I’d like to thank all of the respondents who engaged with my essay for making a generous and generative discussion. I’m honored to be able to close the conversation. The responses are thoughtful and anticipate directions that I have been taking in my own work. I enjoyed reading them. There is still much more to be unpacked. The responses articulate two common concerns: my starter essay has a level of abstraction that might obscure rather than illuminate and my diagnosis lacks concrete practice.
To meet these concerns, I will offer a concrete medical case. But first, some background on my clinical practice will contextualize the case. I am a practicing Palliative Care physician. I attend to patients with severe life-altering or life-shortening diseases, so I repeatedly face death in my medical practice. It is precisely because I am attending to dying patients that paradoxically I most fully affirm the life of my patients. Yet, despite my forceful claim that modern medicine is nihilistic, that very nihilism still creeps into the way I see patients in the clinical encounter. Nihilism doesn’t only crop up in the contested ethical spaces of obstetric ultrasound, organ transplantation, or euthanasia. Flannery O’Connor once wrote to a friend in 1955: “If you live today you breathe in nihilism. In or out of the Church, it’s the gas you breathe.”[1] Because nihilism is in the air of medicine, it still appears in my day-to-day practice, which I will call the banality of nihilism.[2]
A while back, I was the Palliative Care consultant for a patient who we’ll call Betty.[3] (Be aware that medical cases like Betty’s are common for my practice.) Betty was in her 60s with known dementia and a recent diagnosis of incurable metastatic cancer, residing in a nursing home. At baseline, she could not carry on a conversation, but she could make sounds and gestures to communicate. Betty was admitted into the hospital because she had stopped eating and became less interactive to the point that she would not communicate, although she was awake. She likely had what we call “hypoactive delirium” in the setting of a urinary tract infection. Typically, if you treat the infection, the delirium improves. She was treated for her infection, but still did not fully recover her ability to communicate prior to the hospitalization. It is likely that she had reached a new normal. Because she was not eating, I was called in by the primary medical team to assist with helping the patient and family decide whether a feeding tube should be surgically placed into her stomach. With Betty’s medical conditions of progressive dementia in the setting of incurable metastatic cancer, she likely had months to live at best. The standard medical recommendation in a patient like Betty is not to place the feeding tube.[4]
The real reason why Palliative Care needed to get involved is because the patient’s husband – the one with the legal authority to provide informed consent – wanted a feeding tube surgically placed. In light of this discordance between the medical recommendation and the husband’s desire for a procedure that is not recommended, the medical team did not think the husband truly understood the bad consequences of feeding tube placement. Since Palliative Care specializes in communication and shared decision-making, I was consulted to get to know the patient’s husband and to help him make the best decision for his wife. From the medical perspective, the best decision is not placing the feeding tube and instead comfort feeding by hand.
Up to this point, all communication with the husband had been conducted over the phone. To facilitate good communication, my practice is to insist on an embodied, face-to-face meeting when making big medical decisions. I met the husband face-to-face at the patient’s bedside. As part of my custom, I try to understand each family member in his context, discerning where he is coming from physically, emotionally, spiritually, relationally, and then figure out what he knows about the patient’s medical condition and what that means practically in terms of quality of life, prognosis, and treatment possibilities. The husband was well-to-do, articulate, and intelligent. But he was very closed off with me.
I tried asking get-to-know-you kind of questions such as his work, his other family, how he’s doing. All my questions were met with short, curt answers and with suspicion. He asked, “Why are you asking me these questions? Why am I really here?” I explained his wife’s medical condition, discussed the question of the feeding tube, and laid out why it wouldn’t be recommended. As I was explaining these things to the husband at Betty’s bedside, I was referring to Betty in the third-person, not the first-person. The husband picked up on this. He said angrily, “Who do you think you are? Who are you to talk about my wife like she’s not even in the room? Why don’t you talk to her instead of about her?” At that moment, I knew that I had committed the sin of medical nihilism: I had reduced Betty to an object of the medical gaze, under which she is “patient” to the categories of medicine. It was precisely through my attempt to help this patient not undergo an unhelpful procedure that I had unwittingly exchanged the imago Dei for a medical idol. The very thing that I teach my medical trainees not to do, I had done to Betty. I humbly told the medical student that was accompanying me that I had committed metaphysical violence against this patient by forgetting her humanity and objectifying her. Even my own vision can still be jaundiced by the banality of nihilism.
How do we remove the scales of nihilism from the eyes of medicine? Following Peter Leithart’s call, we absolutely need an “ontological revolution,” but for this to be realized, it must be mediated through a phenomenological revolution. What we need is a new way of seeing the world. Brian Brock wants to reclaim Heidegger’s phenomenology as a means of seeing things afresh through a kind of existential re-framing but in a Christological way. Brewer Eberly seeks to draw on cultural analogies such as Harry Potter, the care of the sick, and most of all, beauty. Kristen Collier draws our eyes to the primacy of the human body, augmented by a non-dualistic Christian tradition. Alastair Roberts calls on the Church to reclaim its own practices of death and dying in order to re-frame death for medicine. I agree with all of these efforts, some of which I have been exploring in my own work.
