TY - JOUR AU - Arriola,, David AB - Abstract This paper follows two main arguments. First, using the works of Jeffrey Bishop and Gerald McKenny, is the argument that medicine forms physicians to think of both patients and themselves as machines. Informed by medicine’s epistemological norm, the dead body, life is reduced to a series of mechanisms that resist the stasis of death aided by the efficient control of medicine. The physician is supposedly a neutral and objective scientific machine that harnesses the efficient power of medicine to exert force on the moving matter of the body in an attempt to control or at the very least resist death. The second argument counters the first by arguing for the Christian practice of praying the Psalms. The Psalms resist medicine’s attempted control of death by calling on the God who saves. The language of the Psalms allows medical providers to view themselves and their patients as contingent human beings. I. INTRODUCTION A few years back, there was a great to-do about the supercomputer Watson and its performance on the show Jeopardy. Watson soon moved into other areas of work, including medicine, and the question arose, will computers like Watson soon replace doctors? Some estimated that up to four out of five doctors would be replaced by machines, whereas others vehemently argued that machines could only aid, not replace, the physician. A common argument for the necessity of doctors would be like what was published in The Atlantic: “Physicians, after all, do more than process data. They attend at patients’ bedsides and counsel families. They grasp nuance and learn to master uncertainty” (Cohn, 2013). Physicians retain a human touch that cannot be replaced by a mere machine that processes data, though the physician’s work could be aided by such a machine. I find this counter ironic, however, because it is my contention that medical education is geared toward producing physicians who in fact regard themselves as machines and not as embodied human beings. For the first three sections of this paper, I will argue that medicine’s reductionist metaphysics forms practitioners not just to dehumanize their patients to a physiologic machine, but to reduce themselves to (supposedly) objective, scientific machines. These scientific machines function to fight human contingency, whether by eliminating suffering or by fighting against restrictions on human choice. Their point of reference is medicine’s greatest informant and greatest foe, death. For the final section of the paper, I will look to resources within the Christian tradition as an attempt to counter this (mal)formation of physicians, namely, through praying the Psalms. The language of the Psalms is the language of witness rather than efficient control, and through the practice of praying the Psalms, the reader will discover it is God who fights for us, not the physician, because only God can and has defeated death. II. BISHOP ON THE POWER OF DEATH I shall begin with Jeffrey Bishop’s work in The Anticipatory Corpse where he follows Foucault’s work from The Birth of the Clinic on the philosophical underpinnings of modern medicine. The starting point is the shifting space in medicine that coincided historically with shifts in political space. With the rise of the clinic, patients were no longer located and embedded in the social space of their homes, “the natural place of disease and healing,” but dislocated to the “unnatural” space of the clinic (Bishop, 2011, 41). Here in the clinic, “the space of the patient’s bedside was the joining together of seeing and knowing and their relationship to saying” (Bishop, 2011, 45). It is here that the patient’s disease is subjected to the “medical gaze” at the hand of the master physician and his pupils and subsequently described with medical language. In Foucault’s terms, the physician is able to elicit “signs” of the disease beyond what the reported “symptoms” are. The symptoms can be arbitrary or misunderstood by the patient who reports them, but “the sign is purer . . . it is what is observed by the physician, by his trained eye,” that is, through the medical gaze (Bishop, 2011, 47). These pathognomonic signs are then captured by the physician in medical language, which functions differently from lay speech which is subject to interpretation. The language of medicine tells the truth of the disease through the naming of “signs” in the space of the clinic more so than the language of the patient reporting “symptoms.” It is in the space of the clinic that the physician attains “the view from nowhere” that is able to see and name the disease. There is no room here for theory, forms, or philosophical inquiry, but rather “with the shared language of the clinic, master and pupil clearly see the future, the terminus of the disease, even to the end of life” (Bishop, 2011, 48). Accordingly, some of the earliest formation on the wards involves the proper use of medical language. One of my first patients told me that he had “chills” during his fever, and upon reporting his words to my attending, he asked me, “Were they chills or rigors?” Because I did not know there was a difference (which was the wrong answer), I returned to gather more data. The student’s job is to report faithfully the signs of the disease with the exact language of medicine and thus to reveal and name the truth of the disease, and in that instance my language, using the patient’s words, was not exact enough. As the clinic developed, the method of scientific hypothesis and the practice of anatomy combined with the clinical gaze and language of the