Medical Dental History Contact Update (Required Every: Fill & Download for Free

What is the most callous thing that hospital staff have done in your presence?This was said to me three weeks ago today, on March 5, 2020 at 8:45 am, by the heart surgeon for my partner of 13+ years, who was at that time in the hospital’s ICU unit, on a respirator and in a coma…“Oh, then you can’t really make decisions for him, not really…”He slapped his palm on the countertop of the nurses’ station, as if he had just proved a point or won a bet. To me, he sounded relieved as he said it.I’m not afraid to mention names, because there were witnesses who heard Dr. Robbin Cohen (CA license # G45914) say this to me, particularly my partner’s nurse Maria, who loudly and pointedly called out from behind me, “Ross said Dave was to make all decisions for him, he said it several times before he went on the respirator, Dave makes all decisions on his behalf!”Having just arrived at Huntington Hospital in Pasadena, California, I had barely taken a peek into Ross’ room, just enough to see that he’s finally sleeping peacefully for the first time in weeks; I hadn’t even sat down yet when this was how I found out that Ross’ condition had actually deteriorated sharply and he was now on life support, after waiting ten days for an unplanned, hour-long emergency procedure to remove the source of a life-threatening infection.After pulling me quickly into a nearby waiting room, Dr. Cohen updated me on Ross’ current condition, adding that if it were up to him, as the lead physician in the case, he would cease treatment altogether at this point; it’s risky and very costly. He made sure to bring a witness with him; I had nobody but myself and my state of shock. “You mean he’s dying, Ross is dying?!?”A few minutes later, after I’ve pulled myself together, the three of us - Dr. Cohen, Dr. Cohen’s witness and myself - followed by an orderly or nurse, returned to Ross’ room, and after listening to some alarming revelations from Dr. Cohen, the room looks different now. Ross is in bed, asleep for the first time in days, tilted slightly up, pale and grayish; his head rolled over to the far side, his eyes shut, his mouth open. A blue plastic hose big enough to fit a vacuum sweeper has been shoved down his mouth and throat. Tubes, wires and plastic lines hang down from above, plastic bags and drip lines surround him and hold him captive. He’s fallen asleep in a spider web; he’s in trouble, real bad trouble.One step into the room, another, another. I’m still processing the surreal that Dr. Cohen had told me just moments before, when I hear a voice trembling, it’s my voice, distant words forcing their way up and out. “Oh, God… Ross… Ross…” My knees don’t work, they’re gone; the floor flies up at me and the room goes black.WHAT HAPPENED?Let me back up a few days.Ross had been admitted nearly two weeks earlier through the ER on Friday, Feb 21 with chest pains, dry cough, difficulty breathing, shortness of breath, dizzy, painful to lie flat or reclining. On Medi-cal, he is admitted for testing and observation. Diagnosis was made over the weekend: strep infection has attacked his heart valves, causing blood to flow backwards into his lungs. There was an established protocol: (1) antibiotics for the bacterial infection, (2) removal of infected tooth or teeth, and (3) followed by open heart surgery to replace damaged heart valves. Oral surgery must precede heart surgery to prevent reinfection; without these surgeries, Ross will die.It’s serious but the protocol was known and even with the risks, survival rates were 80%. Ross being middle aged in otherwise good health should not have trouble recovering. If all went well, he could be back home in 2 or 3 weeks to recuperate and be himself again by Memorial Day. He’d have to be monitored regularly, but most patients who experienced this went on to live normal lives.Antibiotics were started immediately. A team of cardio specialists was assigned to him, as well as an infections specialist, a pulmonary resident, and an oral surgeon was brought in for consultation on the teeth. The consultation lasted no more than 10 minutes, and ended with Dr. Tiner (CA license #A87203) saying, “You have seven infected teeth that need to be pulled. I charge $250 per tooth, so that’s $1,750. I don’t take your insurance, so how would you like to pay for it and when?” Ross was taken aback, saying, “I don’t know if I have that kind of money immediately available; I’ll have to ask.” Dr. Tiner told him to let him know; and as soon as he had an answer he would schedule the surgery. He left. Ten minute consultation, tops.Ross relates this to me in the afternoon when I visit. “Does that mean if we don’t have the money, he won’t pull my teeth, and the heart surgery won’t happen, and I just die? Can they do that, would they really just let me die?”That has to be illegal, I tell him, surely he’ll put it on a payment plan like any other dentist. Ross seems skeptical. He had told this to Dr. Cohen, heart surgeon; he didn’t like Dr. Tiner’s bedside manner, which was “mechanical and cavalier,” to use Ross’ words, and he was worried about this payment in advance. Dr. Cohen brushed his worries aside: “Yes, we have had problems with him in the past and there have been some complaints, and I’ve spoken to him about that, but he’s one of the best at what he does, and he is who we use here.”“Can you believe all that?” Ross asks me.No, I can’t, it’s outrageous. What if it had been $20,000; would we still have to pay in advance? Would the hospital just let you sit here and wait until we come up with the money? It’s hard to believe. I’ve been a patient here before, and the doctors and care were outstanding. I can’t imagine a doctor here acting like that or being so nonchalant about it. An acknowledgment of past problems but he is the one they use? What kind of complaints and problems, what kind of corrective action was taken, who spoke to whom about what? Ross didn’t know, it was all rather vague, and anyway, there is no other oral surgeon available. Did anybody look? Ross doesn’t know; he supposes Cohen and Tiner must be personal friends outside the hospital; that’s the impression he had. Tiner was brought in from outside and Cohen didn’t seem worried about Ross’ apprehension.This can’t be right, not at Huntington Hospital. Surely they’ll put the dental work on the bill. No, says Ross, he already asked. It’s separate billing. Dr. Tiner had an assistant with him too, who didn’t say much, but he looked very uncomfortable when Dr. Tiner talked about payment in advance. He wouldn’t make eye contact with Ross. Dr. Tiner spent more of those ten minutes talking to his assistant than he did to Ross; he didn’t even ask if Ross had any questions or concerns about the procedure. Just open your mouth, let me see, and he called out some numbers, then the payment part and that was it. “I might as well have not even been here for most of it,” he says. “It was like I was a demonstration dummy for teaching a class.”Were the complaints about his personal style or about payment, and were they formal or just talk? Ross didn’t know. “We’ll file our own complaint and make it official with the state board. You and I would be required to report it.” Ross agrees; we both have advanced