The most reverent thing I did that night was nothing
The Integrated Life — Personal philosophy written from the bedside. Short essays building one idea at a time, by a surgeon who works inside the organ that makes us who we are.
The call came a little after one in the morning. A man at a memory care facility two towns over had stopped moving the left side of his body. Seventy-eight years old. A decade of Parkinson’s, severe dementia, and now, on the scan the stroke app pushed to my phone, a clot in a small branch of the right middle cerebral artery, the one feeding the strip of cortex that drives the left arm and leg. His stroke scale was a seven. Not catastrophic. Not nothing. The kind of number that, in a different patient, sends me out the door and into the car.
I looked at the images. The arch of his aorta was a corkscrew, the sort of anatomy that turns a thirty-minute retrieval into a two-hour wrestling match and stacks the odds of tearing something on the way up or never reaching the clot at all. The ED physician told me he was awake and agitated, pulling at the lines, unable to understand where he was or why strangers kept touching him. To thread a catheter from his groin to his brain, I would have to put him under general anesthesia and hold him still by force. Intubate him, run him to the angiography suite, fish that corkscrew arch, and pull a clot from a vessel the width of a pencil lead, all so that he might, or might not, regain the use of a hand he could no longer reliably feed himself with.
I want to tell you why I said no, and why saying no was not the failure of reverence but its fullest expression.
There is a picture of reverence most of us inherit without choosing it. It is religious in its bones even where the religion has been left behind. Every life is sacred; therefore every life must be defended to the last; therefore the doctor who does everything is the reverent one, and the doctor who stands back has given up. It is a beautiful instinct and I do not think it is foolish. It built most of what is decent in medicine. But it carries a hidden assumption, and the assumption is wrong: that to revere a life is to preserve the body that carries it, by every available means, for as long as the machinery will run.
Reverence does not need heaven to ground it. Its real object was never the body. It is the someone the body is for, a being for whom things can go well or badly from the inside, who has a vantage, a view from somewhere, a night that is going badly right now, and a suffering my colleagues and I will soon have to decide what to do about. Take the theology out and that is what remains, and it is all you need. The worth of a person is not a reading you can pull off a monitor. It lives on the inside, on the experienced face of things, in the bare fact that there is an inside at all. The philosophy I work from has a name for value of this kind — constitutive valence: worth built into the having of an experience, not conferred from outside and not reduced by damage.
I have to be careful, because the easy and ugly reading is sitting right there. I am not telling you his life was worth less because his mind had been taken from him. That is the opposite of what I believe and the opposite of what I did. His standing as a subject, someone it matters what happens to, was not diminished the slightest bit by the dementia or the Parkinson’s or his age. A man whose inner life has narrowed to something small and frightened and confused is still the bearer of an inner life, and that is the whole of what reverence answers to. His worth was total. It was precisely because it was total that the question changed.
The question was never whether his life was worth saving. It was what this particular intervention would actually do to him and for him. And the honest accounting is brutal. On one side, a procedure he could not consent to, could not understand, would experience only as assault, requiring me to sedate him into stillness and breathe for him through a tube: certain burden, felt from the inside. On the other, a chance, no better than a chance, of restoring blood to a small territory of cortex, with no guarantee that a brain already this far gone would convert that flow into a working hand or a life he could use: uncertain benefit, very possibly futile.
This is not the cold arithmetic it can sound like. I was not weighing his life against a bed, or a budget, or another patient’s chance at the table. The only thing on the scale was him: what that night and the days after it would be like from the inside, for the man they belonged to. A clinician who takes the whole of this in, who lets the man and not the scan be the object of his attention, comes to care about the burden and not only the deficit. I am not deriving an ought from the scan. I am telling you what attention to a person, given fully, tends to produce in the one who pays it.
So here is the objection, the strongest one, the one I feel the pull of every time. If a conscious life is irreplaceable, does not reverence demand that you fight for it with everything you have? Does not standing down and declining to treat simply dress up abandonment in gentler language?
No. And the proof was in the room before I ever picked up the phone. He was agitated. He was pulling at the lines. That distress — the thing the ED physician named as an obstacle, the reason I would have had to paralyze him to perform the procedure — is not a complication of the case. It is the case. It is the inner life, present and protesting, the someone whose night this is. Reverence for that someone is exactly what argued against forcing the machinery on him. To treat the body at all costs would have been to mistake the readings for the man, to revere the part of him a monitor can see and override the part it cannot. His family said it plainly, on the phone, in the worn voices of people who have been watching this for years: they were tired of seeing him suffer. They were not telling me his life had stopped mattering. They were telling me he was still in there, still a person, and that what was happening to that someone was bad. That is testimony, not permission.
We decided together — the emergency physician, the family, and I — to manage him medically. To keep him comfortable, treat gently what could be treated, and not put him through the rest. I heard the relief come down the line when the family understood I was not going to intervene. I did nothing dramatic that night. I did not drive in. I did not save the day.
It was the most reverent thing I did all week.
Reverence is the first of the virtues this philosophy is built to hold, and it is secular all the way to the floor. It is what the standing of a single conscious life is worth, and that worth is real, and total, and owed to everyone who has an inside. Sometimes you honor it by doing the hard and heroic thing. And sometimes, at one in the morning, with a corkscrew arch on the screen and a frightened man two towns away from his home, you honor it by being still.
— Michael
Glossary — a few terms
Constitutive valence — worth built into the having of an inner life at all: the value a being carries simply because there is something it is like to be it, neither conferred from outside nor reduced by damage.
Standing — the moral status of being a subject, someone it matters what happens to; in Integrative Realism it belongs to any being with an inner life and is not diminished by illness, age, or a narrowing mind.
I read every comment, and they shape what comes next — which questions get an essay, how often these arrive, and where the project goes from here. Tell me what you think.
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