clinic. Particularly from the Flexner Report onward, “the clinician is a scientist engaged in the scientific methodology of generating and testing hypotheses” (Bishop, 2011, 50). Through listening, questioning, and examination the doctor gathers the appropriate data and nothing is to be held back by the patient. “One questions by probing more deeply into the depiction of the patient’s depiction of his symptoms, into the crevices of his body, his psyche, and his social life” (Bishop, 2011, 51). From this data, a hypothesis of what the disease might be is formulated and confirmed by further testing. The disciplines of anatomy and autopsy expand this scientific model and provide further data in confirming medical hypotheses, yet all within the same epistemological framework. These practices brought to the bedside not just the scientific laboratory but the anatomist’s laboratory and the autopsy room. The anatomist can take apart dead bodies and discover the effects and end results of disease processes. Now, time and space can fold together at the bedside with death as the norm (Bishop, 2011, 53). This analysis takes place purely within a mechanical metaphysics that focuses solely on material and efficient cause. With the powers of medical language and the penetrating gaze of the anatomist, physicians can know disease and life from the viewpoint of medicine’s epistemological norm, the corpse (Bishop, 2011, 52). Without any epistemological discussion, medical students learn intuitively within the first few months of matriculation that death is the norm. The cadaver is commonly referred to as “your first patient” who is systematically pieced apart and examined over the course of months. Incidentally, working with the cadaver is often the longest relationship a medical student has with any one “patient,” living or dead. Beyond the cadaver, there is also the simple, test-taking pearl passed down from older students: the ultimate diagnostic answer is “confirmed by pathology.” The work of physiologists in the 1950s and 1960s further illustrate medicine’s need for the death of the body as its epistemological norm. Bishop’s historical study of respiratory failure, mechanical ventilation, and defibrillation reveals interesting patterns. “Survival” of the test subjects (usually dogs) was often ill-defined, and in some studies, no subjects were resuscitated because that was not necessary for attaining the information sought. For mechanical ventilation, “warm corpses” were used to determine the efficacy of various methods of delivering airflow to tissues and organ systems. Cardiac studies used return of electrical rhythm to the heart as the endpoint with no eye toward survival or functioning of the body as a whole (Bishop, 2011, 103–4). Again, the corpse is found as normative in understanding the “machinations of life” within the framework of efficient causation. The claim of nineteenth-century physiologist Bichat is validated; “‘life consists of the sum of the functions by which death is resisted,’ death being the more mechanically likely state and life being an accident of motion” (Bishop, 2011, 224). This understanding of physiology was most clearly illustrated to me as a student while rotating through the cardiac critical care unit. A patient who had been transitioned to comfort care, though remaining on cardiac telemetry with all the alarms silenced, was actively dying during rounds. The supervising physician had the team remain in the patient’s room and watch the telemetry as she died and observe the changes in electrical function because it was “an incredible learning opportunity that you’re lucky to get during medical school.” We remained in the room and watched the dysrhythmias progress to asystole and the blood pressure and heart rate drop in concert. One intern, on loan from the emergency department, left the room and watched from the work station because he was incredibly uncomfortable standing in the room watching the patient die (for which he was duly teased by his superiors). The critical care nurse remained in the room with us holding the patient’s hand because, as she stated, “I hate to see people die alone.” The techniques of maintaining physiologic control are requisite for the functioning of that staple in contemporary medicine, the intensive care unit (ICU), and in its discussion the sovereign agent is introduced by Bishop. As Bishop astutely notes, “[a] metaphysics of efficient causation and an epistemology of stasis always result in a kind of violence, for one merely has to exert a greater force over the dying body in order to keep its matter in motion” (2011, 97). This violence is felt acutely by patients, family, and loved ones in the space of the ICU. The ICU is not a technology in itself but rather a space demarcated by the technologies it employs to efficiently support and assess physiologic function (Bishop, 2011, 111). The ICU contains dying patients, patients whose organs are failing and threatening to turn to stasis, and the outcomes are uncertain and limited. In the face of patients living a “life worse than death,” where dead matter is kept in continual motion through medical intervention, liberalism provides the counter of the sovereign agent versus the machine of medicine. To use Bishop’s definitions, liberalism “assumes an autonomous master that can push back against an agentless social apparatus” such as the ICU. In order to be such an agent, one must assume “a self that exists independent of social influence, which can exert efficient mastery over mechanism” (Bishop, 2011, 117). Bishop provides much insight