degrees in psychology; he has a PhD, I have an MA, we’ve both had experience as counselors, and we know the laws and ethics that apply. I imagine they must be fairly similar for physicians. Ross has also had a career as university faculty and administrator too, Dean of Students. He’s had to document student behaviors and conversations; he’s had to deal with the courts and the licensing boards before, and he agrees to document those conversations.There is still the matter of payment. “Do we have that much in the bank? It’s the end of the month.” No, I just paid the mortgage on my way here. I could stop payment on it, and… “No, we just got out of forbearance, don’t muck it up now.” We’d been going through a rough patch this year, and nearly lost the house three months earlier. This would be the second payment since ending the forbearance plan. I could try to do an early withdrawal from my retirement account; that would get here by next week, maybe the end of this week if I can convince them it’s an emergency. I can send the paperwork first thing in the morning. Let’s try that.I spend the night sleeping in the window sill of his hospital room: they are wide enough to support a small mattress and long enough to support an average height person. A little cramped for a six-footer like myself, but I can make do. I am at least better off than Ross; the poor guy is miserably uncomfortable. If he tries to lie flat, he can’t breathe; if he sits up, he has chest pains, and so he spends the night tossing and turning. “If I could just get some sleep…” he mutters a few times during the night.But all that afternoon he has had a look on his face that I’ve rarely seen; Ross is not normally a worrier, he’s always upbeat and confident. Not today. He looks dejected and defeated. He’s worried, very worried, a premonition. “What if we don’t have the money, does that mean they would just let me die?”Apparently it means exactly that. In any case, that is how it plays out.WHAT WENT WRONG?Tuesday Feb. 25, morning. Ross calls me at home. I tell him I’m about to send the request to my retirement account, it should be here by Friday, four days away. Ross says Dr. Tiner can’t put Ross in his billing system but he does take credit cards. That’s strange; Ross is in the hospital and Dr. Tiner is going to operate on him; how does that make him not a billable patient? Who pays for hospital surgery by credit card when they have insurance; why do we have insurance at all then? Something is wrong with this picture. I know, says Ross, but everything else is ready and he’s nervous about waiting; he really hates to ask this, he knows finances are tight but can I put it on a credit card? More than embarrassed, he’s scared, I can hear it. Of course I’ll do that, don’t even ask, don’t be embarrassed. I give him the card number over the phone and tell him I’ll bring the card itself later. When I get there, he says the surgery will be the next day, Wednesday.That’s a relief. It’s been five days since Ross was admitted. I spend another night sleeping in the window sill.Wednesday Feb. 26, midday. Ross calls me at home to say the surgery has been canceled; credit card payment was declined, over the limit by a couple hundred dollars; they must not have actually processed it yesterday but waited until this morning. Can’t they do the surgery anyway with what’s available, and let me pay the balance another way? No, payment in full first. Why didn’t they call me directly and let me take care of it right away? The credit card is in my name, not Ross’ name. Ross doesn’t know, it’s done through Tiner’s private office, not through the hospital. And nobody thought to call the actual card owner? I could have corrected that in two minutes.A call to the credit card company confirms it: four attempts were made to pay on that credit card that very morning, all between 10:00 and 10:15 am. There were no attempts made the previous day, and nothing after the fourth attempt this morning. And nobody called me, the credit card owner, to let me know; they just put it back on Ross to deal with it… Ross, who is worried, in pain and hasn’t been able to sleep. Apparently there is no sense of urgency on the part of the medical team. Dr. Tiner is dragging his feet and nobody is noticing or doing anything about it.So I bring all my credit cards with me today; we’ll spread the payments out if we have to. Another night in the window sill. listening to Ross trying make himself comfortable. It’s getting noticeably, audibly, worse each day but still, no sense of urgency.I’ve never heard of such a thing as this, having to pay by credit card for a patient already in the hospital with a life-threatening infection. Something is wrong here, really wrong.Thursday Feb. 27. Payment goes through. Done. Surgery rescheduled now for Friday afternoon, a full week since he was admitted through the emergency room.Friday Feb. 28. overnight. With his heart pumping erratically and blood flowing in the wrong direction, leaking out backwards into his lungs, unable to sleep properly and get some rest, Ross had a sub-dural hematoma during the night. Once again the extractions are canceled, but this time the reason is medical, not financial.We all carry strep bacteria in our mouths; it helps protect the teeth from other bacteria, but the danger is that if it gets into the bloodstream and it gets to the heart, it colonizes on the heart’s valves. This is why strep throat can so dangerous; it’s why a dentist puts you on antibiotics before and after deep tissue work on your gums or teeth. Once the strep gets on the heart valves and colonizes, it builds deposits which interfere with the valve’s ability to open and close. Blood can be sent in reverse, it can overflow and go into the lungs; the pieces of deposits that break off are sent through the body. If a piece of that debris gets into the brain, it can cause a stroke. It might get caught in the liver, or anywhere the blood takes it. Some infections take longer than others to attack the heart, but they all do it in time. It can be seen and measured in scans, and the more that debris builds up, the more dangerous it becomes. With each heartbeat, a little more infection is pushed through the body, a little more catches onto the heart valves, a little more growth builds up. 100,000 times each day, and if not stopped, it will be fatal. Always. This is why the source of the infection has to be removed first and quickly followed with surgery to clean, repair or replace the heart valves afterwards.It’s been a week since the emergency room admitted him and five days since the initial consultation: 500,000 more heartbeats have passed while waiting for an hour-long dental procedure that is never going to happen. The clock had been ticking and both doctors knew it; they had begun prepping him for heart surgery to follow while waiting for Dr. Tiner to do his part. But a piece of debris broke off from Ross’ heart valves and went to his brain, and he had a stroke. That means he can’t have anesthesia for either surgery; we have to wait to see how he responds to the stroke. In the meantime, the infection is still working on his heart valves, and blood is still backing up into his lungs, 100,000 times every day.Why did they make him wait a whole week when they knew this could