Without Love, We Perish

July-August 2009


Br. Sulmasy is the Clinton-Kilbride Professor of Medicine and Medical Ethics, schools of Medicine and Divinity, University of Chicago.

Gospel-Centered Health Care Is a Radical Approach in Today's Secular World

Editor's Note: This article is the text of the keynote speech Br. Sulmasy prepared for the 2009 Catholic Health Assembly.

Several weeks ago, I went to a restaurant near our hospital with a group of fellow friars. Customarily, our routine is to have dinner together as a community on Sunday nights. On this particular night, since one friar in our community had just started working Sunday nights as a chaplain at St. Vincent's in New York, we were trying to accommodate his schedule by eating together at a restaurant near the hospital during his dinner break.

Responding to the size of our party (by which I mean not only the number of friars but also, literally, the size of the friars), the waitress who was seating us began to open an extension on the table. As she did so, however, she accidentally caught the finger of one of the friars in the hinge, and he let out a blood-curdling yell. We fumbled about frantically trying to find the release lever for a period that felt like five full minutes but was probably only 20 seconds. When we finally did manage to free his finger from the vice-like grip of the table, "Brother Doctor Dan" played his expected role and examined the injured finger of this frail, 78-year-old, legally blind friar. It was severely bruised and swollen. The nail was intact, but there was a half centimeter long laceration, moderately deep, and it was bleeding. Nothing appeared broken. His sensation was intact. He reported that he had received a tetanus booster last year.

This occasioned a therapeutic mini-dilemma for me. Should I march him across the street to the emergency room? I didn't really think he needed sutures, but then, I'm not a hand surgeon. He was up to date with his tetanus vaccinations, so that would not be a reason to go to the emergency room. In all probability he needed nothing more than a good cleaning, some bacitracin, Steri-Strips, and a decent bandage. But to register him, process the insurance, have him wait there in the emergency room nearly forever … To put Charlie through all this for so little gain didn't seem to add up. It would ruin everyone else's dinner as well. So, I thought up an alternative plan.

"Stay here, Charlie," I said. "I don't think you need stitches and you don't need to go to the ER. The waitress has a band-aid. I'll put it on your finger and have you hold it upright, like this. You can even start eating one-handed if you'd like. This will only take a few moments. I'm just going to zip over to the emergency room and get some antibiotic ointment and a special bandage called Steri-Strips and a few other things and I'll be back in a flash."

Fool that I am.

I had not even thought about the fact that I did not have my ID badge with me until the emergency room guard asked, "Can I help you sir?"

"I'm a physician on staff here and someone with whom I'm eating at a restaurant across the street has a finger laceration that I don't think needs stitches but could just benefit from Steri-Strips and some bacitracin and so I thought I could handle it myself if I just came over here and borrowed a few things without having to burden you with a much-less-than-emergency problem and also saving him all the trouble of registering and waiting. I just want to speak to one of the ER docs on duty."

"You can't do that, sir."

"What do you mean I can't do that?"

"We can't let you talk to one of the doctors."

"But I am a doctor. I'm on staff here. I'm chair of the Department of Ethics. Look, I don't have my ID badge, but here, look, here's my NYS physician ID card."

"I'm sorry sir, but you'll have to speak with the triage nurse."

"OK. OK."

I looked in the glass booth. There was a clerk seated at the triage desk and, immediately next to her, a heavyset woman in hospital scrubs bent down over the desk, writing out notes and filling out forms.

"I was told I that need to speak with the triage nurse."

"She's busy right now. Can I have your insurance information?"

"I'm not the patient."

"Then, where is the patient?"

"He's across the street. I just want to speak with the triage nurse about getting some supplies so I can help him myself."

"We can't help you without the patient, sir."

"But I'm a physician. I work here."

"I'm sorry sir."

"Can I speak with the nurse? One of the ER docs on duty? Who's on duty tonight? Tell them it's Dr. Sulmasy."

The nurse never looked up from the desk once during this entire exchange. She took a bite out of a sandwich, a sip of coffee, and kept on writing. The clerk said again, "I'm sorry sir. The nurse is busy and I'm not authorized to let you speak to a doctor. We can't help you."

It actually got worse. Much worse. In the interest of time I'll spare you the painful details.

