For the past twelve years as a staff chaplain at Memorial Sloan Kettering Cancer Center, I have followed a general rule of thumb in spiritual care by addressing questions of “Why me?” by addressing patients’ grief, not their intellectual anger (Machiano, Reference Machiano2014). Yet, when I encountered these three patients, the demand for a true intellectual answer and the tragedy of all three patients goaded me to change my spiritual care approach when a legitimate intellectual question is asked of me. I thought about the answers of patients and about my own spiritual tradition and faith for an answer that satisfied me personally.
My Three Patients
A Jewish female patient is dying of cancer having given birth to a newborn ten days before. Her Jewish family friend stands at her bedside and confronts me in the hall about the coming patient's death as well as the death of her own son who died in a traffic accident ten days before. She wanted to know why neither the newborn child nor mother would ever know each other and why her son had died in a traffic accident. My attempts as a chaplain to affirm the friend's anticipatory grief for the coming loss of her friend and her current grief at the loss of her own son (Massey et al., Reference Massey, Barnes, Villines, Goldstein, Hisey Pierson, Scherer, Van der Laan and Summerfelt2015, Table 3) were firmly rebuffed. She wanted answers from her Jewish faith! I had none that satisfied.
A young, religiously observant, unconscious and pregnant woman is dying of cancer. Her unborn child is too young to be removed by cesarean section. Her pious husband and she previously agreed to decline chemotherapy for fear of harming their child. I attempted to speak with her husband, but the family “gatekeeper” screened my conversation and would only allow uplifting words, in keeping with the family's faith tradition. I offered a prayer for healing. As a chaplain, I was unable to encourage the husband to access his religious resources (Massey et al. Reference Massey, Barnes, Villines, Goldstein, Hisey Pierson, Scherer, Van der Laan and Summerfelt2015, Table 3) about the ethical question of saving his wife at the expense of the unborn fetus. He was darkly silent. Still, I was able to ascertain that he had spoken with his spiritual leader, perhaps about this very urgent question. Both mother and unborn child died. I was frustrated with myself and with the burning theological question, “Why?” Why was this happening to this young family?
A 35-year-old woman with terminal cancer asks the chaplain, “Why am I dying? I have lived a good life. I have not harmed others. I have played by the rules. I am a good person. Why am I dying?” This young patient appealed to an unwritten and unspoken contract that if she obeyed the rules of Life, no harm would come to her. Her medical condition directly contradicted her assumptions. For patients who are agnostic or atheist, I encourage them to self-actualize by assessing their legacy to family and to the world and to decide what goals they want to achieve with their remaining time. Yet, her question remained. Was the universe indifferent and unfair or malevolent?
Each incident challenged me to consider when “Why me?” requires an intellectual answer first and how I was to justify for myself, a just, all loving, omnipotent and omniscient God or a fair and just universe in the face of the evil of cancer, suffering, and premature death. This is the question of theodicy. When should I be open to discussing this intellectual question with patients and family or simply acknowledge their grief?
Merriam-Webster's dictionary defines theodicy as “defense of God's goodness and omnipotence in view of the existence of evil.” The problem for some of my patients and their loved ones is:
1) Why would a good, loving, and fair God give me (my loved one) cancer? or
2) Why does a universe that I believe to favor what is good and fulfilling in my life repay my good life with pain, suffering, and death due to cancer?
I was unsatisfied by the rule of thumb of professional chaplaincy that such questions only reflect grief that needs to be addressed. I searched for the collective wisdom of patients and families who question a just and divinely ordered world or simply a benevolent world that is inflicting on them worry, suffering, and the possibility of a painful death.
What do patients and family members think?
By and large, in my experience and according to researchers (Nelson et al., Reference Nelson, Rosenfeld, Breitbart and Galietta2002; Walton and Sullivan, Reference Walton and Sullivan2004; Henderson et al., Reference Henderson, Gore, Davis and Condon2003; Cook and Wimberley, Reference Cook and Wimberley1983; Swinton et al., Reference Swinton, Bain, Ingram and Heys2011;
Taylor and Outlaw, Reference Taylor and Outlaw2002; Black and Rubinstein, Reference Black and Rubinstein2004; Gall and Cornblat, Reference Gall and Cornblat2002; Taylor et al., Reference Taylor, Outlaw, Bernardo and Roy1999), patients and family members conclude:
1) God or the universe is indifferent to suffering for reasons beyond our understanding;
2) God or the universe justly punishes misdeeds or balances life for life by balancing a good life outcome with death and suffering;
3) God or the universe encourages the sufferer to model a good life in the face of suffering before death and then suffering is relieved by death;
4) Suffering is a human concept only;
5) God or the universe is always present to the ill but has no direct impact on the illness.
As chaplain, I acknowledge the importance and legitimacy these concerns have for the sufferer and family and so I explore with them what these thoughts mean. Their answers may be an open door to spiritual distress. Yet, they are not enough for me, personally.
In the instance in which a patient or family member truly wants an intellectual answer, I would be an ineffective chaplain if I posited an indifferent, distant, or even a cruel God or universe to a suffering patient. Such an idea is not nurturing nor supporting to a patient in a time of all manners of distress. Yet, to those patients or family members who wanted a thoughtful answer, I wanted to offer a message of hope. I dug deep into my religious tradition.
Some patients or patient families understand illness as punishment, whether divine or from the way life works. The Bible (throughout Deuteronomy, Leviticus 26, and the second book of Kings 7:7-23) and Talmud (Shabbat 31b-33b and Sotah 8b-11a) agree.
I was unsatisfied. Punishment assumes time to learn from mistakes and an opportunity to change attitude and behavior. No loving punishment could justify the death of mother and unborn, nor a random traffic accident, nor a newborn and mother who will never know each other, nor a just and kind young adult robbed of the joys, pleasures, and responsibilities of life.
I found what I consider an open door and an answer to my dilemma in a Talmudic debate about reward and punishment. The Talmud (Kiddushin 39a-40b) mentions an incident in which a young son is asked by his father to fulfill the commandment of collecting bird eggs for food and protecting the mother from seeing her young taken from her by shooing her away (Deuteronomy 22:6). The Bible promises “it will be well with you and you will prolong your days” (ibid).
Following his father's instruction, he climbs onto his family's roof and dies in the attempt. Believing deeply in a just God, the rabbis of the Talmud did not posit a theological answer but a practical one. They said, “The ladder was rickety (in this case) so the danger was fixed and wherever the danger is fixed we do not depend on a miracle” (Kiddushin 39b).
Here was something I could say with a clear conscience. First, the Talmud said that things break. Ladders break or wear out. Our bodies wear out or something goes wrong in our biological functions. Secondly, when these events result from every day unchangeable processes, God does not intervene. No miracle. Rather, we are obligated to protect ourselves (Babba Kamma 15a) by not knowingly put ourselves in danger.
Things break
In the world in which we all live, things grow and decay. Recently, Tomasetti and Vogelstein (Reference Tomasetti and Vogelstein2015) and Wu et al. (Reference Wu, Powers, Zhu and Hannun2015) suggested that many cancer cells may be the result of what they call “luck,” due to the increased probability that the DNA helix will become malformed after millions of replications over the lifetime of a cell.
A broken ladder in the Talmud or a broken DNA helix are the results of fixed physical forces, not divine punishment. Our obligation is to seek out medical help and to care for the sick (Exodus 20:19).
Should a patient or patient's family member ask, “Why, why is there cancer here?” I tell them that the answer is medical or scientific. They may pray for a miracle, while their spiritual obligation is to work for a medical healing.