happen? They knew what this infection could do, they had told us what it could do, so why were they all waiting around and letting Dr. Tiner hold up their work?If I had known he needed a dentist, and if I had known that the only oral surgeon Huntington uses is permitted to bill separately from the hospital, and that lack of financial oversight allowed him to delay or cancel treatment until he gets paid first even though the patient has insurance for it, and the condition is unpredictable and potentially fatal, I would have taken Ross to any other hospital. But we didn’t know what was making him sick. Huntington is nearest, they routinely earn the highest ratings and reputation nationwide for their quality of care. I’ve been a patient there myself and had excellent care and praised them to my friends and colleagues. Of course that’s where I would take him.Who could have guessed a hospital hires an oral surgeon who does not take dental insurance?Or who bills separately, away from the scrutiny of the hospital’s accounting systems, and is the only oral surgeon they use? That does not make sense. I truly believed I had placed him in the best and most capable hands around, but Ross was held hostage for $1,750 and by the time I was able to pay the ransom, it was too late.CAN ANYTHING BE DONE FOR ROSS?I am not going to attempt to describe the conversation that night after he had the stroke and was transferred to the ICU. It’s too hard, it’s private and personal, and too painful. I trust the reader can imagine it without having to undergo the actual experience of it.I’ve been told I don’t have “standing” in a case like this; Ross and I aren’t married, and we didn’t file as domestic partners either. Our mistake. We’ve only lived together as partners for 13 years in the same house and with shared incomes, but it’s not “official.” That is the reasoning behind Dr. Cohen telling me I can’t make these decisions for Ross, “not really.”Never mind that we’ve known each other nearly 20 years, and that we’ve been living together for the last 13; or that we’re colleagues with similar backgrounds and advanced degrees; or that I took Ross into my home when he had no place else to go; or that he pulled me through a serious bout of suicidal depression five years earlier; or how we replaced the kitchen floor after a flood; or that he learned to cook and brought down my A1C from 13.2 to 6.7, my daily glucose from 300 and 400 to low 100s; or that we raised $10,000 two years in a row doing the AIDS Lifecycle Ride together; or that I’d been teaching him to speak German these last months; or that we do each other’s laundry; or that we’ve been writing a book and website for LGBT people who come out in mid-life; or that we argue at the grocery store; or that he gets mad at me for leaving a dish in the sink…Never mind that I paid for those extractions to clear the way for Dr. Cohen himself to perform that heart surgery…Obviously Dr. Cohen, the heart surgeon, knows nothing about us, our history or our relationship, and even though it was the last thing Ross had said before being sedated, he tells me I can’t be the one to make these decisions on his behalf, “not really…”The “not really” is the most insulting part, especially when nobody had told me that I “can’t pay for those extractions. not really.”I don’t care about standing; I don’t care about a piece of paper, I only care about Ross coming home again; that’s all. That was what I had trusted this hospital to do.; that was why I had brought him here and not somewhere else. That’s why I paid for the extractions, that’s why I was willing to risk the mortgage. Now the lead doctor on the team, who was in the best position to make sure it happens but had done nothing about it, is telling me to let it go.This is not about standing; this is about personal morals and values, and I don’t need standing to talk about those. This is about understanding why Ross is not here anymore. His life is just as valuable as the next person’s whether I’m in it or not.I don’t know if Dr. Cohen would agree with me about that; some of the things he says over the next few days leave doubts in my mind - scare me out of my wits, to be honest.Ross did not deserve what was allowed to happen to him. I’m not afraid to be a pain in the ass when Ross’ life is at stake.HOW DID IT GET THIS BAD?This Thursday morning, after nearly another week has gone by, I got a phone call from the hospital at 4:30 am, asking if I give permission for Ross to have a blood transfusion. What for?!? Why does he need a transfusion, and why are you asking me, why aren’t you asking him? (It’s 4:30 am, and I’m not awake yet.) My first thought is that they must be preparing him for those surgeries. Finally! It’s been taking them long enough. Yes. of course, yes, whatever he needs, do it. I’ll come early today. I had other errands planned for the morning, and to go to the hospital later in the afternoon, but I can switch those around and come after breakfast, as soon as visiting hours are open.So now I arrive at 8:30 to find that Ross is on a respirator, leaving instructions that I am his partner and I am to make all decisions for him, but his heart surgeon is telling me, “Oh, then, you can’t really make decisions for him, not really…”Funny, nobody had objected when I prepaid for his oral surgery and nobody had objected when the surgery was delayed or canceled. That was all okay, but now that the situation has turned, it’s not okay for me to make the biggest decision imaginable?I would have thought Dr. Cohen to be disappointed or frustrated if I were unable to make the decisions, I would have expected him to want someone who can make these decisions so it would not fall on him. But he sounds relieved and he would persuade me to stop treatment now; that’s the recommendation of the doctor who ten days earlier had dismissed Ross’ concerns about this very possibility.THE WRONG DOCTORI’m going to jump ahead a few days to let the reader know something that I did not yet know at this point, then I will return to this Thursday morning to pick up the narrative of my experience.It turned out later that Ross’ insurance would have covered those extractions if they had been done by a licensed dentist or oral surgeon. Dr. Tiner is licensed for plastic surgery.This was not plastic surgery, this was not an elective, this was a necessary precursor to a life-saving operation, and it was covered by Ross’ insurance plan… when performed by a licensed dentist. There was no need to waste days scrambling and swapping credit cards around to pay for this. Why is a five-star hospital relying on a plastic surgeon who delays a life-saving surgery until he gets paid instead of a licensed dentist who takes dental insurance? How can the lead cardiologist be aware of it, knowing that there have been problems in the past, but do nothing about this? Ross had the insurance to cover it all that time; they’re using the wrong kind of doctor, and the lead physician on the case is fully aware of that; he defended the plastic surgeon.How did I learn about this? A week later, in Ross’ duffel bag I will find papers and forms he had signed. One of them he had signed that same day that I had prepaid the second time, and it was from Dr. Tiner’s office, Ross had checked a box on that form that