Miracles: Healing or Harm at the Bedside?
Notes from a Family Meeting, Vol. 3., No. 9
Paul Smith lay silent on the bed. His chest rose and fell. Instead of the hum and hiss of his ventilator, his nurses and physicians heard “Take It Easy” by the Eagles. His wife had a speaker on a small table, as close to his head as possible without being in his bed with him.
“Mrs. Smith,” the physician began, hands clasped in front of her. All of them look the same - scrubs and white coats, papers poking out here and there. “Mrs. Smith, his kidneys are doing a bit worse today. His lungs are the same, but his kidneys are worse. We know from before that his heart wasn’t the strongest, and we’ve had to add more medicine to keep his blood pressure up, but his kidneys are worse.”
The information washed over Mrs. Smith. Her sister sat next her, holding her hand. She may have been Paul’s sister, too. They were all very close. Mrs. Smith shook her head, too bewildered to be sad.
“Thank you, doctors,” her sister replied, nodding. She was resolute. “Thank you. We appreciate what you’re doing. We know you can only do so much, but God can do anything. We’ve been praying, our church has been praying, that God will heal Paul. We’re expecting a miracle.”
The doctor licked her lips, looking at the nurse. The information she provided didn’t have its intended effect. “Oh, yes. Okay. Well, what do you think he’d want us to do if his heart stops? There’s a real risk of this. If it stops now…” She proceeded to provide a vivid description of what the nurses and doctors would do to try to revive Paul.
“Again, thank you, doctors,” the sister replied, more curt than before. “You should do all you can to help Paul live. We’re waiting for a miracle. We need to be faithful. We need to trust that God is going to restore Paul to life. If that means some broken ribs during CPR, so be it.” Mrs. Smith nodded along.
“I’m Alright” by Kenny Loggins was next on the playlist, filling what would have been an otherwise awkward silence with lyrics.
“Okay. Yes, okay,” the doctor nodded. “Well, we’ll let you know if anything else changes.” The team shuffled from the room. The nurse rearranged some sheets and assessed the infusions. “It looks like it’s going to rain,” he said, looking out the window.
Mrs. Smith and her sister nodded, thanking him for his service.
I'm alright
Nobody worry 'bout me
Why you got to gimme a fight?
Can't you just let it be?
Miracles in medicine fascinate me but I’ve never seen one.
I’ve seen some mighty wonderful things. Folks have beaten the odds or had terrible diagnoses overturned. But an honest-from-God miracle I have never seen in the clinic or hospital. Still, their mystery enthralls me.
It wasn’t always so. For most of my short career in medicine, hope for miracles has been so bedeviling. Once a patient or family member summoned the words, conversation ceased. What more could be said? How can you argue with miracles, let alone hope for miracles? I’m a man of faith, but the time for discussing ventilators and antibiotics was upon us. How can we talk about miracles at a time like this? So I’d murmur something and slip away like Mr. Smith’s physician, bracing myself for the moral distress that would soon afflict everyone around awaiting faithful.
Becoming a palliative care physician, I encourage these conversations almost every week. Sometimes they’re voiced in a benign fashion in the clinic, when things are going well: “I have deep faith, and God can work miracles if he wants.” Everyone nods along, knowing that this religiosity is a good reserve to help a patient cope with the rigors of treatment. Other times, though, the situation is similar to Mr. Smith’s.
I think clinicians struggle with this for a few different reasons.
Miracle talk seems duplicitous. In our better moments we would want to give our patients and their families the benefit of the doubt, but isn’t it true if they really believed in miracles, they wouldn’t insist on human intervention? God can perform a miracle with or without a ventilator - and indeed, the greater miracle would seem to be one without the imposition of medical technology. This feels like they don’t really believe in miracles; they’re just using the language to strong-arm the healthcare team into doing what they want. We’re no longer partners in this journey toward health. In my heart of hearts, I don’t think patients do this intentionally. I think, as I’ll describe in a moment, people talk about miracles for all sorts of reasons that might not be overtly religious. Even for the religious, I believe they fall victim to supplanting their faith in God with faith in medical technology. God works through the medical interventions. A failure of the technology is a failure of faith, even a failure of God - unfathomable.