into the interaction of the autonomous self and the social apparatus of medicine through Robert Veatch’s work from 1976. Thanks to technological advancements in medicine, physicians now for the first time have the power (or at least the illusion thereof) to control death, thus prompting Veatch to ask, “Is death moral in a technological age?” What is moral in this scheme is according to human choice. Because medicine has the power to keep the patient alive—that is, can use the power of efficient causation to keep matter moving—the choice of whether or not to intervene, or when to cease intervention, is paramount (Bishop, 2011, 122–3). The responsibility of choice is pressing, and the significant moral question is, which agent is responsible for making the choice? Veatch’s solution is that the responsibility be shifted from doctor to patient, which is now the accepted standard except under extenuating circumstances that would render the patient incapable or unsuitable for choosing. In light of the efficient causality of medicine, Bishop recasts this question as “who has the power—the greater force—to deploy those forces [of medicine] or to push back against them. Thus patient power is pitted against medical power” (Bishop, 2011, 124). There are two consequences of the sovereignty of choice in the social apparatus of medicine in this discussion. The first is that the doctor is removed as a moral agent and is now a cog in the machine, a dispenser of adequate medical technology. Regardless of their own moral leanings, “doctors do not engage in moral deliberation, because morality is merely choice, and the doctor does not choose” (Bishop, 2011, 125). So where is the doctor left? The second consequence is that the dualism of “will (power) and matter” becomes clear. The patient is the sovereign agent even as his own body is the sovereign subject. So what happens when the subject rebels? III. MCKENNY ON THE BACONIAN PROJECT Although the physician may be regarded as having no moral input in the system that Bishop describes, modern medicine does in fact put a moral burden on its practitioners. McKenny argues that modern medicine rests on the imperative to “eliminate suffering and to expand the realm of human choice—in short, to relieve the human condition of subjection to the whims of fortune or the bonds of natural necessity” (2012, 398). McKenny makes a historical argument using Charles Taylor’s work concerning the development of the modern self. With the rising influence of Protestantism, human work was seen as not useful for salvation, so it was applied to meeting the needs of the neighbor. The neighbor has practical needs, and in order to fulfill them actions must be effective. The turn Francis Bacon made was that “effectiveness would require an instrumental approach to nature, ultimately including human nature, in order to fulfill its moral project.” This turn was supported theologically by the claim that God providentially provided creation for human use toward flourishing. Enlightenment thinkers like Jeremy Bentham later reduced the moral categories to pleasure as good and pain as bad, categories seen as more neutral and universally applicable than religious doctrine. This shift in thinking combined with the advances of Baconian science resulted in what McKenny calls the Baconian project. In short, The mechanization of nature means that suffering from natural causes is no longer an inevitable feature of the world but is, to the extent that human beings are capable of controlling nature, an object of human responsibility. Hence the new worldview both requires the elimination of suffering and makes it possible. (McKenny, 2012, 400) Veatch’s previous argument that death itself can be controlled by the physician could be cast as a specific, if not the ultimate, instantiation of the Baconian project. From a student’s perspective, a hospital pecking order can be observed based simply on who wields the greatest effective control over the patient’s body, summed up well in an old hospital joke: “The internist knows everything and does nothing. The surgeon knows nothing and does everything. The psychiatrist knows nothing and does nothing. And the pathologist knows everything and does everything just a day too late.” McKenny continues using Taylor’s conception of inwardness that, stemming from Augustine and Descartes but modifying and flourishing with Romanticism, looks inward for a particular uniqueness in each individual that each is obligated to fulfill. The inward turn leads to the modern imperative of self-determination. This widespread ethic combined with the Baconian project results in “expectations that the expansion of the reign of technology over the body should be accompanied by, and in fact should make possible, the expansion of the reign of human choice over the body, and that medicine should enable and enhance whatever pattern of life one chooses” (McKenny, 2012, 401). There are multiple problems that result from this project, one of the most significant being the problem of the body. The body is reduced to a machine with medicine being the technology by which persons choose to exert control of the machine. A question from the previous section returns: what if the subject (the body) rebels against its sovereign (the choosing self)? Suffering from disease in effect leads to a separation and alienation of the individual from one’s own body; the body becomes the Other, the enemy, as it is subject to death and decay against the wishes of the self. From this standpoint, medicine is charged with not just ending suffering, but finitude