said, “Yes, please submit my claim to my insurance company.” Then why were we told our insurance wouldn’t cover this procedure, when right there on Dr. Tiner’s own form, it says “Yes, please submit my claim to my insurance company?” The letterhead explains: Cosmetic and Reconstructive Surgery. WTF? This isn’t Cosmetic or Reconstructive Surgery. This is an emergency, requiring the removal of strep infected teeth or he will die, and it’s covered by his dental insurance, but strangely enough, this guy doesn’t take dental insurance… well, of course he doesn’t take dental insurance: he’s not a licensed dentist.Still, there was another way out. The insurance plan has a clause for emergencies: a “qualified physician” may perform the extractions in an emergency or life-threatening situation. As a plastic surgeon who does facial reconstruction, he is qualified to remove teeth, repair jawbones, and other oral surgeries. Despite what he says about Ross’ insurance plan, he is covered and would have been paid, 100%. There is no reason from the insurance company’s point of view for Dr. Tiner to tell us insurance won’t pay for it. The ombudsman confirmed that for me in a five-minute phone call.“One of the best at what he does” Dr. Cohen had said, but does that mean plastic surgery or dentistry? His website displays successful boob jobs, tummy tucks, and cheesecake photos, and buried away in there, it also mentions facial, oral surgery. Neither Ross nor I were aware of this; one of Ross’ previous partners will discover that some days later while I’m at the mortuary.Does hospital administration know the “oral surgeon” they’ve contracted with to perform dentistry - and the only one they use! - is not a licensed dentist, doesn’t accept the patient’s dental insurance, and can bottleneck a life-saving operation? How does this escape notice when the patient voiced his concerns; where is the patient advocate? The hospital is either aware of and complicit with it, or unaware and complacent. I’m not sure which is worse.I had assumed Dr. Tiner was a licensed dentist - who else does oral surgeries? Surely he would work with us on a payment plan, pull the teeth now and send us a bill. I had suggested we go to my dentist - he might not be “the best at what he does” - but he’s very good, he’s done emergency extractions for me, and he certainly won’t demand payment in advance. I even suggested we go to the public health clinic three miles up the road where dental service is done pro bono. But there is a wait to be seen there, and Ross didn’t have the luxury of time, nor was he in any condition to be transported. We’re stuck with what we’ve been offered.By the date Ross signs this form, Feb 27, he is sick, very sick, he’s not been able to sleep, it’s hard for him to breathe, he can’t eat, he’s desperate and frightened, he’s suffering, drowning in his own blood, and hours away from having a stroke that will render the extractions impossible.His worst fear was about to come true.PLAYING GODSo here it is a week and a half later, Ross is in a coma on a ventilator, he’s had the blood thinners in preparation for the heart surgery, and the teeth have been paid for but they remain in place, the infection is continuing to do damage, and after being told by Dr. Cohen that I can’t really make these decisions for Ross, he tells me that if it were his decision, he would discontinue treatment at this point.Ross had expressed his concerns from day one to his lead physician who had done nothing about it even after admitting there had been problems with him in the past. No wonder Dr. Cohen wants to stop treatment now, no wonder he sounded relieved when he thought I can’t make those decisions. It took Ross’ nurse to scold Dr. Cohen loudly and publicly for him to back down, but first he pulled me into a private room and brought a witness with him. And what he tells me goes against everything I’ve ever heard about the medical and legal profession; it certainly goes against every ethical and legal training I’ve had as a therapist. It’s the first time in 61 years I’ve heard a medical professional say anything remotely like this.When the three of us were in that room that morning, Dr. Cohen explained that in cases where there is no next of kin, no spouse or children, such as an elderly patient living alone, or a nameless, homeless person, such as often happens with under-insured or uninsured patients who have nobody to make these decisions, it often falls upon him, the doctor, to decide whether or not to operate or provide treatment, to perform procedures and tests that are “risky and very costly” (he uses that phrase frequently over the next few days), or whether it makes more sense to do nothing more than comfort care and let the patient die.Is he letting me in on some sort of professional secret? Is this insider information that only practitioners know and discuss in whispers in quiet rooms? Morally and ethically it sounds dubious to me, let alone legally; what if he misjudges the patient’s situation or makes a decision too quickly? I thought that was the job of a patient advocate, a legally appointed guardian assigned by a court so that such a decision cannot be left to an individual who might have ulterior motives or a conflict of interests.Anyway, what does this have to do with Ross? I don’t get it, he’s not alone, he’s not homeless, he’s not elderly, he has insurance, I’m listed as his emergency contact, our address and phone number are in his file; the night nurse got hold of me at 4:30 that very morning. A Google search of our address would show that we’re only 10 minutes away from the hospital, and that we’re within walking distance of the sheriff’s station. An assigned patient advocate would have discovered that much within 5 minutes. Dr. Cohen must not know anything about Ross, he wouldn’t be telling me this if he did. Those stories don’t fit.But then it hits me. Oh. My. God. He has just admitted to me that he sometimes decides on his own what is “risky and very costly” and sometimes he lets that person die. And now, knowing nothing about Ross, he was justifying a decision he had made.Ross’ had predicted this: they were just going to let him die. In an instant, grief turned to horror: I was sitting across from Dr. Jekyll, Dr. Frankenstein, Dr. Moreau. I had scraped together the money to prevent that, and believed I had brought Ross to the best hospital around, but $1,750 later I realize I’ve delivered him to Moloch.That may sound melodramatic, but that was my reaction. Until this morning, I had thought a doctor’s goal was to save life; I had never heard a doctor say he decides what is “risky and very costly” and ends life instead. What would I have met with if I had arrived half an hour later? What if I had been out of town, or sick in bed, or unreachable?That was why I fainted when we returned to Ross’ room afterwards; it was because of this conversation. I had been looking the devil in the face and he had Ross in his hands.Was I over-reacting? In hindsight, I don’t think so, and here’s why:The witness Dr. Cohen brought with him hasn’t said a word the entire time. It’s weird and uncomfortable; who is she and why is she here if she’s not participating in this conversation?She’s not one of Ross’ doctors or nurses, I know that much; I guess she