Anatomy

Gross lab is getting a little easier because I'm growing a psychological callus: I can touch anything and it doesn't bother me, I can stand for long periods, skeletal hands and shoulders don't faze me....

We're in the abdomen now, which is more familiar to me from dissections in college. I've also noticed I have better days when a certain pair of lab partners isn't there. In fact, the better days are the days when everyone around the tank is Catholic. The conversation is cleaner, I feel more confident, etc. I still get exhausted afterwards (I'm posting right now because my brain is good for nothing else; I was going to study, but just can't).

Today my eyes are full of fumes--the entire surface of my eyeball, all the way back into the orbit, is sore. The body we've been assigned (our third--we rotate after each major region) is developing mold, and bleach + phenol + fat + bile is pretty strong. One of my tankmates is just recovering from a stomach bug. He just got his appetite back today, and he comes into lab to a putrid tank and an open gallbladder! So I can't complain. All A.M.D.G. Time for histology.

Ah, postmodern political correctness...

Got my ethics paper back. Lots of trivial comments about commas and things; however, there is one comment that was truly remarkable.

This is the humanities department. Has anyone any tolerance for the language of the Philosopher and the thousand plus years that translated him? Ho no! We must only respect the whims of the last fifty years' worth of English!

Ahh.... That's a good one.

Schedule nowadays

Some adjustments: praying the rosary along with a podcast in the car is too dangerous! I'm praying it slowly to myself now, in lots of installments throughout the day.

7:00 - wake up, pray
7:20 - walk with notecards on iPhone
7:50 - get ready
8:00 - breakfast
8:30 - leave for school
9:00 - class
12:00 - Midday Prayer, lunch, study (occasional interest group meeting: I only want to be part of OB/GYN and bioethics, but I'll dip into family med)
1:00 - class and studying afterwards
5:30 - Mass, sometimes confession beforehand, read from the Church fathers on virginity
6:15 - go home and study
10:30 - Evening Prayer, dishes, bed

Late-night reviews in the Gross Lab sort of mess this up, but c'est la vie. Also, I'm beginning to meet with a group of peers on Mondays to pray for the upcoming week. They are Protestant, but "test everything; retain what is good."

Dignum et Iustum

I predict the Catholic blogosphere will be abuzz with discussion of the new translation in the next three months. I have looked forward to this change since junior year at TAC, and am so glad to be getting back to a Missal as exalted as the one I loved for four years.

I'll try not to contribute too much to the new translation hype, but I must comment one particular change. The last response in the opening of the preface (right now, "It is right to give him thanks and praise") is changing to "It is right and just." For four years, I said the Latin: "dignum et iustum est."

What is "dignum" is fitting, worthy, appropriate. "Iustum" is very similar: it implies commensurability, fittingness, what is due.¹ The Church is wise, and would not include two synonyms. I posit that the two words are not redundant. My thesis: "iustum" is to "dignum" as politics is to ethics.

A polis (a ruler and those he rules) is an image of our relationship with God: God is a beneficent, provident ruler. He is so great a ruler that our debt is enormous; a holocaust of self is too little, although it is the most we can give. It is "iustum" for us to offer our entire hearts in thanks.

It is also "dignum," for a different reason. "Dignitas" belongs to persons² by their nature, because they have what Aristotle called a "divine" power, the intellect.³ From what St. Thomas says about the origin of "person,"⁴ I gather that "dignitas" has always been associated with persons. So perhaps, "dignum" implies a fittingness between persons, while iustum implies a fittingness between parts of a political entity.

See how much the Church teaches us in just a few words? We completely surrender our hearts to God not only as subjects bound by justice; we do it as persons overflowing with gratitude for another person who has loved us so completely as to merit our whole heart. No citizen owes his king such a complete surrender; a different image is evoked by "dignum."