Miracle talk stops conversation. Most clinicians don’t know what to do with miracle language. It hides the decision-making processes of the patient and their family from clinical scrutiny. That’s a frustrating maneuver for most clinicians, who are so used to scrutinizing. Some might say this is a good thing: not everything should be given up for analysis. And yet it also means miracle language imposes a gap over which most clinicians, even clinicians of the same faith, cannot cross. The patient has so ordered and the clinician, so they believe, must obey.
Miracle talk ossifies decision-making. No one is talking about miracles when starting a statin for high cholesterol. No one is talking about miracles when taking their seasonal allergy medication. Miracle talk comes with crises. However, to get control, clinicians are skilled at turning crises into a series of decisions. They attempt, in their own way, to link those decisions to discernible goals. Whether it’s ethical or not, one of those goals is to do what they believe to be is in the best interest of the patient, even apart from what the patient or family wants. “Who would want to live in the ICU for months?” But miracle language finalizes all decisions and clarifies all goals, generally in the direction of scrabbling attempts to pursue longevity. Respect for autonomy forces clinicians to defer to the decisions of others, but the distress in doing things to someone they believe ought not be done festers in their hearts.
I hope I haven’t interpreted the situation uncharitably. Now let’s add some more nuance. There’s more going on with miracle talk than we might first perceive. When patients start talking about miracles, Daniel Dugan observes they might mean any number of things:
“I’m feeling helpless and out of control.”
“Doctor, your diagnosis and prognosis could be wrong, couldn’t it?”
“I won’t give up and abandon my loved one.”
“I am placing my trust in God.”
“Medicine can work miracles; I’ve read about it in the papers and seen it on TV.”
Each sentiment highlights a particular existential pillar, all of which undergird miracle talk to some degree:
Control
Trust
Love
Meaning
Hope
So, while expressing a hope in miracles may be an overt expression of trust that divine intervention will occur (and maybe this will be a common superficial rationale for the words), there are other things that are conveyed intentionally and unintentionally. Trevor Bibler, Myrick Shinall Jr., and Devan Stahl provide another perspective, although one still highlighting these deeper currents. They describe that the confidence of an expression can be “shaken” or “unshaken.” An shaken existential expression, for example, would be one in which the person “employs miracle language while struggling to understand God, nature, and self.” Another is the unshaken strategic expression, in which the patient uses this to “carve out a space beyond medicine’s reach, a space where theological terms emit greater influence.” This can happen when trust and rapport in the clinical team have broken down.
Returning to Dugan’s frame, clinicians sometimes model these sentiments for patients. Clinicians sustain control through the use of medical technology, build trust through the effectiveness of that technology, and show compassion by deploying medical technology (as Diane Meier writes about). They even advertise that they and their technologies are worthy of such fantastic hope - e.g., Children’s Miracle Network hospitals, City of Hope, “At our hospital, there’s hope!” In so doing, we fail to appreciate what C.S. Lewis observed:
“The serious magical endeavour and the serious scientific endeavour are twins: one was sickly and died, the other strong and throve. But they were twins. They were born of the same impulse. … For magic and applied science alike the problem is how to subdue reality to the wishes of men: the solution is a technique…”
Many people don’t believe in magic anymore, but the vast majority of people still have religious beliefs, and probably with magical elements.1 People are vulnerable to submitting their religious belief and zeal to the purposes of magic or, in this case, science. Medical technology rarely shouts its religious creed, but it whispers it everywhere: “Control, trust, love, meaning, hope.” Sometimes, when patients or families allow their hope for a miracle to influence a medical decision, it’s because the culture of medicine has led them (or pushed them) there.