as well. McKenny uses Foucault to argue that “health replaces salvation; in place of the spiritual techniques and practices one engaged in when suffering or death was unavoidable, the techniques and practices of medicine aim at eliminating or postponing death.” However, the body is still a lived body, but technological control of the Baconian project will determine what sort of bodies should be lived. Thus, “medicine . . . will involve techniques of monitoring the body, disciplines, and even the formation of desires and choices—all of which not only express but form our subjectivity” (McKenny, 2012, 405). IV. THE FORMATION OF ONE PHYSICIAN It is within the preceding framework and social apparatus that the medical student is educated. First, there are molecules and cells, dead matter in the abstract. Then, there is anatomy and physiology, dead matter fixed in space and dead matter moving in ordered fashion. Then, there is pathophysiology, dead matter moving awry. Throughout this process, the language to name these processes in their essence, in the totality of their being, is learned. Next, the student is thrust on to the wards and then on to residency where he learns to fix the dead matter that is moving awry, to exert a greater force on faulty matter so that it moves correctly. At his ideal, he is to do so from the neutral and objective space of the clinic with the calculating reserve of the scientist. The objectivity and reserve also serve the purpose of teaching the budding physician to stand aside and allow the patient to choose if the efficient powers of medicine are to be marshaled. Throughout Bishop’s argument, the powers of medicine, of the clinical gaze and clinical language, reduce the patient’s body to a mere physiological machine, an amalgamation of moving dead matter. However, I would argue that this process is thrown back on the medical student who learns to reduce his own body to a machine. A humorous yet common example would be the classic process of self-diagnosis during the first few years of medical school. While learning a set of abstract signs and symptoms of disease in the classroom, I have convinced myself that I have suffered from diabetes (type I and II), hypothyroidism, hyperthyroidism, lupus, multiple sclerosis, and a host of neurological neoplasms. None of them turns out to be true, largely because these data were abstracted from an actual patient, yet in a way medical language created them even as I misused that language. I learned the words that medicine provided and stuck them onto my body as if it were a machine, rather than first experiencing such signs and symptoms that arose out of my actual experience of living. Driving this neurotic self-diagnosis was the fear that this particular machine was malfunctioning and would ultimately die or possibly be late to rounds. When moving into the space of the clinic where one encounters real patients with actual disease processes at work in their bodies, the problem of the physician reducing himself to a machine takes a more serious aspect than a first-year medical student’s paranoia. The relocation of the patient’s body to the artificial, “neutral” space of the clinic is accompanied by the physician’s relocation to the same artificial space where the physician’s subjectivity is supposedly eliminated, or at the very least cloaked, by the white coat signifying his medical formation. The physician is to be objective, calculating, scientific, supposedly viewing the data from “nowhere,” and knowing it by naming it in its entirety. Scientific knowing, in this sense, becomes an act of power and the doctor-patient relationship becomes more of a subject-object relationship. “[The patient] is passive not only to his disease but to his savior the doctor; the doctor’s agency—the subject pole—masters the status of the patient’s body—the object pole” (Bishop, 2011, 91). The process of relocation is necessary not only so the patient as object may be known by the doctor, but so that the doctor may efficiently and effectively be capable of knowing the disease. Power over subject is power to control. The particularities of each patient are reduced to universal categories of what is true about this object or class of objects. With this knowledge, the desired outcome may be effected. Again, the act of medical knowing, of subjecting the patient to the clinical gaze, is thus not a neutral act but an act of violence, even as it is cloaked in the white coat of scientific objectivity (Bishop, 2011, 92). This process denies the physician’s own contingency, subjectivity, and social embeddedness as a human being as surely as the patient’s, but from a different direction. The physician must be transformed to a subject capable of wielding the power of medicine. Any subject properly formed in the clinical gaze should be able to see and name the object under observation in its totality. To this end, the neutrality and objectivity of the physician must be protected. Violating the neutrality of the physician would threaten the power of the clinical gaze by disrupting the politics of the clinical space. The violence of the clinical gaze is an irony inherent to the supposed objectivity and neutrality of the physician; the doctor-patient relationship within the political space of the clinic is anything but neutral. However, even as the physician is to wield the power of medicine, the only acknowledged moral decision must be left to the patient in order to protect patient autonomy. The doctor must deny his own personhood as a moral agent and maintain the position of a morally neutral piece