"Dignum" and "iustum" capture two images of our relationship with God. Both are helpful but neither is perfect. Together, they form a complex and fuller picture of how we are to act in each present moment: giving completely by gratitude to the holiest of Kings and the most perfect of Friends. I look forward to saying these words in November!

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¹ Summa Theologica II-II q. 57.
² Boethius: "a person is an individual substance of a rational nature," quoted by St. Thomas, I q. 29 a. 1
³ Aristotle, De Anima, III
⁴ Summa Theologica I, q 29, a 3, obj 2, again quoting Boethius (De Duab. Nat.)

Faith & Hope & Love: 2 Weeks Old

This mother gave birth to conjoined twins two weeks ago. When an ultrasound revealed her daughters' condition, she was counseled to abort. Read her reflection here.

Baby's first HPI

I am writing my first "History of Present Illness" or HPI, as a first step to learning how to write a "SOAP" note (SOAP is an acronym for four parts of a good medical encounter: Subjective, Objective, Assessment, and Plan). How exciting!

AIDS and the Church

Shameless Popery: What Impact Does Catholic Teaching Have on AIDS in...: The Catholic African countries have lower AIDS rates than the non-Catholic ones.

Unjust laws

I did a tiny amount of research on unjust laws between studying the leukocytes and reviewing the anterior abdominal wall. I found an incredible page: a compendium to Catholic social teaching, courtesy of the Pontifical Council of Justice and Peace. §399 and §400 deal with unjust laws, obedience, objection, and resistance.

§400 quotes St. Thomas Aquinas: "one is obliged to obey ... insofar as it is required by the order of justice" (Summa Theologiae, II-II, q. 104, a. 6, ad 3um). St. Thomas defines "the just" in II-II q. 57:

I do "the just" when I render to others what is their right or due, i.e., what is "commensurate with" them in their dealings with or relationship to me.

The order of justice refers to the order in the kinds of law (II-I q. 91): eternal law (God's providence), natural law (principles in us driving us to natural goods), and human law (public law, military law, decrees, statues, international law...).
St. Thomas considers the unjust law in II-I q. 96 a. 4.

...laws framed by man are either just or unjust. If they be just, they have the power of binding in conscience, from the eternal law whence they are derived, according to Prov. 8:15: "By Me kings reign, and lawgivers decree just things."

...On the other hand laws may be unjust in two ways: first, by being contrary to human good, through being opposed to the things mentioned above.... The like are acts of violence rather than laws; because, as Augustine says (De Lib. Arb. i, 5), "a law that is not just, seems to be no law at all." Wherefore such laws do not bind in conscience, except perhaps in order to avoid scandal or disturbance, for which cause a man should even yield his right, according to Mt. 5:40,41: "If a man . . . take away thy coat, let go thy cloak also unto him; and whosoever will force thee one mile, go with him other two."

Secondly, laws may be unjust through being opposed to the Divine good: such are the laws of tyrants inducing to idolatry, or to anything else contrary to the Divine law: and laws of this kind must nowise be observed, because, as stated in Acts 5:29, "we ought to obey God rather than man."

Where do inconvenient laws about ebooks fit? One could argue that control of intellectual property doesn't promote the common good, or is outside the authority of government, or is overly burdensome. These arguments don't seem iron-clad to me. And it's certainly obvious that these laws are not unjust "through being opposed to Divine good" or natural law, or Divine law. Other laws, like the court precedents and healthcare bill promoting abortion, are different. These are against Divine and natural law, and we may object and resist according to Catholic teaching, summarized in §399-§400 of the Compendium of the Social Doctrine of the Church.

It's back to blood cells for me; what do you think of this?

First "patient" interview

On Wednesday I took my first "history" as a "doctor." (Look at all those quotation marks!)

Our clinical skills class began a new phase this week. We have finished learning the history and review of symptoms--now we get to practice! Each week, a student will interview a "patient" with a chief complain related to one of the systems in the ROS. This week was "breathing problems," and I volunteered to do the interview.

