that is you!

What is this recognition, this knowledge apprehended by the most learned and the most childlike alike? It is reverence for life, reverence for the impenetrable mystery that meets us in our universe, an existence different from ourselves in external appearance, yet inwardly of the same character with us, terribly similar, awesomely related. The dissimilarity, the strangeness, between us and other creatures is here removed.

Reverence before the infinity of life means the removal of the strangeness, the restoration of shared experiences and of compassion and sympathy. And thus the final result of knowledge is the same, in principle, as that which the commandment to love requires of us. Heart and reason agree together when we desire and dare to be men who attempt to fathom the depths of things.

Rafael Campo

LIKE A PRAYER

Recalling his time as an exhausted intern working through a last, long, in-patient rotation among homeless men with AIDS, physician, poet, and essayist Rafael Campo tells of a harrowing experience on the ward. That experience allows him to realize his capacity for great empathy toward the least among us, while also providing readers with a meditation on the origins of altruism under the most trying of circumstances.

RAFAEL CAMPO, both a teacher and a doctor, works at Harvard Medical School and Boston's Beth Israel Hospital. He has published two books of poetry, The Other Man Was Me and What the Body Told, and a collection of essays, The Poetry of Healing, from which this selection is taken.

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Excerpted from "A Life in Medicine"
by .
Copyright © 2002 Robert Coles and Randy Testa.
Excerpted by permission of The New Press.
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