Those of us who work in palliative medicine ignore the lessons of the great books and sacred texts of our civilizations at our own peril. Wisdom lies in works as disparate as Leo Tolstoy's The Death of Ivan Illyich, the Book of Job, or Ernest Becker's The Birth and Death of Meaning. It is becoming a more common practice in palliative care and psychooncology training programs for trainees to be exposed to the humanities in an effort to learn about the care of “humans.” Reading and discussing The Death of Ivan Illyich is now quite a popular means of teaching our younger colleagues about the process of dying and the potential for redemption and growth even in the last moments before death. The Book of Job however has eluded many of us in palliative care as a source of lessons that can be applied to clinical intervention in palliative medicine. I suspect there are multiple reasons: (a) The Book of Job is seen as a purely religious text with few secular applications; (b) The lessons of the book of Job are perhaps arcane, unclear, and subject to extensive and divergent interpretations; and (c) although not the final reason, I also suspect that too many of us have not really bothered to actually read the Book of Job, and only know what we hear from others of the lessons that may lie within. The truth is, that over the last 23 years as I have been working in the care of the dying, I have referred to Job hundreds if not thousands of times in the context of discussing suffering, and yet I had never really taken the time to read the text myself; completely and with an open mind.

Reading the Book of Job turns out to not be an easy task. There are many versions, of varying lengths and with differing story lines. There is also no paucity of controversy as to which is the accurate version. There is also no dearth of commentary on the interpretations of the lessons of this epic poem. Great thinkers ranging from Maimonides Spinoza to Carl Jung have responded to Job's story with great thought, insight and differing conclusions as to what it reveals about the relationship between man and God. Most of the debates have focused on the questions of Theodicy (can God and evil coexist), and whether God is a “personal” God, involved in the affairs of human beings, punishing those who sin, rewarding those who are deserving, responding to prayer, or whether God is a “natural” God who is unknowable, mysterious, one's whose actions cannot be understood by human beings. These are primarily religious questions about the nature of God, yet they are questions that arise in the palliative care setting quite frequently. “Why did this happen to me?” “What did I do to deserve this?” These are questions we are asked frequently as palliative care clinicians. Although these are often religious questions that relate to an individual's relationship to God, they are also, in essence, universal existential concerns that are being expressed. Patients often turn to us a clinicians for comfort, solace, even answers.

Last month I set out to read the Book of Job. I chose to read the Book of Job translated and with an introduction by Stephen Mitchell (Reference Mitchell1992). Stephen Mitchell is a Brooklyn born poet and translator of sacred texts whose work I was familiar with and had enjoyed reading before. I have particularly enjoyed his translations of the poetry of Rainer Maria Rilke, and his translation of the Psalms. Mitchell does not merely provide a modern accessible translation, but also gives historical context and references that enrich the experience of the reading. This was definitely the case in my reading of his translation of the Book of Job. As an example, I learned that we do not really know who the author of the Book of Job is. There is little evidence as to who the author is, when and where he/she wrote it, or for what kind of audience. One of the greatest paradoxes of this greatest Jewish work of art is that the hero is a Gentile, as might have been the author. Some authorities estimate that this dramatic epic poem, which treats the problems of the suffering of the innocent and of retribution, was written between the seventh and fifth centuries B.C. Despite the uncertainty as to the Jewish origins of the author or hero of this poem, the theme of Job is the great Jewish theme of the post-Holocaust age, the theme of the innocent victim. As a child of Holocaust survivors myself, I was, of course, drawn to some of these elements.