Before class, I'd emailed the professor: "I am looking forward to practicing history-taking on Wednesday. Will I be responsible for taking notes during the interview? Also, will I go through the ROS and complete family/social history?" The response was typically crisp and without all the capitalization I'd bothered with: "no notes necessary...review mostly the general and resp ROS questions so you can do the HPI for this case of breathing problems...thanks for volunteering..." (I didn't add the ellipses: that was the exact text of our emails. Maybe someday I'll send emails that surgical.)

The nights before, I reviewed the ROS and practiced questions to myself. "When do you cough? How long does a cough last? Do you cough anything up? How much?" It was so exciting!

More on ebook behavior

Update on the ethics practical: I presented my question to my online peers. Results are below. Disclaimer: small sample, uncontrolled population, so results are statistically useless. But I am intrigued anyway.

Are unpaid-for ebooks common at your school?
Yes (most students have them)		66	72.53%
No (most students don't have them)		9	8.79
Sorta (maybe half the students use them)		15	15.38
Don't know...		3	3.30%
n: 91

Two sample comments:

it is illegal...everyone, including medical students, share anyway...who cares. If you morally object to it, then don't do it[.]

Man-made laws and your own sense of morality are not mutually inclusive.

In my investigation I also learned that this is a matter of civil law (lawsuits), not criminal law (misdemeanors and felonies). But it is still the law. I believe there is a virtue and holiness acquired by obedience to law, whether be it an excellent law, a pure convention, a harmless hoop to jump through, or inconvenient measure. I didn't say all that online, but I did say "I tend to think breaking the law is not moral." Someone called me "naive" twice in one sentence. And someone simply responded:

...I'm afraid you are wrong.

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Update: I looked up the Church teaching on this legal-moral-ethical-same-thing deal. Here's what I found.

AMA Resolutions

Apparently, medical students can submit resolutions to the AMA. I'd love to work one up on breast cancer and contraceptives, or on contraceptives (and not prescribing them), or on abortion (and never advising it).

I am thinking about working on one of these (probably the first one) this summer. In the meantime, here's a treat for you: all the AMA's policies about abortion. (To search among AMA policies, which influence law in this country, visit the policy search.)

Arts

All these serious ethics posts need a little light--so here is something delightful: cooking! I like ethics; I like cooking. (I'm not a master at either one, but I'm learning.) They're both arts, which means they take practice to acquire and they exist in the soul of the one who has them, like a mark of character.

I learned a lot (about cooking!) today. I made twelve mini turkey-pot-pies in a muffin tin: lunch for the whole week! It was the first time I've made pie crust, but undaunted (or ambitious? stupid?) I began. The result: a harrowing journey with success at the end!

Lessons learned:

1. Make less filling (I had extra and made a pasty!)
2. Use larger rounds in cups to create better seals.
3. Use bigger workspace to roll out dough and cut.
4. Bake at a temperature above 325° for less time.

(I probably won't make these again; the carb : goodness ratio is too high.) In the past few months I have learned so much; there are many more character-prints I need to be perfect. My whole life is a harrowing journey like today's. (I am glad God is in the kitchen.)

Ebooks: ethics practical exam

During the first few weeks of school, everyone was passing around ebooks. I only bought one physical book--everything else was on my computer. How cool, right? Save hundreds of dollars buying books, hundreds of centimeters storing books, hundreds of newtons lugging books...great idea!

Someone posted a comment about the books on facebook, calling them "bootlegged." I became a little alarmed: wasn't this perfectly fine, what we were all doing?

I emailed an M2 who hosted a website full of the books. I asked him what the law surrounding ebook sharing was. Here is his response:

To be legal, you should not obtain these digital copies if you do not currently possess the physical book. To be moral, you should buy the book if you plan to continually use it and keep it. Otherwise I see it as no different than checking out a book from the library, and you should delete them after you are through with them.

I stared at the screen, aghast! We can be "moral" while being illegal?? What kind of doctors are we planning on being?! (Apparently, lousy ones who don't listen to all their elders talk about slippery slopes!)

