A few weeks into our surgical internship, we invited all the interns to a party at our apartment. About fifteen were able to make it. We were all in our mid-twenties, living on shoestring budgets, bright, and excited about our careers.
We were also puzzled by many things. For most of us, other than summer jobs, this was our first real career employment, and our first serious responsibility dealing with those who weren’t young, middle class and college educated. We had culture shock. But mostly we were shocked by our close proximity to suffering and death, and the power of our profession to alleviate the same. And how, at other times, we were so powerless, rendered into unwilling front row spectators at pain and the often quick passing of life. None of it looked like what we learned in the classroom.
That night everybody talked fast and hard, sometimes stepping on each other’s lines, feeling like the emotions of the last few weeks had been bottled up to the point of explosion, and this was the one and only chance each of us had to let it out with a community that just might understand. We should have done it more often, but we only did it that one night.
Only once did the room become silent. One of my colleagues asked, “When does the patient become real to you again? You know, after the operation? Is it when the last stitch is in, or when the bandage is on, or the drapes are off? Or is it in the recovery room?”
For thirty seconds, all eyes turned to him, mostly puzzled, considering. We all knew it was a bad assumption, a question that shouldn’t be asked. The patients are always real, we always treat them with humanitarian dignity. Because that is the right answer, that is the classroom answer.
The responses were interesting. About half the group said that the question was crazy; patients were always human, right? They had the classroom answer, and they were, of course, right. Patients are always human beings with full rights and value.
But a few were like me. I knew exactly what the other intern meant. After the anesthesia, after the skin prep, after the sterile drape, the patient doesn’t have a face anymore. That makes it seem so much more natural to open their skin with a knife (that we call a scalpel so it doesn’t sound like a weapon). It is then possible to dissect through things that have names like omentum, and duodenum, and gall bladder. Because if we remember their face and call their inner parts by common names attached to them by possessive grammar (Joe’s guts, for example), surgery couldn’t be done–not by anyone who wasn’t a psychopath. At some point all surgeons do an emotional step back, dissociating ourselves temporarily from the humanity in order to deal the anatomy and the pathology.
But we never talk about it. Except for that one time when one young doctor found the words to ask. Emotional distance goes up when the sterile drape is laid down.
I like to think he was right. If we recognized the emotional distance we put up to operate, it was because these people already meant something personal to us, something very human, very connected, and we needed the separation. And maybe those who didn’t distance themselves, or at least didn’t recognize that they did, was that possible only because patients had never been “real” people to them from the beginning? Patients had always been patients, never people, so dissociation wasn’t necessary? I don’t know.
Often I have emotionally distanced myself from a patient to do what I believe is good for him or her. But I know my capacity to dissociate is not limited to the operating room, or even the office or the bedside. Sometimes there is a person who is so old, or so intellectually limited, or so drunk or so crazy or so high, or so dirty or so foreign that they could not possibly be like me because I don’t want to be like them. And since I can never be like them, and since I must be a real person, they can’t possibly real. I put up the drape. I take an emotional step back. But now I’m not doing it for them; I’m doing it for me.
Maybe you’ve done this. When you walked past that homeless guy or drove past that panhandler at the freeway exit. When you visited the nursing home. When the guy in the store speaks Spanish or the woman in the checkout line wears a burka. When the drunk at the next table talks too loud or the crazy guy walking down the street talks to people who aren’t there.
Maybe you put up the drape, take a step back. Then those people aren’t completely real, and somehow we feel safer.
We come by this “step back” naturally. It’s literally in our DNA. One of the first social tasks of a newborn is to begin the process of distinguishing between the “us” and the “them” of the world. Mom first, then the family, then other caregivers, then the people who look like them–they become the “us.” Everyone else is “them,” which is understandable, but it can limit us. For example, studies have demonstrated that if children are not exposed to persons of another race before the age of four, their initial response to a person of that other race will be negative. The response can be mitigated by education and experience, but it is always there, an unconscious tendency to put up a drape, to step back, to racially profile, and thereby carry a weighty piece of baggage in a poly-cultural world.
Then there’s another kind of emotional step back, the giant step, the one that says that a person isn’t human anymore, not now, not ever, not as a result of emotional bias but as a result of evilly rationalized doctrine. This is the step taken when a lie becomes imbedded in the mind ignoring the pleas from the heart: They aren’t like us, they can’t help us, they want to destroy us. They aren’t real people. We should separate them, put them in camps, make them work for us, take their stuff, kill them off if they don’t pull their weight. That’s the step back taken by the Nazis, but they are not the only ones who have taken that step in the past, nor will they be the only ones to take that step in the future. From this we should guard our hearts.
Now I repeat the question that intern asked so many years ago in a slightly different fashion: When does a person become real?
Is it at the moment of conception?
The moment the heart beats?
The moment the brain takes shape?
Or is it the moment of birth?
I ask because New York State recently passed a law that allows abortions well past the time (24 weeks) that a newborn could survive independently of the mother. The permissible reasons for late term abortion are: 1.) the life or health of the mother is threatened, or 2) the fetus is deemed non-viable. Furthermore, decisions are to be made by a licensed healthcare provider, not necessarily a physician. Since the health of the mother and the skills of the healthcare provider are not defined, the statute conceivably permits, for vague and possibly trivial reasons, abortion up until the moment of full term birth. In one delivery room a baby, now called a fetus, could be murdered or abandoned, while in the next delivery room a baby of the same gestational age would be treasured and loved.
Nobody wants this. Nobody wants to kill babies. We can make better laws. For our doctors, for our women, for our children. For our souls.
So the question returns: When does a person, a baby, become real?
When you answer, let whatever is imbedded in your mind be guided by the pleas from your heart.