Soren Kierkegaard, Fear and Trembling

A team of doctors was circled around a bed in the intensive care unit of the county hospital. The boy before them had just at that moment raised his head and disgorged a stream of blood into the air. It fell with a slap onto his white sheets and dripped off the side of the bed onto the floor. The bells on his monitors were clanging and the nurses were hustling about, offering him a basin and wiping up the blood on the floor.

Three doctors had pushed aside ventilators and ducked under thick, tense tubing to get close around the bed. Morning sun rushed through the windows, lighting the dust in the room and gracing the doctors' faces with an innocent flush. Old or young, they looked rich and strong in the Georgia morning light. They were listening to a medical student with a gray beard as he presented the bloody patient. A young woman at his side was his senior resident, a clumsy person with a degree in English poetry from Yale. And the handsome man at the foot of the bed was their attending staff, a well-published academic in the South.

The patient was a boy, and his face was heavenly white against the sheets. So unexpected was this sight at the county hospital, where the beds flanking him held two intoxicated and purpled men, that several doctors hurrying through the room paused and looked twice before moving on.

Just then the presentation was cut off when the boy gushed crimson onto his front. He paused to breathe, then jerked his neck a bit as a dribble of clot followed down his chin. He collapsed, panting. The attending swung left and right, then turned around, searching for a quick response.

"He's been doing this all night," said the medical student, tugging him back. "I mean to say he's been throwing up blood all night. The GI docs looked down in his belly, and they saw a ..." he breathed, slowing the drawl, "they saw a stomach ulcer. He's been takin' aspirin, see, he's a wrestler. So anyhow, they saw an ulcer down there, it was bleeding, and they couldn't stop it, they said he needs surgery. You know, but with the Jehovah's Witness thing, we couldn't stabilize him for surgery."

"Huh," said the attending. "Are you a Jehovah's Witness, son?" He tugged at the boy's toe to rouse him.

"Yessir, that's right," the patient said.

"And so you don't take blood transfusions."

The boy coughed, turning his head to the pillow. A look of patience touched his brow, the look of those who are leaning heavily on recited facts.

"The soul is contained in our bodies. Jehovah has chosen my soul to see his face when he calls. That's when I die, I mean. Jehovah will not accept into heaven the body of one who is not chosen, and so I must keep other bodies separate from mine in every way. To receive them would mean eternal damnation." He had been groping on his bedside Table and now produced a laminated card. "Here's a list of intravenous fluids I can't take. The saline you're giving me is okay. It's right there on the back, with a list of the okay stuff." With the recitation over, a look of fear and survival crept back into the corners of his face. Despite his illness, he was a solid boy, shining with youth. The medical student found a warm feeling rise when he looked on the boy, a nostalgic affection stirring the ashes of his own lost son.

The medical student was much older than his peers, older even than the attending staff. He had applied to medical school after his son died, in a twisting rage to escape the memory. In the hospital next to his son, he had once seen a burn victim who could lie only on bare nerves and so recoiled endlessly in bed. After Jason died, he came to know how that felt, and medical school offered an almost levitating escape. The physicians who had treated his son were above his laboring and punished kind. They confronted each other in clever Latin phrases that seemed to echo from ancient Rome. Their jokes were arcane. They seemed to never leave the hospital, to live endlessly and harmoniously together in a world of intellect and healing.

Now he was becoming a doctor himself, surprised by the cracks in that dream. But he knew that he was unique in his ability for medicine. He never told the other students about his dead son, always on his mind, but realized that he had been given a superior sympathy for the pain of the world. He had stayed up with this kid all night, just as he would have with his own boy. As the sun rose at 5:30, he had watched a few heavy raindrops falling off the trees onto the windows of the intensive care unit. The clouds were clearing from a storm the night before, and the sun was slanting across the brown city. At that moment, his heart had flooded with a vast and familiar pity for all things living. It seemed to him then that the pain of life was too great for humankind. It seemed to him that all people were bleeding like this at times, even those that appeared strong, that all people were hoping for resuscitation. And he yearned to help.

"The repair of your ulcer would be a simple matter," the attending was saying. "We could fix you in a snap of the fingers. But we need to give you some blood to do it." He stared at the patient. "Ahemm ..." he throated, filling the silence. The boy was weak, but managed to grin in reply. The attending stiffened. "We're talking about you dying here, and I can't, I won't interrupt it if you won't take a blood transfusion. Ahem."

The team gaped at him.

"How old are you, my boy?" he said abruptly.

"Seventeen," said the patient. He was shivering.

The attending snapped to the bearded medical student. "Have you spoken with his parents about this situation?"

"Excuse me?"

"It's a simple question. The patient is seventeen. Have you spoken to his parents?"

The senior resident stepped in. "I handled that myself, sir," she said. "They're driving in from Macon right now, but I spoke to them by phone. The whole family has the same views. Jehovah's Witnesses. I explained to them that death is imminent without a blood transfusion." As if to punctuate this, the boy sprayed another cup of his own blood onto the cotton bed sheets. "They were very clear on the phone. They are prepared to let Jason die."

The medical student cringed. "There's more to the story than that," he said. "I called the county attorney this morning. She can get us a court order to give this kid blood. A court order, see? Then we can transfuse him. And she's waiting on our reply."

"There's no need for that," the senior resident interrupted. "As I've explained to our medical student, the decision here is clear. There really is no ethical way to justify giving this kid blood. He and his family value their religion more than the life we can offer them, right? We don't have to be paternalistic when patients are weighing their options rationally." The medical student heard the irritation in her voice. She kept her Ivy League accent from college and used it as a weapon here in the South. He knew she thought he was stupid, but she thought everyone was stupid. She was always quoting poetry to them, as though they were her personal tribe of savages.