Talking About Miracles
Most published resources for clinicians frame a patient or family’s hope for a miracle as a communication challenge to be surmounted or, if not, then something with which the clinician must cope. The coping limps from the miracle talk to coping with the fact that it’s likely the clinician must continue to provide a medical intervention they don’t feel is helpful. There are some really good resources in this regard, like the papers by Dugan and by Bibler, Shinall, and Stahl I cited above.
In response to miracle talk, the latter authors encourage clinicians to inhabit a posture of “empathetic imagining,” wherein they set aside their own views and try to humbly inhabit the worldview of the one with whom they’re speaking. From here, the clinician can begin to discern the patient and family’s values and then identify actions that proceed from those values. They then go on to describe how clinicians might respond to the different ways people express their belief in miracles. I won’t go into the details here, though they’re worth reading.
Another popular approach is using the “AMEN protocol.” Calling it a protocol already sets us up to believe that, once we’ve engaged it, the “protocol” need only run its course to deliver a solution. AMEN advises that clinicians should “affirm” the patient’s belief; “meet” the patient where they are; “educate” from your role as a medical provider; and “no matter what” assure your commitment to the patient. This method will probably leave most clinicians bereft of what to actually do. Like, where’s the secret password in here to get the conversation to move forward, to help us make a decision? They’ll check off boxes and then be left with their same frustration.
Some principles and skills are helpful. Embedded within them are gestures toward a posture that I think can honor others and our practice of medicine. But there’s also a trap: if we just say or do this thing, we’ll be able to carry on with our medical agenda. We escape the talk of miracles unchanged.
When this happens, it’s not just collateral damage. It strikes at one of the major existential tasks of human life, as John Swinton and Richard Payne wrote:
“Suffering, death, and dying have meaning, and the shape of these meanings has a profound impact on how a person approaches these experiences. Issues of meaning and the transformation of meaning are not epiphenomenal to the central task of end-of-life care. They are central to it. The danger for us today is that within a techno-medical worldview which is often implicitly or explicitly death- denying, end-of-life issues can easily find themselves stripped of this vital meaning-making dimension. When this happens, it is easy for us to forget that suffering, terminal illness, and death have personal and corporate meanings that reach beyond the boundaries of imaginations and narratives that are shaped by medicine alone.”
Wendell Berry echoes this sentiment, writing, “Science can teach us and help us to resist death, but it can’t teach us to prepare for death or to die well.”
Living with Hope
In a short story by Berry, an old farmer named Burley Coulter has fallen ill. His family, worried about him, takes him to his doctor, who sends him to the local hospital. Soon, he’s transferred to the big city hospital. This may sound familiar to any clinician who has worked in any of these roles: a very sick patient being passed up the chain into ever-more complex care settings. Now, here he is:
“Burley remained attached to the devices of breathing and feeding and voiding, and he did not wake up. The doctor stood before them again, explaining confidently and with many large words, that Mr. Coulter soon would be well, that there were yet other measures that could be taken, that they should not give up hope, that there were places well-equipped to care for patients in Mr. Coulter’s condition, that they should not worry. And he said that if he and his colleagues could not help Mr. Coulter, that they could at least make him comfortable. He spoke fluently from within the bright orderly enclosure of his explanation, like a man in a glass booth. And Nathan and Hannah, Danny and Lyda stood looking in at him from the larger, looser, darker order of their merely human love.”
Those final words echo in my head every time miracle talk makes its way into the clinical conversation: “their merely human love.”
It’s their merely human love: it belongs to this family for Burley. Burley belongs to them through their love. He doesn’t belong to the hospital. As the story progresses, we discover how different the family is from the clinicians. Not a spoiler: their love wins out. Here we have a reminder that we are entrusted with the care of someone who is loved. Or maybe they have no one, in which case we remember they were once loved. Or maybe that was never the case, in which case we remember they are deserving of such love (even if we ourselves can’t be their family).
It’s their merely human love: I don’t think Berry is suggesting that love is feeble. I think he’s playing with the hubris and disconnectedness of the physician in the story and, through that, all modern medicine. In the face of all that medical technology and all those problems these people don’t understand, their love can appear so weak and, worse, so irrelevant. But it’s what they have. Here we have a reminder that even small things can be invaluable, but because they’re small they may be forgotten, disregarded, or overlooked. We need eyes to see.
