Medical (and Theological) Reasoning in a Pandemic
April 13th, 2020 | 18 min read
“a time to kill, and a time to heal; a time to break down, and a time to build up;”
A Common Word Between Medicine and the Church
My day begins at 5:30 am. Not a bad start. Patients to cross cover today who I haven’t seen before. Morning coffee. The gift of a good orange. Music on the drive to the hospital. I have a lot on my mind. We all do. A few COVID-related updates sit unread in my inbox. (Universal mask policy coming soon.)
It’s dark when I pull into the hospital lot. Against my counselor’s advice, I flip open my phone to take another distal pulse of the world, the clinic, the church.
According to the Koranic sūrah, in 632 AD a group of Christians were invited by Muslims for “a common word between us and you.” In a moment where profound discord was most likely, they sought concord. According to tradition, a debate ensued nonetheless. The Muslims eventually tell the dispatch they are free to continue practicing their Christianity in exchange for a jizyah or poll tax. A treaty is signed and the deputation returns home. The Christians may have been offered “a common word,” but they leave paying dues. There may have been some interesting places of theological overlap, but the traditions remained irreconcilable. A man cannot serve two masters.
I feel similar as a Christian physician amidst COVID-19—seeking a common word between medicine and theology and feeling sent away—lock-jawed and taxed.
I. Colliding Goods, Impossible Choices
Mr. Smith has a broken jaw. Can’t eat now. Keeps pulling out his NG tube. We discuss how frustrating this must be but it’s mostly me talking (his jaw is wired shut). His eyes tell me he’s over this. He gurgles that he just wants to eat.
The coronavirus commentary is saturating and increasingly dispiriting. First Things—the great child of Richard John Neuhaus and a journal I love—has become laughably contrarian in this regard. Early critiques from lead editor R. R. Reno have caused palpable frustration, prompting Alan Jacobs to wonder if the church needs a reminder that death is, in fact, bad, but also prompting Jake Meador to toss aside straw men and rather “steel man” Reno’s case. That kind of conciliation and forbearance on the evangelical blogosphere should be celebrated.
As Matthew Lee Anderson has pointed out, “The discussion has not been a model of intellectual clarity or grace, virtues which are all the more pressing because of its very real stakes.” Anderson goes on to lead us in a helpful analysis of the public reasoning at work in this pandemic. Then professor Brad Littlejohn through the moral reasoning. Then physician Matthew Loftus through the ethical reasoning.
All these forms of thinking are important, because the questions before us about social responsibilities, economic collapse, and scarce resources are exceedingly difficult—requiring a Solomonic balance of public policy, moral philosophy, and medical ethics. As the late Christian ethicist Allen Verhey wrote in “The Good Samaritan and Scarce Medical Resources,” “Goods collide and cannot all be chosen. Evils gather and cannot all be avoided.” The questions are “tragic and irremediably ambiguous.” Who among us can answer them?
N. T. Wright in TIME tells us that “Christianity offers no answers about the coronavirus,” and calls us away from both rationalism and romanticism to lament. At the same time, RUF campus minister Derek Rishmawy reminds us that Christianity does, in fact, follow a God of omniscience on whom our questions might crash.
As for those of us in medicine, we check the infection trajectories daily. Update the Johns Hopkins dashboard frequently. We each follow our own state’s forecast projections of hospital bed shortages with the vigor of the nightwatch at his tower.
It all feels desperate and tragic and in some ways it is. Those of us in health care are trying to avoid medicine’s “tyranny of correctness” (the tendency to render all questions into discrete inquiries with clear answers) while also seeking ‘right’ answers to the very indiscrete questions before us—questions the vast majority of us have never had to ask about societies and sick bodies.
II. Anticipatory Corpses
Mr. Johnson is my sickest patient. He’s been here for 31 days. His white count continues to rise and we don’t know why. It’s not lymphoma. Could be sarcoidosis. Most likely it’s his chronic leg wounds. He’s frustrated and so are we. We feel like we’re failing him. I wonder how to tell him his leg may need to be amputated. He has refused surgery.
We have Foucault and Francis Bacon to thank for “the clinical gaze” in which every patient we see is understood as a potential corpse. We think and speak in terms of the things that will render bodies dying and dead.
In The Anticipatory Corpse: Medicine, Power, and the Care of the Dying, internist and philosopher Jeffrey P. Bishop contends that modern medicine’s epistemic norm is the dead body—the cadaver—rather than the living body. It is telling that all medical students call the cadaver on which they learn anatomy “the first patient.” Medicine saturates itself first in what is dead in order to learn how to care later for what is alive. Medicine rips the living body out of its contextual community and history and replants it as a decontextualized, ahistorical machine—“non-living matter in motion.”