Exasperated, I eventually left the emergency room, went to the main entrance, walked right past the guards to the elevators without showing any ID, acting as if I knew what I was doing. Since I usually enter the hospital through the main entrance and never through the emergency room, I suspect it was their recognition of me, rather than my confident attitude, that gained me entrance. I took the elevator to the 10th floor, went to the Medical Intensive Care Unit, found a few residents and nurses that I knew, reported what had happened in the emergency room, had a quick laugh, obtained some gloves, bandages, Steri-Strips, and bacitracin, thanked them for their help, and went back to the restaurant to attend to Brother Charlie.

Certainly, this could have happened anywhere. But this event, small as it is, epitomizes huge problems in health care today. Money. Bureaucracy. Indifference. Burnout. These problems are especially troubling for faith-based health care institutions. The institution in which this incident took place is named for a saint — a man who took to the streets of 17th-century Paris to seek out those in dire need, motivated solely by the Gospel's mandate of love. In this hospital's gorgeous, neo-Baroque chapel one finds written, in beautiful gold letters on the ceiling above the altar, "God is Charity."

Would St. Vincent de Paul have said, "Sorry sir, we can't help you?"

These issues are familiar to all of you. Sometimes we beat ourselves up in health care, convinced that the roots of these problems are firmly and exclusively planted in the soil of health care. Given this implicit assumption, we conclude that the solution must be within our grasp as health care professionals and administrators. But I want to suggest that the problems we face are far deeper than health care. The problems are so deep that they often even escape our attention as we search for solutions.

New York Times theater critic Ben Brantley's review of the recent Broadway revival of A Man for All Seasons can serve as an illustration of these problems. In his pointedly negative review, Brantley faulted not the production, nor the acting, nor even the play, but the subject, Thomas More, as being outdated. He found More "a bit of a bore," since he was actually too good. This review can be contrasted with Brantley's fawning review of a recent revival of David Mamet's Speed the Plow, in which a secretary, who seems to be the play's one good person, able to turn a hardened Hollywood producer toward love, and even toward God, turns out in the end to be nothing but a cunning, ruthless and ambitious scoundrel, feigning virtue in order to make the big bucks. According to Brantley, that's good theater. It shows us what he believes is the real truth about human beings.

Now there are those, even in Rome, who are convinced that Christianity still supports the basic architecture of the Western soul, holding it together like the flying buttresses of a cathedral, even though the altar has been removed, the statues and the paintings placed in a museum, and the sanctuary turned into a theater of the absurd. On this account, all we need to do is to remind people of their Christian heritage and all will be well again.

But Brantley's reviews suggest a more sober reading of the culture at large. Charles Taylor illustrates in his masterful work A Secular Age how the secular has become the default mode of thinking in society. But I am not sure, however, that even Taylor appreciates how far we have come. It is not just that the general Western culture is indifferent in its views towards religion, such that if God exists, God does not matter. I believe the reality is that our culture's fundamental views of beauty, truth and goodness have been dramatically transformed. Christian values no longer lurk beneath the surface, subliminally directing all we think, do and say. At this historical juncture, I do not think it is an exaggeration to say that Nietzsche's transvaluation of the values has taken hold of popular culture. The utter rejection of Christian values is no longer a phenomenon limited to a few members of the intellectual elite. Transvaluation of the values is the norm. We no longer believe, as the Catholic faith holds, that human beings are essentially good even if tragically flawed. We have all become closet Hobbesians. We believe human beings to be essentially self-interested rational maximizers who agree to moral rules only out of the ultimately selfish motive of survival. Morality is just a set of rules that keep us from killing each other in the war of all against all that is our true nature.

Am I not right? Don't our hospitals operate this way? We are beholden to a completely secular ideology — sometimes even when we think we are acting as Christians. Everyone we encounter is now regarded as a customer — someone we serve ultimately only because it is in our self-interest to serve her. Patients are our customers. Doctors, too, are our customers. They are customers of the hospital, because treating doctors well inclines them to admit patients to the hospital — they are the ones who really bring the business.

Alexander Solzhenitsyn once described ideology as a lie that blocks our ability to see reality for what it is. And as Solzhenitsyn also told us once he arrived in the United States, the former Soviet Union had no monopoly on ideology. This surprises us. We have become so steeped in the ideology of the market that we cannot even stand outside of it long enough to see it for what it is. We are compelled to look for measurable business outcomes in everything we do. This is the reality we have been conditioned to see. Everything must be measurable. Only measurable outcomes are real. Medicine is a business — and a tough one at that.