It’s their merely human love: before the face of robot-like clinicians and seemingly magical medical technology to intervene on the body, the family is something human. What they know is pinto beans and cornbread, laughter, fist fights, hand shakes, crying, elder wisdom, and the like. When they offer their love, they offer themselves - human companions, human family. Here we have a reminder that healthcare was made for the person, not the person for healthcare.
It’s their merely human love: the clinicians don’t know Burley. He is a bundle of physiology abstracted from his place. They can’t love him, and certainly not as his family does. The hospital offers medicine, surgery, and machines; Burley may need these, as do many others. But what his family offers is love, and Burley needs it just as much, as do we all. Here we have a reminder about why we care about health. Our health is put to its best purposes when we love and are loved.
Burley’s family didn’t say they were hoping for a miracle. Their merely human love, though, reminds me of the merely human love I encounter every day. That love is in view even and especially when patients and families tell me they’re hoping for a miracle. It’s a bit ironic because what we think we’re discussing is divine intervention. Sometimes we are. Either way, though, what clinicians are facing is “merely human love.” In seeing the humanity of miracle talk, I can also behold the miracle of the human with me.
This goes beyond the individual interaction. Patients and families, hoping for miracles, testify to a system that too often anchors itself to the promise of medical technology to free us from our mere humanity. Their speech, so foreign to our eyes, might wake us up. The words might help us see that there’s more at work here than chemistry and plastic. When we walk with our patients, we walk on holy ground.
Can we believe it?
Trajectories
Following a meandering reading-path, sharing some brief commentary along the way.
“CORE IM: Hope at the Bedside”
Do you find your patients, in their medical decision-making, are “building their budget around winning the lottery?” In this podcast, Bob Arnold talks about the way hope influences perspectives and decisions in medicine, and how clinician should think about it. Clinicians really do need a nuanced view of hope. Whenever we discuss the future - even if it’s in the realm of expectations about what an anti-hypertensive will do for our patient - we’re entering the realm of the patient’s hope.
One man’s tragic account of his father’s journey to pursue euthanasia in Canada. The tragedy of his father’s life meets the tragedy of a clinician that seemingly can’t be bothered to really care for or about their patient. The disconnect between what’s published in academic journals (e.g., clean data sets about prevalence of assisted suicide and euthanasia, reasons for choosing, types of drugs used) and what’s published in popular press and individual accounts is alarming. Will advocates, health systems, and governments listen and change course?
“Accuracy in patient understanding of common medical phrases”
The results of this study should come as no surprise: jargon is difficult to understand. Medical students spend a lot of time learning a new language. Eventually they become fluent and speak with other clinicians in ways others can’t understand. We need another step in medical training where we force the jargon out of our general speech - it can be saved for the journals and maybe the chart.
“Palliative care and documented suicide: association among veterans with high mortality risk”
Reducing suicide and self-injurious behavior is a major priority in the Veteran Affairs health system (and should be in any health system). This is an interesting cohort study showing that palliative care consultation prior to death was associated with reduced risk of suicide. This is definitely something to study more - what interventions were offered by what clinicians in what (medical and psychiatric) diseases are big questions to answer. Also is there any impact on non-suicidal self-injurious behavior. Hopeful and intriguing results.
Closing Thoughts
“The reason that technological progress exacerbates our feelings of impatience is that each new advance seems to bring us closer to the point of transcending our limits; it seems to promise that this time, finally, we might be able to make things go fast enough for us to feel completely in control of our unfolding time. And so every reminder that in fact we can’t achieve such a level of control starts to feel more unpleasant as a result.”
Oliver Burkeman, Four Thousand Weeks
In making this observation, I’m not suggesting that religious belief is, like magic, not real. I’m highlighting that religious belief can be made to serve both magical and scientific purposes - namely, in trying to bend the world to the will of the individual.