And yet the bulk of medical education comes from clinical experience, in which patients are encountered not dead but alive. The clinician does not learn physiology from the cadaver but from the patient in the examining room. A dead body doesn’t have a blood pressure. Surgeons don’t learn surgery on cadavers.
And yet, if you try to bring up the deep purposes of life in the operating room, you will be left with blank stares. To use Aristotelian language, “formal and final” purposes were long ago banished by medicine to the realm of speculative metaphysics in favor of “material and efficient” causes. As Foucault outlines in The Birth of the Clinic, medicine developed an alternate metaphysics in which the human being with intrinsic purpose was generalized into a biological machine with intrinsic function. In medicine, life has no purpose, telos, or end—only a potential ending.
The ICU is a case-in-point for Bishop, and now for us—the object of our COVID-19 fears and the focus of our resource forecasting. There, the body is seen as a physiological machine to be maintained by other machines. Technology becomes teleology, producing an illusion of control that life and death can be fine-tuned just like the settings of a ventilator.
We look to medicine to give us life and yet it leaves us empty, precisely because it does not recognize that when it restores function, “often something other than function is lost or returned”—namely purpose, justice, beauty.
This forces us to give death too much stock. To reason under death’s dominion. We struggle to see our patients as anything more than anticipatory corpses—what the great ethicist Paul Ramsey called “a nation of card-carrying precadavers.”
III. Beholden to Precaution
Ms. Howard is new. Came in last night with atrial flutter. No issues overnight. No complaints. She’s watching something on the TV about hypnotism to cope with COVID-19. Mr. Perry has done well. Blood pressure still a little low but he can likely go home today. We’ll recheck it regardless.
A red sunrise peaks through a patient’s window on the 6th floor. A brilliant line of orange and crimson that slows my step. The sun is a source of hope. The red a word of warning.
A recent dispatch from our brothers at First Things suggests we are seduced by Sod’s Law: “if it can go wrong, it will go wrong.” Our eyes are fixed on illness to the exclusion of reason. We are guilty of epidemiological scrupulosity. Those who are not beholden to the precautionary principle are to be applauded.
Perhaps this is right, and the response of myself, my colleagues, and our medicalized culture to COVID-19 betrays an assimilation into the medical mind. Under the “Baconian Project,” medicine has inherited a goal of relieving suffering under a “technological utopianism” that viewed no disease as incurable. As Bacon wrote in De Augmentis Scientiarum, to admit that any patient is “overmastered by disease” is to give “legal sanction” to “neglect,” “inattention,” and “ignorance.” The West has kept alive this moral charge to relieve suffering and prolong life at all costs even as it has lost a shared moral tradition to properly order the goods of life and moderate the goal of health.
Perhaps we all worship within what ethicist Stanley Hauerwas has named the new “salvation of health.” In that strange religion, modern medicine breaks both its patients and its practitioners as any idol inevitably breaks the hearts of its worshippers—fracturing, resetting, and ossifying us into a certain way of thinking that leaves us bent before death’s dominion and “life at all costs.” R. R. Reno is rightly concerned that we will destroy our economy in the name of longevity. We’re all concerned that the church will have no distinct response to any of this. Indeed, if the sale of wine and sandals among the Christian community bumps up after we all receive a stimulus check from Uncle Sam, we’ve truly lost our way.
At the same time, I think medicine deserves more defense. As obesity physician Davis Ludwig points out, calls to relax the social distancing in the name of sustaining the economy, thereby letting the coronavirus ravage the population, is likely to cause an even greater economic calamity than that produced by aggressive social lockdown.
Maybe society can’t be beholden to precautionary projections. But do you really want a doctor who doesn’t take a fundamentally precautionary approach? That’s 90% of good medicine. Chest pain is a heart attack until proven otherwise, no matter how unlikely. Sod’s Law is why air travel is as safe as it is and why our surgical pre-operative procedures are as strict as they are. Take on the policy makers and media fearmongers and the MacIntyrian “cult of expertise”—fine, good—but what would the critics have us do as doctors?
IV: Practical Wisdom: The Chief Medical Virtue
Morning rounds. Most of us wear masks. It makes it more difficult to understand each other as we can’t read lips. We make more eye contact now. My coworkers look tired.