Just a century ago, William Osler, the most famous physician since Hippocrates, said, "The practice of medicine is an art, not a trade; a calling, not a business; a calling in which your heart will be exercised equally with your head." What would we say about Osler if he spoke those words today? Naïve old man. Actually a bit boring. Maybe a socialist.

The measurable "outcome" for Brother Charlie probably would have been the same no matter what had transpired in the emergency room. He probably didn't even need Steri-Strips or bacitracin. His finger has healed completely.

Love is not a measurable outcome. Love is not an ideology. It is, in fact, the only way to see reality as it truly is. Love is not indifferent about outcomes. We want the best for our patients. But the vision of love is far more comprehensive than outcomes. Love encompasses motive and intention and affect and process as well.

The ceiling of the hospital chapel says, "God is Charity." That is to say, God is love.

In his first encyclical, using the identical words for his title, albeit translated into the Latin, Deus Caritas Est, Pope Benedict XVI begins by reminding us that the religion we profess, which is the foundation and the rationale for Catholic health care, is not an ideology. Nor is it a philosophy of life nor even a moral code. It is, in the first instance, an encounter — an encounter with a Person — an encounter that changes everything.

We are frequently guilty, I think, of turning the Catholicity of our hospitals into a moral code. More conservative institutions will boast of a code which lists the things they will not do. More liberal institutions will boast of a code of social justice. The most Catholic institutions among us will boast of both. But none of these codes can serve as replacements for the ever-new and ever-renewing encounter with the person who is love. That encounter must be the foundation of our health care systems and our institutions.

We have so thoroughly domesticated the 13th chapter of St. Paul's First Letter to the Corinthians that it has lost much of its power. We have turned it into a bit of wedding kitsch, along with the synthetic fog of dry ice from which the newlyweds emerge, illuminated by stroboscopic lights, to the deafening sound of the band playing their theme song. But Paul's words are radical, dangerous and counter-cultural. In a world in which Christian values have been transvalued, we no longer even know what love means. MTV has turned love into a fleeting few moments of more or less simultaneous mutual self-gratification. Our culture regards itself as too sophisticated to believe in the other-regarding love that the New Testament calls agape.

But St. Paul is telling us something different — in words ever ancient and ever new. What Paul is saying, if you can hear it, is that you may have crucifixes in every patient's room; you may not have a single employee who would ever even think of performing an abortion; you may have excellent services for the poor and the undocumented; but if you do not have love, you are nothing. You are Zero. Zippo. Nada.

Practicing the healing arts as acts of love is not impossible. Christians have been doing it for centuries — following upon their conviction that the One whom they have met, the Mystery, the One who washes feet and proclaims that God is love, is the foundation of the universe and the only true healer.

And Christians are still doing it today, in your hospitals, quietly, under the radar.

I am privileged to know quite a few such persons, and I suspect you are as well. For the last six years I have been meeting monthly with a group of fellow health care professionals — a mixed group of physicians, nurses, medical students and psychologists. We are mostly, but not exclusively, Catholic Christians. Sometimes I think of us as a base Christian Community in health care. Sometimes I let my imagination run a little wild and muse that we are in the catacombs, hiding from the bureaucrats who are ready to feed us to the lions. But when I reflect on why I attend these meetings, I think it is, quite simply, to be supported in my faith as a Christian physician. This support comes mostly from hearing other members of the group share with the rest of us what it means for them to find God in their work.