I have now bought paper copies of all the ebooks I use, and deleted all the rest. I hope some of my classmates do, too...but I hate to bring it up. ("Hey, I think your integrity is being eroded by the possession of those e-books. You'd better buy the physical versions for the sake of your soul and the health of your patients." Yeah...that'd go over well.)

The changes in the Declaration of Geneva

The Declaration of Geneva is an international document written in 1948 (after the Nuremburg trials) to replace the Hippocratic Oath. It has since been modified five times. What do you notice? (Besides additions of PC terms like "sisters and brothers.")


          Original Declaration of Geneva:
At the time of being admitted as a Member of the medical profession:

• I solemnly pledge to consecrate my life to the service of humanity
• I will give to my teachers the respect and gratitude which is their due;
• I will practice my profession with conscience and dignity;
• The health and life of my patient will be my first consideration;
• I will respect the secrets which are confided in me;
• I will maintain by all means in my power, the honor and the noble traditions of the medical profession;
• My colleagues will be my brothers
• I will not permit considerations of religion, nationality, race, party politics or social standing to intervene between my duty and my patient;
• I will maintain the utmost respect for human life, from the time of its conception, even under threat, I will not use my medical knowledge contrary to the laws of humanity;
• I make these promises solemnly, freely and upon my honor.

    Current Declaration of Geneva:
At the time of being admitted as a member of the medical profession:

• I solemnly pledge to consecrate my life to the service of humanity;
• I will give to my teachers the respect and gratitude that is their due;
• I will practice my profession with conscience and dignity;
• The health of my patient will be my first consideration;
• I will respect the secrets that are confided in me, even after the patient has died;
• I will maintain by all the means in my power, the honor and the noble traditions of the medical profession;
• My colleagues will be my sisters and brothers;
• I will not permit considerations of age, disease or disability, creed, ethnic origin, gender, nationality, political affiliation, race, sexual orientation, social standing or any other factor to intervene between my duty and my patient;
• I will maintain the utmost respect for human life;
• I will not use my medical knowledge to violate human rights and civil liberties, even under threat;
• I make these promises solemnly, freely and upon my honor.

The Hippocratic Oath, largely unmodified (apart from the effects of translation) in 2500 years, protects life from conception. In the Declaration of Geneva, however, "from its conception" was changed to "from its beginning" in 1984. The clause was removed altogether in 2005.

Hippocratic Oath

Today's ethics class was on oaths of medical professionals. I have a strong respect for the Hippocratic Oath due to an excellent analysis by Leon Kass in his Toward a More Natural Science. I highly recommend his one-chapter analysis to everyone. While you read, compare the Oath and the AMA Principles. (These links will take you to scribd.com.)

The lecture was hard to take. The professor stated that the Oath's abortion clause was not a perennial proscription of abortion; rather, it was an example from the writer's time. I wish she could've heard herself! I regret not writing down her exact words, but I have a crisp memory of her point. She said very confidently, "some will tell you that this clause is forbidding abortion and prescribing deadly drugs. That is not true. It is forbidding," and she sort of hesitated, "the harm that these involve, because...ah...when you give the patient that drug you are...harming. But these examples are definitely from their time." It hurts to hear things so false, so ingrained, and held as so irrefutable.

The lecturer also remarked that the Hippocratic Oath lacks the principle of autonomy. As she said this and as the moderator remarked on the fact, I heard condemnation mixed with respectful confusion in their voices. "Certainly," they seemed to say, "Hippocrates is revered, but how could such a grave oversight stand for so long? A travesty, a deep offense to the patient...." I said nothing--so hard for a TACer!--but I wish I could have spoken. The Hippocratic Oath needs no principle of autonomy. Autonomy is like a bandage, correcting a true fault but not with a real cure.