My favorite dining staffer is gone today. She had been complaining of something in her back. I hope she’s ok. The cafeteria is bizarre. All the chairs have been removed. No visitors allowed except for end of life, pediatric care, or labor and delivery. Patients are left to convalesce alone as those who take care of them are discouraged from eating together. We find ourselves sitting closer at mealtime in the work room in a quiet act of defiance. Food continues to draw us together. I wash my hands for the hundredth time today. Sterilize my stethoscope yet again. Slip off my mask to eat.
I’ve been rereading C. S. Lewis’ “Learning in War Time” from The Weight of Glory, both as a balm and a brace. Lewis joins the critic in reminding us that humans have always been pursuing justice and beauty despite unfavorable conditions. There have always been “plausible reasons” for putting off the good until some crisis has been averted.
But as humans we do not wait. We continue to seek truth and beauty, whether in war or in quarantine. As Lewis quips, soldiers have always been exchanging poems in the trenches.
But it is worth remembering that Lewis’s soldiers weren’t merely writing but fighting—an obvious statement that seems overlooked by the COVID reproach. Those sick during the Spanish flu epidemic did not stop living, pursuing justice, or seeking beauty, but they did take steps of practical wisdom—opening up distinct clinical spaces, practicing quarantine, and treating the dying. Most of them didn’t die from the unique cytokine storms of the Spanish flu (which Coronavirus also causes) but from the lack of infrastructure and medicine to deal with the secondary bacterial superinfections that took advantage of weakened immune systems and crowded conditions.
First Things’ concern is consistent with a Catholic sacramentology that bristles at the prospect of withholding the Real Presences from worshippers (even as Pope Francis himself has reassured Christians to take their sorrows directly to God if they can’t physically make confession). But these last few critiques, warning of a demonic undertow and humanistic sentimentalism at work in our epidemiology and public policy, reinforces a strangely Platonic and dismissive attitude toward the grounded, physical work of Christians in past pandemics and contemporary medicine in general.
The disjunctive critique is consistent with how we think at the intersections of medicine and theology today. Reactionary bioethics is alive and well, and little imagination is protected to sustain a dialogue between the church and the clinic. Theologians sip cappuccinos inside. Scrubbed medical workers hurry along outside. One side says keep the churches open. The other says keep the churches closed. Somewhere between the extremes is a third way.
The great Christian physician and bioethicist Edmund Pellegrino wrote in The Virtues in Medical Practice that the ability to see this third way between extremes—what Aquinas understood as prudence and Aristotle as phronesis or “practical wisdom”—is the “indispensable virtue of the medical life.” Phronesis is the metavirtue that keeps all of our other virtues properly oriented and aligned. Practical wisdom seeks justice among the city but bound to charity for our immediate neighbor. It allows neither paranoia nor dismissal.
Good medicine in the time of COVID-19 means something like this, neither doing all that is possible at all costs (hysterical shutdown) nor avoiding what can be done (refusing shutdown). As Allen Verhey writes, there have always been two strategies for denying the tragedy of limited medical resources: “One strategy is to deny scarcity. The other is to deny sanctity.” Those primarily concerned with lives underweigh the former, while those concerned with the economy too easily dismiss the latter.
Both responses show a lack of practical wisdom and imagination, which is what our clinics and churches desperately need right now. I practice in a rural hospital system in South Carolina, a place unlikely to be a “hot spot” like New York. We recognize the need for a hard lockdown in cities with close living conditions where viral spread and hospital saturation is likely, but we also understand that social distancing habits may be loosened in communities like mine where the COVID-19 burden is less likely.
Still, even and perhaps especially here in the South, we don’t know yet. In morning rounds my fellow residents, attendings, and I each sit in corners of the room—not because we obey death’s dominion—but because we are trying to be practically wise.
Perhaps we can imagine something similar for our worship, keeping our church doors neither flippantly open nor obsequiously closed but cracked, letting the light out. Perhaps we can imagine small gatherings for homilies, evening prayers, or Vespers in which we limit gatherings to ten and situate ourselves in every third seat. Perhaps we can imagine cascading groups of ten or less who might walk the stations of the cross together as Holy Week comes upon us.
V: A Time to Build Up and Break Down
We discuss a patient with Takotsubo cardiomyopathy, a rare form of heart failure caused by an intense emotional event, also known as “broken heart syndrome.” We told her yesterday she has metastatic brain disease, so this development makes sense. The presentation has nothing to do with coronavirus, but the name still feels fitting. Our hearts are heavy. The room is silent for a moment.