of the medical machinery. There are two interwoven points to elicit from these discussions of Bishop and McKenny. The first is to reiterate that physicians are not involved in a neutral project, they are involved in a moral project. This moral project is masked in modern medicine because physicians are supposedly neutral and scientific as seen in Bishop, even as the clinical gaze is an act of violence. Patients are not incognizant of this dynamic; the reaction of hearing a diagnosis that the patient feels to be at odds with his understanding of his life often results in the statement, “I know my own body (better than you do).” This reaction is not merely a psychological act of denial (even though that may occur, particularly in the case of a fearsome diagnosis) but can be seen as a reaction to the clinical gaze. People recognize the violence of being objectified. The second point concerns the body as Other. Understanding the suffering body as a machine that refuses to be fixed and frustrates one’s moral enterprises leads to an alienation of the self from the body. A similar alienation occurs within physicians who must care for those that are suffering in such a way that medicine cannot “fix.” The physician, who is expected to free the patient from finitude, cannot provide the fix; his hidden moral project is frustrated. In the absence of being able to name that tension, there is alienation not only from the patient but also from the physician’s own self and calling. If the physician has been formed as a fixing machine but is incapable of fixing his subject, the patient, then what purpose does the physician serve? One of the most powerful testimonies I have heard from a patient was from a woman with cystic fibrosis who experienced a failing double lung transplant. For months, her doctors had been supportive and encouraging until she reached the point where her transplant rejection was inevitable. At that point, she said, all of her medical team became shut off from her; whenever they looked at her, she felt that they saw in her “the embodiment of their failure.” Though the patient in this story was suffering the greatest, which I by no means wish to downplay, the physicians themselves were undergoing a suffering due to the failure of their project. The suffering could not be articulated or communicated to the patient even as it was obvious to her. Situations like the one above have not gone unnoticed by practitioners of medicine; a notable response is that of Dame Cicely Saunders, the founder of modern hospice. Saunders recognized the presence of “total pain” in her dying patients that medicine as it was practiced was not addressing and in return developed her idea of “total care.” This recognition became a founding concept of palliative care. As Bishop argues, however, Saunders’s idea of total care was transformed by the medical apparatus into totalizing care that sought in just the span of a few decades to control death (Bishop, 2011, 254–5). The short account is that through its introduction to medicine, palliative care became specialized in order to legitimize itself on medicine’s terms, and thus palliative care physicians became scientists, falling back on the same metaphysics of efficient causation. Palliative care had to have observed and statistically validated measures of intervention at the level of the whole patient and the network of relationships, rather than simply specific organ systems. As the classic physician elicits signs of the underlying pathology, the palliative care team must use assessments of the patient, and as Bishop notes, “total care means total assessment” (Bishop, 2011, 264). The assessment of the dying patient borrows from the social sciences; since technology cannot master death, medicine must also use psychology, sociology, and spirituality to control it. Bishop treats Elizabeth Kübler-Ross’s study on grief extensively, but a few of his observations will suffice here. Notably, Bishop argues that the story of the five stages of grief—denial, anger, bargaining, depression, acceptance—can be told as one of institutional efficiency. There is the underlying assumption that “all patients should reach acceptance before dying” (Bishop, 2011, 237). Given the driving engine of efficient causation, the category of a “good death” is created by the experts of death, physicians, which includes movement of the dying patient and their family to a certain norm. That is, there is needed an “‘average death’ against which the individual can be judged and controlled” (Bishop, 2011, 277), and that norm exists for the efficient functioning of the hospital. The patient is assessed in his totality along the way, where medical experts define what “outer dimensions” of the patient’s life are “surface manifestations of cognitive, biological, social, emotional, and spiritual maladaptations” (Bishop, 2011, 267). Maladaptations need to be addressed and corrected by efficient causation in order to reach the medically determined end of a “good death.” So what happens when a dying patient does not follow the path set by medicine? Bishop opened his book with the account of his friend Nancy who refused to follow medicine’s determined path to acceptance and a “good death.” In this situation, the physician’s goal has been frustrated once again. Previously, the concern was that the physician could not “fix” the dying patient by means of efficient control. Palliative care in its specialized and totalizing form as described by Bishop would then work to control death through efficient means of assessment and the movement toward