Indeed, there are a myriad of existential and spiritual themes that one can become immersed in when reading the Book of Job. I focused on two themes really, because of their relevance to my work, our work, as clinicians who care for those who suffer during the dying process. First, I was struck by the relevance of Job's experience of suffering to the experience of so many of the patients we care for. When Job is afflicted with disease of his flesh and bones, the description of his experience reminded me of the experience of a patient I had cared for with leukemia who had undergone a bone marrow transplant and was now suffering from severe graft versus host disease. Job feels his bone marrow swell in pain, his skin is cracked and oozes, and he cries out in despair, even begging for death to end his suffering. “This is exactly what I experienced; I was praying to die so that my suffering could end” my patient recounted as we discussed Job's experience. I was struck by the accuracy of the description of suffering. Second, I was struck by the repeated themes of being “upright” and “whole.” It is these themes of being upright and whole that I wish to explore here today and suggest as useful clinical and psychotherapeutic concepts in the care of those who are suffering in the face of death.

We first encounter the terms “upright” and “whole” in the prologue of the poem, where God says to the Accuser (Satan), “Did you notice my servant Job? There is no one on earth like him: an upright and whole man, who fears God and avoids evil” (emphasis added). Now these terms, “upright” and “whole” are likely used here to describe Job as a man who shuns evil and a man of integrity and goodness, a pious man who fears God. As the story of Job progresses, the concepts of being “upright” and “whole” return over and over again, with an even richer, more powerful meaning and wisdom attached to them.

Our next encounter with the concepts of upright and whole comes quickly after Job is told that all of his material wealth has been lost and that all of his sons and daughters have been killed. Job stands up. He tears his robe. He shaves his head. He lays down with his face in the dust, pouring earth on his head. He then says, “Naked I came from my mother's womb, and naked I will return there. The Lord gave, and the Lord has taken; may the name of the Lord be blessed.” Now some may focus on Job's acceptance of God's will; I however was struck by Job's initial acts of (1) falling to the ground from an upright, standing position and literally humbling himself in the dust from which he was formed (the humus of humanity) and (2) tearing his clothes, symbolically representing the disintegration or rupture of the whole that was his identity prior to losing all that gave his life meaning. Now Job's actions might also strike some as being similar to the Jewish act of “Teshuvah” or repentance for a sin committed against God. It is interesting to note that the term Teshuvah also means “to return,” implying that Job's actions are intended to lead God to restore him to a state of being upright and whole”through repentance. In fact, at the end of the Book of Job, God does restore all of Job's wealth, provides an even greater number of children and grandchildren, and fully restores Job's identity and his relationship to the transcendent. Job is restored to a state of being upright and whole.

I've become interested in how these concepts of being upright and whole might be of benefit in my clinical work with dying patients. I have conceptualized being “upright” in the following way. When one is upright one is capable of exerting his/her will in the world. Exerting one's will, or free will, in the case of a terminally ill patient, may take the form of reassessing priorities in the face of a limited prognosis and deciding to focus on those priorities (e.g., spending time with family, deciding to not take palliative chemotherapy and focusing on pain and symptom control, creating a generativity document, or continuing to work as long as possible). When patients are forced to lie in bed with fatigue or uncontrolled pain (not upright, but literally on their backs) and robbed of their ability to enact their will, they clearly suffer. The concept of remaining upright for as long as possible in the face of the dying process is, in my opinion, a useful construct to utilize in terms of treatment planning and goals of care. I have begun to conceptualize the concept of being “whole” as the ability of a patient facing a life threatening illness “to remain connected to all that gives meaning, value and purpose” to one's life, even during the dying process. Being whole represents an effort to “preserve one's identity” for as long as possible, despite the real or threatened losses and ravages of progressive disease.

Recently, in working with an older man who was struggling with advanced myeloma, we discussed these concepts of facing the dying process upright and whole in our psychotherapy. These concepts were quite attractive to him, and I sensed they resonated strongly with his wishes for how he could find a “way to live while he was dying.” When his wife asked to sit in on one of his sessions with me to discuss the fact that he was still occasionally sneaking a brandy in the evening after dinner (she was concerned this would interfere with his ability to respond to his chemotherapy), he compassionately explained to her that her concerns for his health were very extraordinary acts of love, but he did not want to lose any valuable time in continuing his quest to remain upright and whole until he is finally laid to rest and becomes part of that greater whole.