Our discussion afterwards was mixed. On one hand, people identified what I think are key duties of the physician: treat and prevent. On the other, they wanted to include things like "respect diversity." That is another bandage. As the years progress, oaths and codes get wordier and wordier with more and more bandages. At bottom, these oaths just say "be a good person," and if everyone did this, they wouldn't need to be any longer. But to lousier people (or people who make poor judgments) the oaths prescribe the minimum behaviors necessary to avoid punishment...so our oaths get longer and longer. "A thousand laws are needed wherever a single virtue declines" (Statement of the CMA on Healthcare Reform).

Ethics class

We have an interprofessional ethics course. This is a continuation of the same course that hosted the AMA president emeritus and a few other lecturers earlier this year. The course has changed a bit, and it's a little more like TAC (yippee!). (Even the grading is like TAC. My classmates are all nervy about it, but I sit grinning from ear to ear. At last! It feels like going home.)

A group of eight students (mostly medical students, but one or two nursing students also) and one moderator meet and discuss an ethically-challenging case study. There is a rubric full of questions and issues to cover. If appropriate, I will share these cases with you. This way, I can think through what was discussed in class, you can see what medical students are seeing and thinking, and the discussion can continue here.

The first case was that of Dax Cowart. This man suffered 60% burns and was treated at Parkland's burn unit in the 1970s (narcotics were not well-understood) beyond his wishes. He made a video called "Please Let Me Die," which we were assigned to watch before the discussion. My thoughts:

1. Mr. Cowart's case and video remind me of the patients I've visited in nursing homes. They're alone so often...it's heartbreaking. Who can live without love? I wish there had been someone with Mr. Cowart during all those sufferings.
2. It isn't right to hand someone a gun so that they may kill themselves; however, it is right to allow a patient to decline reconstructive surgery. Somewhere in the middle, there is a line--where is it? What is heroic and what is not?
3. I used to be pretty anti-autonomy, because I thought that "autonomy" only meant the patient coming to the doctor with demands (I need this prescription, I want this procedure...), which seems anti-medicine. But "autonomy" can actually means that the patient has the final choice about what is done to them. That's not so bad.*

That's about all I've got. There's a lot that I'm not very good at articulating right now--a lot about the Cross and suffering and Christ and love. I'd love to have that pour out of my mouth eloquently, but I never feel as though I have the ethos to start it.

What are your thoughts on Dax Cowart and autonomy?

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* Our culture is more allergic than other cultures have been to the beneficent, paternalistic doctor. Reading Aristotle in isolation (which I have spent some time doing) makes it seem like the Greeks thought a patient should fling himself into the hands of the good doctor! The doctor was, after all, the Art personified.

Daily Schedule 2

My day has changed a little bit, since I'm part of some study group and my roomie has moved in.

7:00ish - wake up, pray. Only sometimes walk to mail kiosk, get mail.
8:00 - breakfast
8:30 - leave for school
9:00 - class
12:00 lunch/interest group meetings
1:00 - more class
3:00 - more class or lab (some days) or group meeting
5:30 - Mass, only sometimes
6:30 - go to group meeting (or to anatomy lab)
9:00 - go home, study
11:00 - Evening prayer and bed

Ew. I liked the first schedule better. (Guess who's going to quit some groups?) I want daily Mass, and I want more prayer. Meetings and stuff take the best parts of my day and keep me in the tunnel of a very worldly day. Here's my goal for the next two weeks:

6:45 - wake up, pray
7:00 - walk with notecards on iPhone (get mail)
7:30 - get ready
8:00 - breakfast
8:20 - leave for school (traffic is up since the undergrads started school last weekend), Rosary in car
9:00 - class
12:00 - Midday Prayer, lunch, study (occasional interest group meeting: I only want to be part of OB/GYN and psychiatry, but maybe I'll dip into internal med and family med)
1:00 - class and studying afterwards
5:30 - Mass, sometimes confession beforehand, read from the Church fathers on virginity
6:15 - go home and study
10:30 - Evening Prayer, dishes, bed