acceptance. However, if that is not the goal of the patient, medicine is once again thwarted in its attempt at control; the moral project of the physician is endangered. The body of the Other reemerges not simply as the dying body, but as the body which does not die correctly. As Bishop notes in the closing chapter of his book, he does not want to believe that anyone entered the field of health care “to exercise mastery over other people, to become part of a totalizing biopolitical regime, or to totalize the bodies of the dying” (Bishop, 2011, 285), and neither do I. I, along with many others in the field of medicine, entered this profession with a desire to help and to heal, yet the social apparatus of medicine forms us in ways that may be contrary to our original goals. If indeed medicine has replaced salvation in modernity as Foucault would have it, we who work in medicine have an inappropriate burden placed on us. If it is our job to save our patients from the power of contingency, we cannot be subject to contingency ourselves. We must be beyond contingency as objective scientists who exert the power of pathology by seeing and naming disease and then offering the appropriate medical technology. Our emotions, our biases, our weakness, even our own bodies cannot interfere with that task. Our bodies may be used, as in the skill of a surgeon doing a delicate operation or an internist auscultating an infected lung, but our bodies must never detract from this task. The mechanization of the provider’s body was driven home to me by an attendant sharing her favorite (in a bitterly cynical way) medical adage, “you don’t call in sick, you crawl in sick.” Our own bodies become instrumental to the project of medicine, alienated from our experiences as contingent human beings. Like the body of the suffering patient, the body of the physician becomes the body of the Other, a machine to be subjected to and overcome by the mastery of our will should it ever threaten to interfere with medicine’s project. Oddly (or perhaps fittingly) enough, being called “a machine” on the wards is quite the compliment; it means you are getting the efficient work of medicine done. What has been seen by the critiques of Bishop and McKenny, however, is that the power of medicine has promised more than it can deliver. Medicine cannot remove us from our contingency, even as it removes us from our humanity. Yet, as medical providers, our bodies are pushed, by internal and external forces, to fight mortality and suffering with the “saving” power of medicine, only to realize that physicians cannot save anyone from the slings and arrows of life. Medicine cannot provide salvation. V. PRAYING THE PSALMS What I propose as a Christian health care provider is a recovery of relationship with the God who fights for us through the language of witness. “Do not be afraid, stand firm, and see the deliverance that the Lord will accomplish for you today; for the Egyptians whom you see today you shall never see again. The Lord will fight for you, and you have only to keep still” (Ex. 14:13–14; NRSV). As a Christian, I worship God as revealed in Jesus Christ, a Jewish Messiah. The Jewishness of the person of Jesus Christ is not to be forgotten, particularly in turning here to the topic of the God who fights for us. Throughout the Hebrew Scriptures, there runs the common story of Yahweh delivering Israel from the hands of her enemies. It is within this context that I understand God in Jesus Christ as the only one who delivers humanity from the ultimate enemy, death. “Death has been swallowed up in victory. Where, O death, is your victory? Where, O death, is your sting? The sting of death is sin, and the power of sin is the law. But thanks be to God, who gives us the victory through our Lord Jesus Christ” (1 Cor. 15:55–57; NRSV). No other power is capable of this salvation, including the power of medicine. Reorienting our imagination toward this reality, that it is God who fights for us, that it is Christ Who saves us, is particularly important for those of us who are vested with power by society and are all too often seen to be its saviors. The particular practice I will focus on will be praying the Psalms. I must note at the outset, however, that these are spiritual practices embedded in the life of faith. Although I will argue that they can and do counter the alienating effects of reductionist medicine, I do not intend these practices to be instrumental, that is, a “fix” for physician burnout and empathy fatigue. Nor is the claim that “God fights for us” merely a theologically dressed-up version of Ben Franklin’s pithy quote, “God heals and the doctor takes the fee.” Rather, encountering the living God through praying the Psalms reshapes the imagination, including both successes and failures in the life of the medical practitioner. The Psalms are meant to be liturgically performed, whether congregationally or individually, and they have been so used through the history of the faith. As an Old Testament professor of mine liked to say, the Psalms are “Israel’s theology put to verse.” Walter Brueggemann in his book Praying the Psalms describes this practice as “let[ting] our voices and minds and hearts race back and forth in regular and speedy interplay between the stylized and sometimes too familiar words of Scripture and our experience which we sense with poignancy” (2007, 2). As Scripture is read and ingested, its words bring “power, shape and authority” to the experience of our lives. Conversely, the experiences of our lives imbue the Psalms with a “vitality and immediacy” that allows the