One among them is a young nurse named Veronica. Her nickname is Vero, which means "True." She has a heart so huge that it can only be the case that it is someone else's heart that she is sharing with her patients. She has a fierce passion for people, for nursing, and for Christ. She is Italian-born, was educated in the United States, and works in a secular university hospital. I hear her tell regularly of her struggles with her nursing supervisor who is constantly telling her to stop spending so much time with patients because they can't afford to pay her overtime, and how she says she doesn't care about overtime, she cares about her patients, and how her supervisor retorts that union rules preclude her from working overtime and not being paid for it. I hear her tell regularly of the tragic indifference of some of her nursing colleagues. But my own heart feels bigger when I hear her tell stories like the one she told our group not long ago about an elderly man with Alzheimer's disease admitted for a urinary tract infection. He had had no visitors during his three days in the hospital. She told us, in her odd linguistic mixture of an Italian accent and Valley Girl grammar, "I was, like, you know, really feeling bad for him. I mean, like, he seemed so lonely, you know, and, like, nobody else, like, seemed to care about him, you know, like, as a person and all that. And when I came on the shift he had, like, wet the bed and, like, smelled of urine and stuff. And it must have been that way for a really long time because the sheets were already, like dry, you know, and he had dried food all over his face and, like, no one else really seemed to give a s_ _ _. But I couldn't be like that, you know. I mean I know he's like a real human being and he needs to be loved and so I, like, figured I could be a few minutes late with the meds on the other patients and I, like, changed his sheets and stuff and got a wash cloth and washed his face so he'd look, like, decent and stuff. And well, I don't know, like, isn't this what it's about, I mean, like, nursing? Like I know he can't make sense when he talks but that's no reason to let him sit there all dirty and stuff. And, like, I know he can't thank me but, like, that's not why I became a nurse, right, like, to have people thank me? I mean, like, at least he smiled a little when I wiped his face. But, like, you know, I just get so frustrated sometimes because no one else seems to see it this way."

I could not help wondering, hearing her talk, whose face Veronica saw on that washcloth after she removed the dried remains of lunch from that patient's face.

Veronica's nickname is Vero. What Vero sees is the truth. We need her vision everywhere today. I am persuaded that her experience must be very close to the experiences of Elizabeth Seton and Louise de Marrilac, and Vincent de Paul, and Catherine McAuley, and the Beguines who gave rise to the Alexian Brothers, and Francis of Assisi, and Mother Alfred Moes, and so many countless others in whose shoes we stand today when we enter our Catholic hospitals and nursing homes to work.

We should, after all, be measuring our programs by the light of the Gospel, not interpreting the Gospel in light of the latest business school fad. Speaking with a reporter for a Catholic publication about what I was going to say in this talk was very illuminating. She kept trying to get me to say what sort of education program I would be recommending; what she should write about how ethics committees in Catholic hospitals should change their practices in light of my talk; whether this would have implications for servant leadership programs underway at many Catholic health care institutions. I said to her, this talk has more to do with a call for us to return to a fundamentally Christian orientation toward the world, with seeing Jesus' washing of the feet of the disciples as normative, with understanding that if we name a hospital after the Good Samaritan that we ought to start behaving as if we believed that these stories about the meaning of love were the true meaning of all ethics.

The secular has become the default mode. The idea of Christian love itself has become a quaint relic of the past. In its place we now have management.

Fundamentally, management is the science of figuring out how to make people change their behaviors in conformity with your goals, while making them think that it was their idea in the first place. As Bellah et al., point out in Habits of the Heart, we have become a culture of managers and therapists. The managers manipulate us, and the therapists build us up again from the stresses induced both by managing and by being managed. We even dare to try to manage care, as if the kind of care of which Veronica spoke so eloquently were something amenable to management. The word 'manage' actually comes from the Italian maneggiare (not mangiare, the verb to eat, but maneggiare), which is the term for horse-handling. We are so immersed in the culture of management that we think we can manage our way into the future of Catholic health care. What's the right program? Who's the right consultant? This is ideology — the lie that blinds.

This ideology is far more pervasive than health care. Health care did not create this culture, and the solution is not to be found in a new management program in our hospitals and other health care facilities, to help us manage management. That is why Gospel-centered health care is such a radical idea. It is monumentally counter-cultural. It threatens the dominant ideology.

Gospel-centered health care begins where the Gospel begins — in an encounter with a Person. We meet that person in each patient that we serve — one at a time. Gospel faith tells us that God is love. Love is ultimately an act of surrender — surrender to our heart's deepest desire, which is both of God and for God. The Gospel impels us to serve our patients with love, full of the faith that the infinite God is incarnate in our world, especially in the sick.

Now I am sure that there are plenty of you who have deep doubts about everything I have been saying. You may think this is all vague, pious, abstract and irrelevant to the work we must undertake — which is not only assuring the survival of Catholic health care, but providing for its flourishing in the 21st century. Some of you may even think that what I have said is plainly untrue.