just happened to be there and he had grabbed her to come along. A bit younger than he, with long brown hair about halfway down her back, green scrub suit, she’s pretty; that’s all that registers at the moment. No idea who she is, and I won’t see her again for several days and when I do, it takes me a moment to recognize her. She is the examiner who pronounces the time of death; that’s when I will see her again.It was not a random coincidence that she was waiting there with Dr. Cohen this Thursday morning.Thank God nurse Maria spoke out when she did.But all of that is anticipating somewhat; those realizations are to come later and gradually, a day at a time. Right now, on this Thursday morning, I’m in shock, I’m horrified at the stories Dr. Cohen has just told me, and my first thought is to protect Ross from this monster who prefers to let Ross die and nearly made it happen.Before I can make any decisions for Ross, I need an explanation for why the extractions had been delayed for a whole week, when that had been his one and only chance to come home alive, and Dr. Cohen knew that was his only chance. Why didn’t it happen, why hadn’t anything been done? He tells me it won’t matter now anyway. That was not what I asked but I’m too much in shock to notice the deflection for what it was.I didn’t know it then, but that was the first in the pattern to follow: there will be other deflections, distractions, evasions and excuses, even insinuations that I’m the one who is harming Ross, but nobody explains the reason for that week-long delay. Instead, over the next ten days, I am going to be pressured subtly and not-so subtly to terminate Ross’ life.I cannot do that to Ross, not without understanding the reason for it.Of course my decision is to fight for Ross; he was admitted with the expectation this had its risks, but everything had been prepared except the oral surgery. If there is any chance at all, no matter how slight, I am going to choose life, not death. I know Ross, they don’t, Dr. Cohen has made that frighteningly obvious. If I hadn’t been in a state of shock I might have asked for more precise definitions of his criteria, for example, how much exactly is “very costly” when saving someone’s life; what’s the number? And how is not operating less risky when that means he will die? I don’t want to hear about “very risky” or “very costly.” Risky is still better than dead, it means there is still a chance, and “very costly” is mine and Ross’ business, not Dr. Cohen’s.What does “risky and very costly” mean when it comes to saving a person’s life? In other words, it’s not wise to try saving him because something might go wrong, and it isn’t economically sound, it’s financially imprudent. Ross isn’t worth the effort and expense required to take a chance on saving him; it’s safer and more cost-effective to let him die. Ross isn’t worth it; that is what “risky and very costly” sounds like to me.(Imagine the captain of the Titanic telling his passengers they can’t take to the lifeboats, it’s too dangerous, they might tip over, and besides that, lifeboats are expensive.)Ross had trusted me to make the decision for him, and his nurse knew that; I have to believe Dr. Cohen knew it as well; he backed down immediately and pulled me away into this private conversation. How does he imagine he can take it upon himself to overrule Ross’ expressed intent? Ross’ question ten days earlier was eerily prescient: “Would he really let me die, just like that?” It seems to me he was ready to do just that.That was why I had fainted.A MIRACLEFriday March 6th. It is decided that Ross, although comatose on a ventilator, is able to undergo the extractions. No need to wait. (That’s actually the tagline of Huntington’s current marketing campaign, currently seen throughout Pasadena on buses, billboards, and their website.)No need to wait ten days for an emergency procedure that could save a person’s life. (I guess Dr. Tiner and Dr. Cohen didn’t get that memo.)Huh. Just 24 hours earlier I had been told he was a lost cause, terminal, treatment should stop. But now Dr. Tiner is finally going to do the job he was contracted to do, after making Ross wait ten days due to a billing issue. Is this a miracle? Or an attempt to cover up a mistake too late?Before I go on, I have to say this. The nurses, the support staff, the technicians were all amazing. Whatever they earn, it’s not enough, they deserve double whatever they get paid. I have nothing but the greatest respect and praise for them, every single one. Cynthia, Clara, Eric, Erik, Erin, Jennifer, Lucas, Tamara, Christa, Maria, Marta and anyone whose name I missed.. Ross thanks you, and I thank you, more than I can ever say. I’m sorry if I did or said anything offensive. You all seemed to understand where I was coming from every moment and had the patience of the gods. Thank you for being there. You are a rare type and you deserve so much more.I finally meet Dr. Tiner myself late in the afternoon, up to this point I’ve only heard Ross’ description of his bedside manner, and the insistence on prepayment. Mind you, he has my $1,750 now. What do I have? Ross in a coma, dying before my eyes… because this man could not be bothered to do anything until he had my money first.Tanned, casually dressed, all smiles and handshakes, he strikes me as slick, more politician than medical man. He strides into Ross’ room, checks the monitors and IVs, gives Ross a once-over, says everything looks good. (Really? Did you notice the respirator over there and the big blue tube going down his throat? How and why did that get there?) I would have thought that, as one who surely must realize that he is the reason for this, he might be humble or apologetic or at least careful about what he says, but he doesn’t address me at all beyond a perfunctory and obligatory introduction. So I make an effort at interaction.I’ve had two extractions myself, each one took about a half hour, and I ask Dr. Tiner how long he expects this to take? “Oh, about 45 minutes to an hour,” he says. “Really, for seven teeth, that seems awfully fast…” “Hey, man, that’s how good I am at what I do…!” and with a snap of his fingers, he saunters out the door.No wonder Ross didn’t care for his bedside manner. Jeez. Mechanical and cavalier? I’d add narcissistic too. This took no more than ten minutes, just like his first consultation. Not so much as “Any questions?” (Just this one: why couldn’t you have done this a week ago?) or, God forbid, “I’m sorry about this; I’m going to fix it.”It might sound as if I resent Dr. Tiner having $1,750 from me, but that isn’t it. I’d have paid ten times that and more to have brought Ross home alive. What I cannot understand is how, knowing the seriousness of Ross’ condition, a trained professional could not or would not spare “45 minutes to an hour” to apply his special skills and knowledge so that someone might live. I’d have paid any amount he asked, I’d do menial labor for him, I’d have mowed his lawn and washed his car for a year, I’d have given his kids free piano lessons, I’d have worked something out somehow to repay him. It’s not about $1750; it’s about being able to save a person’s life but choosing not to do it. I don’t understand that.Soon an anesthesiologist, two nurses and a pair of orderlies arrive. The orderlies begin preparing Ross to be rolled out. Nurse 1 calls out to Nurse 2 different instructions, confirming what is to be done. Between calls, Nurse 1 puts a piece of paper in front of me: “Sign here.” And another one. “Sign here.” And another one. Another one. By now the orderlies are rolling Ross’ bed toward the door. I don’t know if I like this; Dr. Tiner caused this after all, and he barely said a word to me, and now they’re taking Ross to him when just yesterday Dr.Cohen had told me Ross could die on the operating table; this was risky; very costly; he would stop treatment now. So I’m more than nervous here, I’m scared. Will Ross be alive when he comes back?