"Can I have a drink of water?" the patient said. The student was startled at the transformation in the boy's face. Death was really nearby now, hovering around his dry lips and dimming the smile he tried to flash after speaking.

"I'll get some water," said the senior resident when the two men did nothing. She strode off to the sink and was back in a second, lifting a plastic cup to the boy's lips. She watched the water sink into his tongue, watched his Adam's apple tremble with the job of drinking. When he finished, he was exhausted and touched the senior resident's hand to push her away. She was startled by the cold palm that lay across her fingers, and her hands closed reflexively around his to warm them.

It softened her heart to feel those hands. The boy was so young. It wasn't that she wanted him to die, she thought. She wondered if she should be fighting for a transfusion, like the medical student. But she was so offended by the student's shallow impulses that she couldn't help opposing them. There were a hundred doctors like him at this hospital, pursuing a cure as if it were a spot on the map, swaggering out to rounds and drawling about their big saves the night before. Try telling them that disease was a subtle dealer, that each victory demanded a concession, and you lost them. Her attending was another good example. These so-called academics were the worst, all fighting to break into the literature that overwhelmed her desk. They were laughable and, on reflection, sad. Couldn't they see what a waste it was? There was too much writing. Even the very best stuff-Brenner, Braunwald-it, too, would be buried soon in mammoth volumes, indistinguishable from the rest. She missed her poetry, missed its humble fear of certainty, its parsimonious use of words.

"Give me the okay to call the county attorney," said the medical student to his staff. "Tell me we should give this kid blood. There's still time before his parents get here."

The senior resident met his eyes with disbelief.

"If I make the call now, we can have an answer in an hour," he continued. "He's bleeding to death, he's seventeen and he's gonna bleed to death, right here. We can still save this kid."

"His parents disagree," intoned the attending. He was wavering. "We can't overrule them."

"We can if we get a court order," he said, heading toward the phones. "What's happening here is plain crazy."

"Wait," said the senior resident. "Come back here." She lowered her voice to a harsh whisper. "What are you doing? Do you have any concept of this boy's basic human rights? No, wait. Have you even heard of ethics? You can't do this. It's his body. His decisions win, yours lose, every time. That's just how it works."

"But you're sending this kid to a death that doesn't need to happen. His parents are buying a world of pain that they're gonna regret. This is wrong."

His drawling confidence was too much for her. "Listen now," she said, as she tapped on the bed. "You might think you're Superman, here, stepping in and pulling life from the jaws of death. Well, get over it. Grow up. We don't save lives here anymore. We settle for a lower cholesterol or a higher urine output. That's what we do. And then they die."

"But this is not them," said the medical student. "We could save his life."

"Oh, I see. Here he is at last, the perfect patient." She gestured theatrically around the room. "Here he is, a boy who needs us to help him live! And he looks at all that medicine has to offer and he says ‘no thanks.’ He says that what we are doing is unnatural and ungodly. He preserves the purity of his body like a monk, and we bring him someone else's blood, we sell him something never meant for exchange. And he refuses! He suggests that doctors were wrong to dabble with God's ingredients in the first place. Infidel, you say! Well, I look around," she paused to let the ventilators rhythm fill their ears, "and I can't argue with him. Can you?"

"You bet I can." He stared her down. "And I'm pretty sure I'm right."

"Well, smarter people than you think you are wrong," she shot back. "Lord Byron, for one. ‘Whom the Gods love die young,’ he wrote. ‘And many deaths do they escape by this; for the silent shore awaits at last even those who longest miss the old archer's shafts.’ Listen to those words, will you? You save this kid today, the archer is still waiting for him, just a heart attack or a heartbreak away. He doesn't want it. Dammit, you're more scared of it than he is. He's ready to brave the archer right now, today. How can you tell him to wait?"

The patient was fading as she spoke, no longer really aware of the conversation. His eyes rolled back in his head every few seconds. The medical student felt he would burst. A familiar sense of loss was drowning him. He grasped the boy's shoulder, jostling it up and down. "You're wrong," he said, and the drawl cracked. "I know you're wrong because my own son was twelve when he took one of your ‘arrows.’ And I can tell you Lord Byron never had a little boy die of cancer, doctor. That's for damn sure." His eyes stung red but he persisted, turning his efforts to the attending. "If there was a way to save him I would have done it. My son should still be alive. This kid should live longer than today. You know I'm right."

The attending was provoked. "The parents have not given their assent," he repeated sternly. "This is all by the book. We can't give blood to someone who has refused it. We could get sued. We could be arrested for assault."

The medical student lifted his head to the ceiling. "You're right," he said. "We could get sued. We could even be arrested. We will probably have to pay for doing what is right." Then he turned to the senior resident. "You can't fight with medicine this way, you know," he said. "You'll go nuts. And you're too young. At the end of the day, you kick the questions out of the room and you try to believe. When it's quiet, you'll know. People need us. People need us to believe."

She looked at him, briefly speechless. The empty cup in her hand sounded a heartbeat click as she gripped it and released.

The boy had been trying to watch their mouths, but now his trembling became still. A smoothness settled across his brow. He lifted a hand to grope at the aging medical student. "Help me," he said. "I can't see. Why can't I see? Are my mom and dad coming? I'm scared. I'm really scared. Help me."

"I'll help you," said the medical student. "I will help you." He squeezed the boy's hand tightly. Then he stood.

"I'll make the call," he said. "You order the blood. Six units. O negative. There's still time."