But if what I have been saying is irrelevant at best, or a distracting fairy tale at worst, then the Gospel itself is either irrelevant or a fairy tale. And we might as well all go home, dissolve this organization, and merge with the American Hospital Association. But before we do that, I would invite all of you, in all of your doubt, to go down to your hospital's emergency room when you return from this meeting and visit the trauma section. Don't just visit and observe like an outsider. Don't go there with any preconceptions. Try for a few seconds actually to cast aside your ideologies. Don't divorce yourself from the experience by abstract observation. Put on a gown and a pair of gloves and stick your hands into the bloody wounds of one of the patients being treated there. Feel the warm blood of life. Experience the pulse of the beating heart of a fellow human being. I can guarantee you that the Wounded One is there. Touch him. Really touch him. Touch his reality and see that He is no ghost. Touch Him that you might believe. It is only by His stripes that you can be healed.

Quite obviously, a spirituality of health care that is only about our experiences of the Divine in the work we do will not be sufficient. I am a physician. That means I am a practical person. We cannot jettison a commitment to competence nor abandon our reach for excellence. All I am trying to say here today is that technical excellence, commendable outcomes, and satisfied patients are not enough either. Even the Pharisees strive for as much.

Christian health care must be based on love, and love is not an abstraction. Love is concrete. We will need programs. We will need skilled administration. We will need extraordinary physicians and nurses and chaplains and social workers and patient transporters and lab technicians. But unless all of this is pursued in love, it will come to nothing.

Tina Turner, perhaps most famous for singing that she had "Pumped a lot of 'tane down here in New Orleans," once asked the musical question, "What's love got to do with it?" The poet John Greenleaf Whittier wrote a remarkable poem that says more succinctly and eloquently all that I have been trying to convey. The text has been set to music as a hymn by various composers. I am most familiar with a version composed by the late Franciscan friar Anthony Fedell. You may know other versions. Fear not — I will not try to sing it for you. But I will recite it. It is called, "Immortal Love."

Immortal love, forever full,
Forever flowing free,
Forever shared, forever whole,
A never ebbing sea!

Our outward lips confess the name
All other names above;
Love only knoweth whence it came,
And comprehendeth love.

We may not climb the heavenly steeps
To bring the Lord Christ down;
In vain we search the lowest deeps,
For Him no depths can drown.

But warm, sweet, tender, even yet,
A present help is He;
And faith still has its Olivet,
And love its Galilee.

The healing of His seamless dress
Is by our beds of pain;
We touch Him in life's throng and press,
And we are whole again.

Through Him the first fond prayers are said
Our lips of childhood frame,
The last low whispers of our dead
Are burdened with His Name.

O Lord and Master of us all,
Whate'er our name or sign,
We own Thy sway, we hear Thy call,
We test our lives by Thine.

Faith-based health care faces all the agonies of Olivet. We experience these agonies on a daily basis. Love-based care calls us forth as people of the resurrection — into the wilds of Galilee, into the depths of its never-ebbing sea.

What's love got to do with it? Love has everything to do with it. We must learn to sing "Immortal Love" and believe it. In a sense, we must start all over again, joining the chorus of our founders and foundresses.

Now is exactly the right time to do this. Precisely when the going is toughest and we are frantically busy putting out so many fires that we think we have no time for spirituality in the workplace is exactly the time in which we must return to fundamentals. Management can't do this. The kind of health care workers we want in our corridors will not be persuaded by slogans adapted from Henry Ford. Only through grace and our openness to the gifts of the Holy Spirit can we do this. We must return to a conception of the whole health care project as an enterprise based squarely upon love. We must start our ethics there. We must start our administration there. We must start every operation performed in our hospitals there. We must start each spoonful of medicine we administer, crushed and mixed with applesauce, right there. If we do not, whatever else we might be doing, we will not be doing Catholic health care.

America desperately needs faith-based health care. But such counter-cultural health care will not be an easy sell. It is a common human tragedy that we avoid the things we most deeply need and want. And so faith-based health care will also have to be hope-based care — care based on the hope that we can actually pull this off even in the 21st century. Because what we all desperately need and want is loved-based care. Of the three things that last, we must never forget that the greatest of these is love.

May the Lord give you peace.


Copyright © 2009 by the Catholic Health Association of the United States
For reprint permission, contact Betty Crosby or call (314) 253-3477.

Without Love, We Perish

Copyright © 2009 by the Catholic Health Association of the United States

For reprint permission, contact Betty Crosby or call (314) 253-3490.