Later in the day, lots of humor in the resident work room. Most of it gallows but much of it the laughter of comrades and friends. We’re all sustained in a state of anticipation. It feels good to laugh with coworkers, all of whom are working hard. We’re all a bit more on edge. Anxious. We are getting more COVID-19 patients daily.
The New York Times and The New Yorker call us heroes. It’s a nice sentiment that feels cheap and sticky. As a physician once told me, “we speak in sanctimonious terms about ‘saving lives,’ but healing is like redemption, and redemption is about taking what’s broken and making it whole.”
Physician Lydia Dudgale calls us rather to “ordinary heroism.” As our own ethics committee wrestles with categorizing preventative, curative, and defensive critical health care workers, we recognize that the janitor rightly joins the pulmonologist at the table.
It has been my closest friends who have sent the most galvanizing texts:
“One reason why it all feels hollow, from the NYT to First Things, is that it’s not doctors doing the commentary for the most part. Doctors are insanely busy and stressed, and the rest of us are sitting on our butts with nothing to do but commentate.”
“You’re trying to help people when the rest of humanity is shutting themselves indoors and watching some show about a dude and tigers.”
One of my dear friends—a missionary in Belgium—charges me with a word from Mark 3, that “all who had diseases pressed around him.” Indeed, I signed up for this to make sense of Matthew 25’s call to see Christ in the sick, to care for the sick “as if it were Christ himself who were served” as The Rule of St. Benedict renders it. For Christians who are attempting to live faithfully within the world of healthcare right now, the suggestion that participating in (let alone encouraging) the state’s pandemic response constitutes faithlessness to Christ’s command is an assertion that is truly discouraging to read.
VI: What to Be and What to Do
My backup resident asks me if I believe in God. I answer yes. He asks me to pray with him—an exceedingly rare event, even for the Christ-haunted south. We pray together.
Theologian William Jennings once quipped, “I’ve never had so many people tell me what theology should be and do than when I talk to doctors.” I sincerely hope our theological leaders continue to question medicine and our medicalized age. We need it. As an old friend recently taught me, St. Bonaventure called theology queen of the sciences. In that light, medicine may be a separate sphere of royal reason, but it answers to the King.
After the sick pressed in upon him in Mark 3, Jesus retreated into solitary places to pray and be with God. When all this is over (July 1 according to the most recent IHME projections; June 20 for my home state), all of medicine will need to retreat into solitude and soul searching before God. We will need to examine the ways we have told theology “what to be and do” and repent accordingly. Medicine already needs to be chastened, and it is already undergoing something of an apocalypse—a radical unveiling. As Peter Leithart asks in a prophetic volley:
What will we do when things return to “normal”? Will we recognize the decadent abnormality of our pre-pandemic norms? Will our common effort ease partisan divisions, or will Washington return to business as usual? Will we learn self-restraint and delay our gratifications? Will the students and faculty who repopulate abandoned campuses redouble their efforts to woke-up our universities, or will progressivism be exposed as a puerile indulgence? Will a post-pandemic entertainment industry sober up to offer penetrating, edifying art, or will it continue to feed our insatiable hunger for titillating distraction? Will the pandemic make us more or less addicted to the belligerent virality of social media? Will self-isolation permanently isolate neighbors from one another, or will our common battle and common fear bring us closer together? Most important: Will we come out of the pandemic with a deepened knowledge that there’s a God in heaven? Will we fear him, or will we, like Pharaoh, harden our hearts as soon as the Lord gives relief?
VII: A Time to Heal
Home, blessedly, while the sun is still up. My wife and boys are playing on the porch. I happily let COVID slip from my mind. A well-made meal. A good beer. My youngest throws his spaghetti on the floor. Evening songs. Goodnight Moon. Rest.
A fellow medical worker reminded me that faithful responses to Jesus lead to differing paths. When Rudolf Bultmann encountered Christ, he wrote more theology. When Albert Schweitzer encountered Christ, he became a medical missionary.
Medicine and theology and public policy and ethics are in an Ecclesiastical moment, in which goods collide and cannot all be chosen and evils gather and cannot all be avoided and paths diverge which cannot all be walked. The days risk being full of sorrow but also promise to be full of opportunity. In the gathering up of our commentary and knowledge we find both anxiety and hope, and in the loosening of our grip in the face of this absurdity we find something like conversion, where there is nothing better to do for a person than that he should eat and drink and enjoy his work—fearing the God who welcomes weariness and heavy burdens amidst the days and diseases before us.
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