Psalms to take on a new life in our present situation (Brueggemann, 2007, 2). Although I had occasion to pray with patients as a medical student, prayer was a daily experience during my hospital chaplaincy while on loan to the divinity school. Daily I looked to the Psalms with my patients to find words that neither of us knew how to form. Patients quickly found their story in the words of the Psalms, and I was present to see such familiar language take on new life. Brueggemann differentiates the language of the Psalms from a modern “positivisitic understanding of language.” That is, commonly “we believe that the function of language is only to report and describe what already exists” in modernity (Brueggemann, 2007, 18), and as seen with the language of the clinic, the element of control is added. The language of the Psalms, however, is different. Psalmic language is poetic, hyperbolic, and ultimately “restive with what is.” When the Psalmist says his “flesh trembles,” it would make no sense to ask if the trembling was from chills or rigors. Instead, Psalmic language “races on ahead to form something new” and “permits us to be boldly anticipatory about what may be, as well as discerning about what has been” (Brueggemann, 2007, 19). The Psalms point beyond present circumstances, either calling God to task for God’s promises that have not been realized or proclaiming that God is good and will be good. The Psalms call witness to divine faithfulness. The language of the Psalms could not be more different from the language of the clinic, which claims complete knowledge of the essence, origins, and terminus of disease. Not only is that language often insufficient in its predictions and control of disease, but it is restricted solely to a mechanistic understanding of life. It has no horizon beyond its epistemological norm, the corpse, and its goal is efficient control. It is tempting for prayers to follow suit, especially during times of duress such as grave bodily illness. The language of prayer can easily slip into the language of control, reducing the divine to just another tool alongside medicine in the attempt to bring about the desired outcome. Throughout the Scriptures, however, there are warnings against attempting to control divine power for personal outcomes, from Saul offering a sacrifice at Gilgal to assure victory against the Philistines (1 Sam. 13) to Simon the sorcerer attempting to buy the gift of the Holy Spirit from the apostle Peter (Acts 8). The Psalms counter the language of control with the language of witness. Though the psalmist may speak of deliverance from specific grievances, including bodily illness (e.g., Ps. 41:3), the arc of the psalm is about witness to the faithfulness of God even in the midst of uncontrollable circumstances. Brueggemann (2007, 3) characterizes the life of faith encountered in the Psalms in three basic stages: (1) being securely oriented, (2) being painfully disoriented, and (3) being surprisingly reoriented. In each psalm, the psalmist may find himself working through any or all of these stages. The familiar words of Psalm 23 illustrate these three stages nicely. The Psalm opens with secure orientation, “The Lord is my shepherd, I shall not want.” Through the journey, the Psalm reads, “Though I walk through the valley of the shadow of death,” where the psalmist experiences painful disorientation. On the far end of the valley, however, is surprising reorientation, “You prepare a table for me in the midst of my enemies.” The health care provider is frequently privy to all of these stages in the extreme. There is the secure orientation of the yearly checkup or the well-child check where rapport is built between patient and physician. There is the painful disorientation that comes as an unexpected trauma in the emergency room or a devastating diagnosis of cancer in the clinic. And, there is the surprising reorientation that comes when an infection is cleared, when cancer is sent into remission, or even when a person faces their death with a witness and faith that changes those that behold it. Being present to these struggles as providers does not put us in the place of those who suffer and rejoice, yet in being present we are affected and are changed. In many ways, providers accompany and intercede on behalf of those who suffer through illness, and when tragedy strikes, grieve as well. By reading the Psalms, these struggles may be reimagined in the life of faith, in relation to the God who fights for us, who heals us, and walks with us even through death. In that narration of the events of the hospital, I discover that as the physician I am not the hero, I am not the one who saves, and I can be returned to my own contingency and humanity. A common motif of disorientation in the Psalms is the Pit, which can be considered in reference to previous discussions by Bishop and McKenny. The Pit is the experience of “being rendered powerless . . . the speaker is characterized as being forsaken, among the dead, slain, not remembered, cut off” (Brueggemann, 2007, 33). It is a place of “total pain,” to borrow Saunders’s words. The Pit is the place that the Baconian project tries, unsuccessfully, to overcome through medicine, and yet all will experience it in the throes of death and disease. The physician may not experience the physical suffering of the patient but can experience a pit of his own facing his powerlessness to cure the one with whom’s care he has been entrusted. The Psalms give voice, often hyperbolically, to these experiences and are not satisfied with the language of medicine where “being