“No, wait a sec, wait!” I tell the orderlies, and they stop where they are. “Give me a minute..” They stand back while I lean down and whisper in Ross’ ear. Come on, Ross, be good, you can do this, get through this; it’s only an hour, I’ll be here when you get back. I kiss his forehead and then to the orderlies: “Be good to him, take good care of him.” They must think I’m nuts, but who can blame me? His own doctor would have let him die, and they’re wheeling him now to the doctor who screwed this up. Neither of them has said, “I’m sorry this happened; it wasn’t supposed to be like this.” Instead his lead doctor has tried to justify why he would have allowed Ross to die. I think I have grounds to be paranoid.The anesthesiologist was watching, and after Ross was gone, he tells me he’s been doing this for 30 years, he’s seen this before, and he can’t promise of course, but he’s pretty sure it’s all going to turn out alright. I hope so. It’s the last good news I’ll hear.WAITINGRoss survives the extractions, and the plan is to reevaluate his condition on Monday. It will be a long weekend. One morning over that weekend after I’ve spent the night on the little sofa bed next to Ross, I ask if it’s possible to lower the sedation just enough so he and I can talk? Sitting on a footstool next to me, Dr. Mauer gently and humanely advised against it; it would cause Ross to suffer. Oh, then, of course not, I don’t want to do that to him. He is thinking of Ross first and appropriately so. But Dr. Cohen’s initial remark that I “can’t make these decisions” has left a bitter aftertaste; that was poison. My voice cracks, “I just want Ross to know I’m here with him, that’s all.”Dr. Mauer: “He knows. We all know. We all see it, we’ve seen you spending the night here, we’ve seen you with him, we can see it, we all know.”Does Dr. Cohen know, can he see it too? He sounded so relieved to think otherwise. I thanked Dr. Mauer for saying it; he’s decent, he has a good bedside manner and his concern is genuine. He has that talent of hearing the real question behind the surface question and he goes there. I’m not too sure about anyone else yet.Two of my brothers have been taking turns watching over Ross so I can take care of matters at home, shower, change my clothes, and come back. Today it’s my older brother who is there with me.Dr. Cohen enters on his morning rounds with what I suppose must be interns following behind. He explains the case to them: there is a slight chance to do something, a one-shot deal, a Hail Mary, and the case will be reevaluated on Monday. He explains this is “one of those cases they will inevitably see, where tough decisions have to be made, and this can be hard on doctors and support staff and hospitals, hard for all of us…” and then to my brother “…and the friends and families too,” and finally to me, “to have this dumped on you…”I wonder how he’d react if our places were switched and I had said that about his wife. Ross didn’t “dump this” on me; Dr. Cohen and Dr. Tiner did. My brother gives me a look that tells me he’s thinking the same thing I am.PONTIUS PILATEMonday, March 9th. Morning. Outside Ross’ room, Dr. Cohen beckons me to come out there, a little smile or smirk. “Can you stand up, can you walk?” he asks. Of course I can walk; does he think I’m going to faint again, did he think that was funny? I am told Ross is still inoperable, and again he recommends no follow-up heart surgery, and I should “prepare for the worst.” I intend to fight for Ross if there is even the tiniest chance. He tells me the surgery is risky (I know that); it’s very costly (that’s not your concern); there are no guarantees he’ll survive (but you told me he’ll die without it), chances of survival are slim (I’ll take slim over none). No, I will not sign a DNR order, not just yet, not when there is still a chance, I am not going to make any such decision prematurely. Dr. Cohen assures me, “It won’t be premature.”Seriously? Nice touch, thanks for the comforting words. It must feel good to be so smart.But it’s really a mixed message. My brother agrees. Yes, of course it’s risky, but Ross will die without it; it’s riskier not to have the surgery. And costly? Ross’ insurance covers it. Dr. Cohen hasn’t said it can’t be done, he has laid out the odds for why he won’t do it. He can’t wait to rid himself of this, that’s the message I’m getting. He could have intervened to prevent this two weeks ago, but he didn’t; he had defended Dr. Tiner and then stood by, and now he’s washing his hands of it: Pontius Pilate.The critical care unit takes over now, and that is the last time I see Dr. Cohen, who apparently is no longer on the case. No, actually, that’s not quite true. I do see Dr. Cohen a few days later: during the early morning break between visiting hours when I’m sitting in the lobby, he comes in the front doors. Besides the person at the information desk, I am the only other person in the lobby, and he has to cross in front of me to get to the elevator bank. Does he stop to say hello, or ask how I’m doing, or “we’re all so sorry about this” or even make eye contact? No. He strides on past; I am just another piece of lobby furniture on his way to the elevators. At least he didn’t ask why I was still there.In contrast, a little later I bump into Dr. Mauer in the cafeteria; I’m on my way out, he’s on his way in. He gives me a nod of recognition and a “Hello.”The critical care team valiantly tried everything they could to restore Ross to a condition where he has at least that slim chance to undergo heart surgery, but nothing is working. It is a gradual, steady decline, and he never comes out of that coma.Tuesday, March 10. The infectious disease specialist stops by to see where things stand. Dr. Joo is very precise in his language, calm and soft spoken, and his explanation of the strain of strep that has caused this is clear.Ross indicated in his notes that he liked Dr. Joo, and I can see why; they both stick to facts, they both have a dry sense of humor, and they are both true scientists at heart. There are a few things I don’t understand yet: is this strep contagious, do I need to be tested or concerned for myself, since Ross and I live together? No, he explains, we all have strep in our mouths. It’s only a problem if it gets into the bloodstream. Okay, then if Ross’ blood is clear of active infection because of the antibiotics, why couldn’t the heart surgery be done, why do the teeth have to come out? Because the antibiotics will clear the bloodstream, but they don’t get to the root of the infected tooth, and the infection could flare up again. Ah, got it. The biology