Unsouling the Patient: Notre Dame's Lessons for Medicine

The cathedral at Notre Dame has reopened, over five years after it caught fire in April of 2019. In The New York Times interactive piece “A Miracle: Notre-Dame’s Astonishing Rebirth From the Ashes,” architecture critic Michael Kimmelman and graphic artist Mika Gröndahl explore the remarkable work that has gone into Notre-Dame’s restoration. They highlight exquisite details and features of the reconstruction that are truly awesome to behold: the care taken, for example, to select individual oak trees to match and replace each beam of the roof that was lost in the fire.

As Kimmelman points out, these are wooden beams that will never be seen by anyone but those who carved and constructed them. The work to restore what is fittingly called “the forest” echoes those ancient stonemasons who set the foundations of the canon of great cathedrals in anonymity, knowing they would never worship in the very spaces they were building. Such efforts remind me of the hidden art of miniaturists like my mother, who paint impossibly small watercolors, only to tuck them away neatly in tiny, handmade drawers, in delicate desks, to be seen by no one, remembered only by the few who know the secrets.

Kimmelman quotes Philippe Jost, head of the restoration task force of Notre Dame: “Each day we have 20 difficulties. But it’s different when you work on a building that has a soul. Beauty makes everything easier.”

I don’t want to be the voice of protest at the ribbon-cutting, becoming the gadfly who can closely read a quote but can’t read the room. And yet, “Beauty makes everything easier,” is worth responding to with a warm “No,” even as I would count it an honor to shake Jost’s hand with gratitude. Restoration and repair are lost arts worth celebrating. They resist the tyranny of the next, the discarded, the smoothed out.

But beauty does not make everything easier. As Elaine Scarry writes in On Beauty and Being Just, the beautiful “creates, without itself fulfilling, the aspiration for enduring certitude. It comes to us, with no work of our own; then leaves us prepared to undergo a giant labor.” And I suspect Jost would agree. Perhaps the conversation took place in French and an important nuance was lost in translation. Either way, I read in his quote something more like “It is easier to work on a building that is beautiful.”

This truth is apparent not only in Kimmelman’s article, highlighting the speed of the rebuild, but also in the work of Jost’s team. Beautiful things are easier to fight for and work toward. The philosopher Byung-Chul Han argues that beauty “is situated at a preliminary stage to work.” The collapse of Notre-Dame’s roof made a call on the community that was not easy to answer, even as the work has proven easier to accomplish, in some sense, because the “why” of the beautiful is so deeply felt.

As a family doctor, I think physicians have something to learn from Jost and these remarkable craftsmen, not just about beauty and hard work but about ensoulment. “Each day we have 20 difficulties. But it’s different when you work on a building that has a soul.” Looking at patients like Jost looked at Notre-Dame might hold a clue to medicine’s rebirth, especially as clinicians continue to search for moral categories and descriptors to capture their ennui and frustration. Medicine, as another “House of God,” has been on fire for some time.

I can easily imagine a clinician—especially a medical trainee—saying “Each day we have 20 difficulties.” It is much more difficult to imagine the follow-up: “But it’s different when you work for a patient that has a soul.”

The great unsouling of the patient is said to begin in medical school, in the cadaver labs of first-year gross anatomy, where medical students dissect a corpse, labeled their “first patient.” They begin to see through the eyes of one trained to reduce things to their component parts through the dissecting, analytic gaze. Medical students embody ana+lysis, meaning “to cut apart.” Despite all that cutting, at no point in human anatomy is the soul identified, labeled, and placed on an exam.

The closest I saw to such a thing was when we dissected the brain. Our professor, an austere anatomist named Erika Blanck, called us to pause and gather in close as she slowly lifted the brain from the calvarial floor, held it up in the morning light, and quietly said “Here are all the dreams and fears and hopes of your patient.” It was a lovely moment, even if the material reductionism was not so subtle. Dr. Blanck demanded nothing less than reverence, wonder, and excellence in her anatomy lab. She constantly drew us to the beauty of the body, the radical gift of the donors and their families, and the demanding responsibility of what we had signed up for. Unlike her predecessors, she did not suffer disrespect toward our first patients.

But even with an elegant professor who resisted what Wendell Berry has called “the melancholy of anatomy,” the momentum of reductionism and mechanistic metaphor was overwhelming. Cutting into a cadaver was one thing. It was much more distressing to realize how we were being formed to treat patients who were still alive. Having learned to see patients as “card-carrying precadavers” (in the unforgettable phrase of psychiatrist Aaron Kheriaty), we entered clinical training prepared to endorse—if not embrace—a view of patients as machines with broken parts that need fixing. We embraced this idea because machines were easier to control, act upon, do something about. Souls were too abstract, uncertain, unbillable. For all the tasks we painstakingly listed on the backs of our patient lists (check potassium, consult cardiology), “attend to the soul” was never an actionable item.