does not exceed what is known.” The Psalms reach beyond the here and now. On the other side, there is the shelter under God’s wings, a common motif of reorientation. Shelter is a powerful testament to God’s faithfulness and a polemic against the controlling powers of medicine and the Baconian project as it recognizes “the resources for life are not found in us, but will have to come from another source outside the self” (Brueggemann, 2007, 37). The metaphor of being covered by God’s wings “embodies an openness to a new purpose, a submission to the will of another, a complete reliance upon the protective concern of another” (Brueggemann, 2007, 38). This prayer is particularly important for the physician. Medicine often renders the patient subject to its power at the hands of the physician, which can warp us into thinking that we medical providers are in control. The psalmist reminds us that we are not in control, we are contingent on God’s faithfulness. A final word must be said about the move from disorientation to reorientation, namely, that it does not always happen. When it does, we must be prepared to rejoice with the patient and be reminded that it is not by our own might or power but by God’s grace. However, when tragedy strikes, the words of the psalmist still ring true, particularly in psalms of lament such as Psalm 88 that ends in darkness. Even though many psalms of lament end by returning to a profession of faith, some still end in darkness; there is no “correct” movement through stages of grief to a statistically normative end in the Psalms. The place of darkness is still a place in which God’s faithfulness is known. Even in the midst of suffering and darkness, the psalmist cries to God shouting, “Where are you?” This cry is itself an act of faith and hope in God’s good future beyond this present darkness. Christians can know that these are words of faithfulness, not of doubt, because these are the words of Christ, taken from the Psalms and spoken on the Cross, “My God, my God, why have you forsaken me?” This cry can only make sense if you actually expect God to listen, if you actually expect that there should be something more, something better, than this. Allen Verhey writes beautifully of the relationship of lament and hope in his treatment on the beatitude, “Blessed are those who mourn.” He writes: This beatitude calls us to be visionaries. It calls us to dream. We’ve got to dream of God’s good future, to imagine that the sick are healed and the suffering restored to themselves and their communities. We’ve got to hope. Hope does not deny the sadness of this world. On the contrary, it is those who hope who mourn. To share the vision of God’s good future is, here and now, to ache for it. Here and now such visionaries ache. So, the text calls us to hurt a little. (Verhey, 2003, 139) The Psalms, as prayers offered to God, recorded and given to us as Scriptures, and now prayed and offered back to God, hold a special place in the life of the Christian. The Psalms offer prayers of faith, of hope, of fear, of lament, and of uncertainty, but all are directed to a God who hears, a God Who has and will defeat death and usher in a good future. The language of the Psalms needs to be remembered and spoken by medical providers. Rather than make the patient an embodiment of our own failure, or looking at our own bodies and seeing a suboptimally performing medical machine, the Psalms beckon providers to cry out to God in reminder of God’s good promises. Rather than being dispassionate, objective machines, the Scripture beckons us to hurt with the suffering and the dying. From that particular space within the life of faith, rather than the “nowhere” space of the clinic, the physician need not be a machine, a suboptimal Watson, but a contingent human being capable of weeping with those who weep and rejoicing with those who rejoice, all the while witnessing to a faithful God. REFERENCES Bishop J . 2011 . The Anticipatory Corpse . Notre Dame, IN : University of Notre Dame Press . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Brueggemann W . 2007 . Praying the Psalms . Eugene, OR : Cascade Books . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Cohn J . 2013, March . The robot will see you now . The Atlantic . http://www.theatlantic.com/ magazine/archive/2013/03/the-robot-will-see-you-now/309216/ (accessed November 10, 2016 ). Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC McKenny G . 2012 . Bodies, bioethics, and the legacy of Bacon . In On Moral Medicine , 3rd ed., eds. M. Lysaught, J. Kotva Jr., S. Lammers, and A. Verhey, 398 – 409 . Grand Rapids, MI : Eerdmans . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Verhey A . 2003 . Reading Scripture in the Strange World of Medicine . Grand Rapids, MI : Eerdmans . Google Scholar Google Preview OpenURL Placeholder Text WorldCat COPAC Author notes " *Address correspondence to: David Arriola, MD, MDiv. Jackson Memorial Hospital Internal Medicine Residency Program, University of Miami, 1611 NW 12th Avenue, Central 600-D, Miami, FL 33136, USA. E-mail: david.arriola@jhsmiami.org © The Author 2017. Published by Oxford University Press, on behalf of The Journal of Christian Bioethics, Inc. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com TI - Medicine, Machines, and Mourning: The Formation of Physicians and Praying the Psalms JF - Christian Bioethics DO - 10.1093/cb/cbw018 DA - 2017-04-01 UR - https://www.deepdyve.com/lp/oxford-university-press/medicine-machines-and-mourning-the-formation-of-physicians-and-praying-mnciDoJ0xO SP - 7 VL - 23 IS - 1 DP - DeepDyve ER -