Randomness and Compassion

What the poets call “kismet” and the romantics “fate,” the philosophers call “contingency” and the mathematicians “randomness.” (DJB)

Eat right, drink right, die anyway. (Anonymous)

It’s somehow “reassuring” that when someone gets sick they have risk factors: lung cancer in the smoker; renal failure in the poorly controlled diabetic; hemorrhagic stroke in the elderly lady with hypertension. We can congratulate ourselves on our control over our risk factors (Don’t I exercise? Don’t I take fish oil? Don’t I monitor my lipids?) We build a false sense of security around the illusion of control.

But fate has a different perspective. It honors no security fences. It smiles ironically at our brave shields of presumed protection. It mixes in both the predictable and the haphazard. The people affected by random cruelty appear on my patient roster daily: the non-smoker with lung cancer; the runner with angina; the vegetarian with peripheral vascular disease; etc. Of course, statistics do “hold” statistically. Nature plays “I told you so” often enough to be said to be following certain predictable rules. But she also bends and breaks those rules enough to be called fickle.

As far as human illnesses are concerned, sometimes we nod our head in understanding, and other times we shake it in disbelief. Sometimes punishment is meted out in due portion; other times it’s more like the lotto in reverse: suffering is scattered out to the kind and cruel, the scoundrels and the saints, with equal disregard for character or merit.

The Book of Job in the Hebrew Bible can be seen as a treatise on randomness and on the limits of logic in human understanding. The good man Job seems to be doing everything right and being “justly” (i.e., logically) rewarded. He is devout and humble. He gives to charity. He is kind to those he meets. He is “rewarded” with a large, happy family and an enormous, thriving flock of sheep. In a medical context one can imagine that Job gets yearly checkups, always wears his seat belt, eats five servings of fruits AND vegetables daily, exercises three and a half hours weekly, and is rewarded with excellent blood pressure and a low PSA. His life insurance rating is perfect.

The Biblical Job crashes and burns for no logical reason. When he asks God for an explanation, he gets the famous reproach from out of a whirlwind: Where were you when I laid up the foundations of the earth? (How can you, puny little man, ever hope to understand even a wisp of the mysteries of the world?) Broken, deprived, smitten by physical pain and personal loss, he is left to contemplate the unpredictability of it all (at least until his magical restoration in the final chapter).

We might imagine that our jobian patient finds that he has hepatitis C from a transfusion he received in the early ’80s, and the benign palpitations that began after a bad “flu” turn out to be associated with a post-viral cardiomyopathy. His wife leaves him after his depression renders him impotent; his work fires him for excessive absenteeism; and his insurance offers him COBRA, but it will cost more than his disability checks.

As doctors we are not given the luxury of simply contemplating these philosophical conundrums, but of doing something, even some small thing, to set things right on a daily basis. There may be randomness (the existential perspective) or God working in mysterious ways (the classically religious perspective). But there is also some part of the world, some part of this patient’s world, that we can set aright. Getting the diagnosis correct, prescribing the appropriate medication, interpreting the tests with skill, and communicating it all to the patient and their family — this is what we can do in the face of the disruptions and suffering that fate metes out.

Externally, our enemies are microbes and organ dysfunction. Internally, our opponents are various kinds of disregard, including smugness and complacency.

I hope you who are reading are well and your families are well. I hope that your health and success translates into a prayer of gratitude and a commitment to compassion. Remember, as the famous Harvard naturalist Stephen Jay Gould said: “We will not protect what we do not love.” To which I would add the words of the Dutch philosopher, Baruch Spinoza, who reminded us: “We are [only] as large as our loves.”

The following poem, “Theodicy,” is one attempt to deal with the unfairness I encounter daily in my medical practice and in the headlines. By asking a series of questions, it implies that these issues may have “explanations” but no definitive answers.

Theodicy

Theodicy: the branch of theology that defends God’s goodness and justice in the face of the existence of evil.

Did God blink or turn his head
That left you crippled, suffering, dead?
Was it a simple roll of dice
That turned your turn to sacrifice?
Was it just the twists of fate
That doled out poison on your plate?
Is that the way the cookie crumbles?
One man steps, another stumbles?
Is it the random rain of angels’ tears
That has placed you there and left me here?