This story arose from a conversation I had with my friend, James Booth. Jamie Booth is married to my friend and classmate Jane Easdown. They both work in Nashville. Jane is a professor of anesthesiology and Jamie is a professor of moral philosophy. Jamie moonlights in the prison system as a lay minister. He described his group, men who had sometimes done terrible things, lost everything, and were struggling to find meaning and comfort in their lives. They were men whose lives had been marked from childhood with poverty, drug addiction and lack of education. All the aces had been removed from their decks.
As we hung out at their country place in the Laurentians, Jamie and I started geeking out, discussing a biblical quote I love, and the translation of a single word.
The word in Hebrew is chesed which in the King James Bible is translated as “mercy” but in Jewish sources is usually translated as “loving-kindness.”
The most famous quotation about chesed comes from the prophet Micah:
Micah 6:8
He has told you, oh man, what is good, and what the Lord demands of you;
But to do justice, to love loving-kindness (chesed), and to walk discreetly with your God.
Chesed, I believe, means finding something intrinsically lovable and precious inside every person, that part of each person that demands recognition for who they are at core, acknowledging their intrinsic worth.
Thinking about chesed made me consider how much the concept of “loving-kindness” is so important in the practice of medicine.
Taking care of lovely people is lovely! It is easier to work hard and do our best for people who are easy to relate to. It becomes more difficult when we must care for the unpleasant, the ungrateful, and most importantly people whose actions we despise.
I wonder how the physicians who receive those who attack synagogues, mosques, and churches, like the recent one at the Belleville Synagogue, deal with trying to save the life of someone who intended to be a mass murderer? As doctors, we have taken an oath to save lives, to do our best. Yet sometimes it is hard. It may help to hang onto an image of a damaged person, consumed by their own demons.
In my own life and practice, I have had patients whom I struggled to care for.
I have cared for gangsters, bikers, and people who used patient confidentiality to make me complicit with their infidelity.
I had a borderline patient, in the early days, who was so violent and damaged that she was banned from the Douglas Psychiatric Hospital for beating a security guard to a pulp, although she weighed only 98 pounds. Honestly, imagine what you have to do to be banned from a psychiatric hospital! I learned a lot from her. Knowing her history of childhood neglect, sexual abuse, and the complete denial of her intrinsic worth as a person by all those who were supposed to love and protect her, opened my eyes to compassion. I found something to love in her angry, fragile, soul.
Then there are the patients who I, personally, find the hardest to deal with, the ones who question my every decision. The ones who have consulted Dr. Google, their Naturopath or their Dr. Cousin across the ocean. These are the ones who expect me to fill in the requisitions, send them to the specialists or prescribe the drugs they desire without respecting my opinion or judgement. This just pushes my buttons! I have to take a deep breath and remember that this behaviour comes from fear. I have to force myself to remember, with loving-kindness, that they are suffering because they lack trust. I try to build a bridge. Sometimes I don’t manage. The struggle itself has worth, and I try to do better.
I believe that working toward an attitude of loving-kindness makes me a better physician and perhaps even a better human being.
Then there is the first part of the injunction, “to do justice.” I admit I was hesitant to even address this part of the quote. The complexity of politics in the world, the horrors of what is happening in the Middle East and the growth of antisemitism across the globe has created a world where being publicly Jewish is often problematic. Interestingly, it is seldom the patients who have this issue. The multicultural community of patients that I have cared for throughout my practice and teaching career, many of them Muslim, have rarely hesitated in their trust and respect. It is often at the university level where these issues arise.
Yet justice is necessary. One cannot condone every act because people have a tough life or because they perceive that their actions are necessary to bring about a desired outcome. This is how criminals, madmen and despotic leaders justify their crimes. Another of my friends works as a parole officer with young offenders. Very often, he says, these young people justify their crimes by saying, “I needed to do it.” They do not consider the impact of their actions on others.
To return to the clinical, what does “doing justice” mean in medical practice? I believe that the gentle understanding and relativism of “loving-kindness” must be tempered with a stiff dose of the truth. It is not justice to do bad medicine simply because that is what the patient wants. We cannot use our “physician’s mantle” to scam patients. We need to refrain from the temptation to indulge in what may be lucrative but unnecessary products and procedures. We need to be honest about what we know, what the patients must do, make the hard calls with the limited knowledge that is the truth of being a physician in the real world.
We need to act with our eyes, minds and hearts open, with chesed.