But this new way of seeing can’t be merely phenomenological. Catherine Pickstock describes a “liturgical turn” in theology.[5] Likewise, I think we need a liturgical turn in medicine. The lens of liturgy can be helpful both as a tool of social-cultural-political analysis of medicine and as a framework for understanding a normative theology of medicine. Liturgy as an analytical tool can both deconstruct and re-envision medicine.[6] Liturgy can expose everyday medical practices such as obstetric ultrasound, organ transplantation, and euthanasia[7] as false liturgies to false idols. Seeing medicine liturgically even in its nihilistic guises clears the space for seeing medicine in a richer, fuller Christological way. Liturgy serves as a natural mediator between medicine and the Church and creation, which is a “cosmic liturgy.”[8]
Liturgy is an embodied practice that engages the senses and mediates between the divine and the human. Liturgy trains the body and the soul of the participant, re-orienting their moral imagination, their loves, and their desires, thereby changing the way they see the world. On the one hand, liturgical training can be perverse in the case of nihilistic medicine that sees the world and human bodies as dead, waiting to be manipulated by human will-to-power. On the other hand, liturgical training can also be virtuous in the case of a Christological medicine that sees the body – but not merely the body – as the body that already signifies the divine. A Christological medicine needs the liturgy of the Church to re-shape our vision to see the world the way God does: that all of creation is made to praise God, with humans as priests. Liturgical training in the Church can make the spiritually blind to see again, especially in medicine.
A Christological medicine also needs, of course, Christ. This is why I recruit Maximus the Confessor in the starter essay. He is arguably the most incarnational of Christian theologians in history. His entire theological metaphysical vision is predicated on what Andrew Louth calls a “Chalcedonian logic.”[9] Maximus’s creaturely metaphysics is characterized by the four alpha-privatives found in the language of the Council of Chalcedon: the divine and human natures of Christ are without separation, without division, without mixture, and without confusion. Creation itself is incarnational in the sense that the Creator relates to the creation without separation, without division, without mixture, and without confusion. In this way, creation – indeed, reality itself – is marked by profound mystery, paradox, and wonder.
In affirming the incarnational metaphysics of Maximus the Confessor, I affirm the central wonder of embodied life. One of my central practices in Palliative Care is to affirm the embodied life of my dying patients. This is why I consider touching the patient’s hand as one of the most therapeutic acts I can perform. When I hold the patient’s hand, look her in the eye, and comport myself with vulnerability, I disrupt the banality of nihilism and open the space for wonder. But here is the true wonder: in attempting to comfort my patient through touch, I am the one who is touched and comforted. The simple incarnational ritual of touching hands can mediate the divine and the human, providing a glimpse of grace and glory.
Kimbell Kornu (M.A.R. Westminster Theological Seminary) is assistant professor of medicine and health care ethics at Saint Louis University and is a practicing Palliative Care physician. He holds an MD from the University of Texas Southwestern and a PhD in Theology from the University of Nottingham (UK). His teaching commitments include palliative medicine to housestaff, health care ethics to undergraduates and medical students, and theology and bioethics to graduate students. His research focuses on the historical, social, philosophical, and theological determinants that shape the metaphysics and practices of modern medicine. He has published widely in the philosophy and theology of medicine. He is currently working on a book that traces the philosophical history of medical knowing back to the origins of Western medicine through the lens of anatomical dissection.
[1] Flannery O’Connor, The Habit of Being (New York: Farrar, Straus and Giroux, 1988), 97.
[2] This phrase is a play on Hannah Arendt’s concept of the banality of evil. See Hannah Arendt, Eichmann in Jerusalem: A Report on the Banality of Evil (New York: Penguin, 2006).
[3] Per the custom in medical case presentations, details of the case have been altered to protect the patient’s identity.
[4] This recommendation is not based on a culture of death nor less value placed on elderly patients. Groups that advocate for the elderly, such as the American Geriatrics Society and the Alzheimer’s Association, make such a recommendation. In patients with advanced dementia who stop eating, the standard of care is not to surgically place a feeding tube for two reasons: (1) it does not improve mortality (i.e. she would not live longer because she can still aspirate the tube feeds into her lungs), and (2) it increases morbidity (i.e. burdens would increase, such as placing wrist restraints so she doesn’t pull out the feeding tube).
[5] Catherine Pickstock, “Ritual. An Introduction,” International Journal of Philosophy and Theology 79, no. 3 (2018): 217–21.
[6] For example, see my Kimbell Kornu, “Medical Ersatz Liturgies of Death: Anatomical Dissection and Organ Donation as Biopolitical Practices,” The Heythrop Journal, 2020, 1–15, https://doi.org/10.1111/heyj.13574.
[7] It should be noted that euthanasia is becoming or has become normalized in the countries where the practice is legal: Belgium, the Netherlands, and Canada.
[8] Hans Urs von Balthasar, Cosmic Liturgy: The Universe According to Maximus the Confessor, trans. Brian E. Daley (San Francisco, Calif.: Ignatius Press, 2003).
[9] Maximus the Confessor, Maximus the Confessor, trans. Andrew Louth, The Early Church Fathers (New York: Routledge, 1996), 47–50.