of what is happening is clear to me now.Just one more question then. Was there any reason the teeth could not be extracted once the blood was clear of active infection? Not that Dr. Joo was aware of, no; but I’d have to ask Dr. Tiner about that. “No, I don’t want to see Dr. Tiner, he’d better not come anywhere near this room while I’m here.” A short, barely audible and probably involuntary chuckle escaped under his breath. I was only half-kidding. Grief and horror were turning to anger.CONFUTATIS MALEDICTUSWednesday, March 11. Someone from the “Customer Relations” group calls on me in Ross’ room, and I ask my question: why weren’t those extractions done, why was that surgeon allowed to delay that for payment, in a life-saving operation? She evades that; even if the extractions had been done, Ross still might have had a stroke, and he’d still be in this condition. That’s not an answer, that’s a deflection. I tell her, “True, we don’t know what else might have happened, but we do know what should have happened and didn’t, and if it had happened the way it was supposed to happen, we wouldn’t be having this discussion right now, we’d be having a different discussion.” She agreed and dropped it. Ross is dying here; I need to understand why. All I know at this point is Dr. Tiner cares more about money than Ross’ life, and Dr. Cohen did nothing about it and he’d rather let Ross die now. That’s what it looks like to me.Dying from infectious endocarditis is one thing, and it’s already hard enough. Dying from infectious endocarditis after waiting a week for treatment from a doctor who insists on being paid first is quite another. It might be the same infection, but they are not the same death.THE MACABREI’m hearing a strange rumor in the afternoon - I am not going to say from whom - that the goal for Ross has been changed. It’s no longer to see if Ross can be revived enough for heart surgery, it’s to see if he can be brought out of sedation enough to ask him directly himself, does he want to continue treatment for a chance at life, or would he rather die? (Of course it isn’t phrased that way; they do have more tact than that, but that’s ultimately what it means. Lipstick on a pig.)I am speechless. Can you imagine? A few days ago, to bring him out of sedation would cause him needless suffering when I had asked for it, and I had understood and accepted that the humane response was to not do that to him. So all of a sudden, it’s okay for them to bring him around, causing the same needless suffering so he’ll grant permission for them to give up and let him die?What the hell is that, I ask the chaplain, who is in Ross’ room with me this afternoon. Do they think they’re being merciful to Ross because I am being obstinate with them? I don’t know who to trust, maybe I’m becoming paranoid but it’s obvious that something is wrong here. I don’t trust anybody now. Will I be present when they ask Ross that, or will they wait until I’m in the cafeteria?The chaplain looks at me sideways with a knowing look. “It’s like they’re trying to do an end-run around you, isn’t it?” Yes, exactly. But who and why? (The answer should have been obvious, but I didn’t have all the facts yet.)The chaplain answered my next question, what kind of surgeon holds up a person’s life for money that way? with another sideways look. “I was told he’s the only one we use.” And he’s allowed to hold up surgery for cash; the hospital allows that? Do they even know he’s doing that? How is this possible?I’ve known Ross for twenty years, and for 13 of those years he’s lived in my house with me. You’ve all known him for two weeks, and he’s been unconscious for half of that time because your guys screwed up. And you expect me to give you permission to let him die now? It’s unreal.I decide to go home, have dinner, change my clothes, get the mail and come back later, probably spend the night again. It might be a good idea to take Ross’ duffel bag home, along with his laptop and cell phone, maybe people have been trying to call him without knowing what’s been going on. In the mail is my alumni directory from Harvard: this year will be our 40th Reunion. I can bring that back with me, it’s something to read anyway. After dinner I empty out the duffel bag, and find the notes he had made during his first week before the stroke, along with some authorization forms and other papers. Looks like he signed this one on Feb. 27, the same day I had paid the second time, the night he had his stroke. “Yes, please bill my insurance company…”Whoa. I thought Dr. Tiner doesn’t take our insurance; what the hell…? The letterhead on this form does not mention anything about being a dentist, it says cosmetic surgery. The only one they use and he’s a plastic surgeon? Dr. Cohen had to have known that when he told Ross “Yes, there have been problems with him in the past… but I’ve talked to him… he’s a fine surgeon... the one we use here…”Nobody at any time had referred to him as a plastic surgeon. Nobody. It was always either “dentist” or “oral surgeon.” In fact, the Supervisor from Palliative Care will tell me… but I will let that wait until the time comes.It was time to go back to the hospital. I can look into this a bit more from there.THEY LIED TO USIt had been raining the last several days and tonight was no exception. It’s a bit late by the time I get to the hospital, but it shouldn’t be a problem, visiting hours in the ICU are practically 24 hours, except for during shift changes. It’s a little after 10 pm when I arrive at the main entrance. Security tells me sorry, front doors closed already, I have to go in through the ER, all the way around the other side of the hospital. Arggh. But it’s raining, can’t I… No, sorry, you have to come in through the ER, all the way around… So it’s off to the ER parking lot and entrance.It’s a long hike from the ER to the ICU, and for a first timer, something of a maze, but occasionally there is a window so I know I’m headed in the right direction. At one point I come across a long corridor with portraits hanging on the wall, the various committee members and their titles, the board of trustees, different specialists. There’s Dr. Rosenberg; he was my doctor about ten years ago, he went to battle with my insurance company to get me some expensive and experimental medicine I needed, and it had worked. I’d probably not be here today if he hadn’t done that; great doctor (and Harvard too!). Oh, and there’s Dr. Shriner, another of my former doctors. She continued seeing me pro bono once when I was between jobs and without insurance. Another time I had a swollen rash on my elbow; she didn’t like the look of it and arranged a referral with a specialist for the first thing the following morning; she didn’t wait around. Fortunately it turned out to be nothing serious. Another great doctor; both of them were exceptional. They went out of their way.I wondered what either of them would have done if a colleague had delayed treatment for one of their patients who had a potentially lethal infection? I can’t imagine Dr. Shriner would sit still for that, or Dr. Rosenberg either.At the ICU I settle in for the night, but first I check the insurance company’s website. Extractions are covered when performed by a licensed dentist or oral surgeon, or, in case of