While few would likely articulate their medical training in this way, it is the default metaphysic that colors the background of modern medicine. If the patient had a soul, we certainly didn’t talk about it. How could we? Bringing up the soul while on rounds was a form of mutiny—the kind of thing that would get you dressed down in public. “We have chaplains for that sort of thing.” And we remembered dissection. The brain was too small to hold the soul.

One of my attendings used to quip “You can’t paint a burning room.” The lesson was that some healing is only possible if you can first identify and stop the inflammation. I’ve found that statement resonates elsewhere. It is difficult to facilitate healing in a patient whose marriage or vocation is on fire. Sometimes the most important first step in a patient’s life is pointing out that the room is full of smoke and soot, and none of the paint we’re lathering on is going to help until we address that. Something similar is required in the spaces of medical education, refusing to furnish a burning church and looking instead to the deeper issues—the masonry that needs rebuilding. Doctors can learn from the perspective of these craftsmen who have restored Notre-Dame, who claimed not just a monument in disrepair but a building with a soul.

We need what my friend, palliative physician and medical educator Kimbell Kornu, calls the education of “an iconic perception” that changes how we see the patient—not with the “soul” of the material reductionist who claims it only as an inconvenient emergent property—but creaturely ensoulment in which we encounter “the patient as a living icon.”

When I was a medical student, this meant not just theological anthropology but repentance—waking up and learning to see the patient as embodying Christ himself, from Matthew 25: “I was naked, and you gave me clothing. I was sick, and you cared for me.” But how can such a perspective be taught among today’s medical trainees? The powers and principalities of medicine are poised to work against the iconic—reinforcing a vision of the patient that is dissective, reductive, and lucrative. In the hospital, even spiritual care can strangely reinforce a vision of the body-as-machine, especially when it is employed like a gloss over medicine rather than something suffused within the practice itself. Re-enchantment will take communities of counterformation who resist and transfigure the medical gaze.

I witness a re-enchanting education here in the Theology, Medicine, & Culture Initiative in which I serve, where we invite students across health care disciplines to gather and explore what difference the Christian tradition makes in the long work of healing. We do this through formational programs, spiritual disciplines, and a growing network of Christian health care workers who practice with iconic perception. At our best, we bear witness to a way of healing that certainly does not make medicine easier, even as it does make health care deeper, more whole, which is to say more healthy and—Lord willing—holy.

In so far as the life, death, and resurrected wounds of Christ are the standard by which we claim to receive iconic perception and participate in the renewal of all things—whether an ancient cathedral or the work of health care—then such beauty will not facilitate ease. Wounds make a claim on you. They draw the vision in and through, like Christ’s command to Thomas in John 20 to “stretch out your hand,” transfiguring the analytic gaze with a sense of wonder, faithful fear, grit-virtues, and I daresay a readiness for difficult work. Like Jost and his team, in the shadow of that which is wounded, we stand prepared to undergo a giant labor.

The wounds of Christ will no doubt be meditated upon in new ways within the renewed walls of Notre-Dame. It reminds me of the goldsmith and architect Lando di Pietro’s “Fragments of a Figure of Christ,” 1338, made with ink on parchment and polychromed walnut, which I recently had the privilege of witnessing at the Met. This work comes from a church that was also damaged, in this case not from fire but by bombing during World War II, such that the crucifix was “reduced to splinters,” leaving only a sculpted head of Christ with a large gash down the face.

After the destruction of the crucifix, two handwritten parchment notes were found hidden in the carving, one where Pietro claims the work as his own, and another where he asks God for mercy upon his soul. When the art critic Holland Cotter reviewed this exhibit, he observed that “devotional objects, from any culture, if taken seriously, make awkward demands on our attention, on our willingness or ability to meet them on their own terms. ...You look at them and, the assumption behind them is, they also look at you.”

As Kornu points out, this phenomenon is also true of the cadaver. There is a reason we covered the faces of our first patients: “Although dead, there is a sense in which you can be seen by the face of the cadaver.” Iconic perception means the icon reads you back. It makes awkward demands, like looking at the faces of others anew, as if it is really true we are not machines but ensouled creatures—split down the midline with longings and laments.

On the days in my clinical practice where there are 20 difficulties, I can say it is different when I look at the patient and find the patient looking back at me. It is different when I am reminded of their soul and reminded that I am an ensouled creature too—one that has burned and been burned and is also in need of a costly, astonishing, and often hidden love. I find myself asking questions I otherwise would not have asked. And I find patients asking me questions I could never have anticipated, sharing wounds long left unseen.

Doctors can learn much from the iconic vision of those craftsmen who restored Notre-Dame. Whether encountering someone suffering or a church aflame, beauty makes difficult demands on our attention, what Simone Weil famously called, like Notre-Dame’s rebirth, “a miracle.” To take a patient seriously is to welcome the miracle of the ensouled creature that waits before us, a beloved child of God who makes a claim on our work. In so doing, doctors may not find themselves rising from the ashes so much as stepping deeper into them, prepared to undergo a giant labor where beauty makes everything harder.

The author would like to thank his friend and colleague Warren Kinghorn for sharing Kimmelman’s article, inspiring some questions, and inviting him to reflect upon them.