emergency, they may also be performed by a qualified physician. So that’s why Dr. Tiner said he didn’t take Ross’ insurance. Then why does the hospital give us someone who doesn’t accept the insurance for the very procedure he’s expected to do? Who makes a decision like that?Next stop, Huntington Hospital’s website. How is Dr. Tiner listed there? Plastic Surgery first, Oral Maxillo Facial Surgery second. So then if he is qualified and if an ongoing, lethal infection is an emergency, he would have been covered by Ross insurance. Scrolling backwards through the listings, one catches my eye. What was that one? Dr. Stephens, oral surgeon, licensed. What the f*ck!! There is another oral surgeon here after all, and a real oral surgeon, one with a license?Who is running this place?This is unreal. They lied, and here is Ross on this ventilator waiting for treatment, never knowing that we had been told a lie. And Dr. Cohen tried to tell me I don’t have the right to make this decision, “not really...” Lying there unconscious, Ross has no idea this has been going on; that’s the only saving grace in this. It’s a nightmare that started out as a lie.Whether that was deliberate or incompetent, I don’t know, and I don’t really care either way. What I know now is that we had been misled from the very start. How much of what followed was an attempt to cover it up?“IT WON’T BE PREMATURE”Wednesday-Thursday, overnight. I wasn't sure I wanted to tell this next part because it's really hard and to write it I have to relive it, but in the context of Dr. Cohen's certainty that "it won't be premature," I do think it belongs here. I’ll simply describe it and let readers draw their own conclusions.“For those who believe, no explanation is necessary. For those who do not believe, no explanation is possible.”Before dawn the night shift would always lower the sedation a little bit to see if Ross was responding neurologically, if he would respond to commands like "move your finger" or "open your eyes." It was questionable, I'd say, but there seemed to be something there. Was it Ross or not? There was no way of knowing. This night a different nurse was on duty, and he did the usual procedure, and the response was about the same. Hard to tell. But then he told me, "You talk to him." So I moved over to the side of the bed, and just said his name, "Ross...? It's me, I'm here, I'm right here."His left hand twitched and shifted and then it rose up off the bed an inch or two in the air. That was more movement than I had seen since this started. I grabbed his hand and held it. The nurse was standing in the doorway watching, a big smile on his face and he nodded for me to continue. "Ross, you're okay, everything's okay, I'm right here next to you," and his other arm reached out, trying to find where I was holding his left hand; he fumbled about in the air. I grabbed that hand in my left too, and with my right hand, I stroked his hair and rubbed his neck, and patted him about the head.I don't know why I did this, but I started talking to him as if he were a little boy or a puppy. "Good boy, Ross, that's good, atta boy." His head rolled slowly toward his left shoulder, in the direction of the sound of my voice. "Ross, when this is over we're going for a bike ride, we'll get the bikes out and fix them up and go for a ride to the beach, we're going to do that, I promise." (He was always trying to get me to go for a ride with him, but I usually made up some excuse.) As I was saying this, his brow and forehead wrinkled and furrowed, his eyelids squeezed rapidly as if he were trying to blink and open them but couldn't do it, and his head wobbled to his left side, nodding up and down like a bobble-head toy while I stroked his hair. I think he was trying to figure out where I was, so I tried to position myself where he could rest his head against my shoulder, but the bed was too wide and in the way. I positioned myself instead where he could see me, if he could just open his eyes.I looked over at the doorway to see if the nurse was still watching; he had grabbed the nurse from the next room over and they were both standing in the doorway, wide-eyed and smiling, big broad smiles. The other nurse said it, "He's interacting with you."I had to let go of his hands for a minute to wipe my eyes, they were dripping now, but Ross' hands reached about trying to find where mine had gone. I grabbed his hands again and held on, this time I wasn’t going to let go for anything. I said all kinds of stuff, I called him by his nickname, I repeated some German words and phrases I had been teaching him: “Guck mal hier!” and “ich hab’ dich lieb,” and other stuff, I don't remember all of it."Ross, be good, get well, you have to get well, everything's going to be okay, I'm right here with you, I’m not going anywhere, don't be afraid, I love you, Ross," and I can't remember what else I said. All this time his eyelids were squeezing and blinking, his head turned toward my voice, I was holding his hands and rubbing his head, and his head bobbed up and down at my touch. The nurse let us have a few minutes before he had to put Ross back under sedation. As he relaxed back into his sleeping position, I kissed his hands and his forehead, told him to go back to sleep, everything’s all right, I’m right here, and he drifted off to wherever he was now. But that was enough to tell me, he's still here; Ross is still in there somewhere.Thank you, nurse Erik, for doing that.No, I am not going to give DNR, not as long as he shows me that. I am not going to make any such decision prematurely, so stop asking me; I won't do it, and that’s why I won’t do it. I know Ross; you don’t. Screw Dr. Cohen and his "it won't be premature." It must feel pretty good to think so, but you don't know everything; “there are more things between heaven and earth, Dr. Cohen, than are dreamt of in your textbooks.”Don’t get me wrong, this is not some magical, dreamy, romantic Hollywood moment; it’s awful. Awful. This should not have happened, look at what you’ve done to him! He didn’t do anything to deserve this, he trusted you and believed you and this is what you did to him! It’s heart breaking and pitiful, but he’s still in there somewhere. Stop asking me to give up on him.THE HIV EXCUSEThursday March 11. Dr. Banta, head of ICU, with a team of three interns in tow, stopped by to explain how things stood. Ross was still not responding. Again, the talk about stopping treatment, DNR, letting Ross go, quality of life even if he did pull through, tracheotomy perhaps, or feeding tubes, or bedridden... prognosis is poor. Yes, I know all that. He asked me how I was doing.I had been staring at the floor, listening to this same speech again. The day before, I had taken Ross' duffel bag and laptop home, and I had read the notes he was making for the formal complaint to the state board; I had found the form he had signed and I had talked to the ombudsman at the insurance company. I know now what happened. I didn’t look up at Dr. Banta; I knew I had better not."I'm angry," I said, still staring at the floor. "I'm really angry. You have a doctor associated with this hospital who held up Ross’ life for payment, a life-saving operation, and we were told he's a fine surgeon, the best at what he does, and this is what happened. He held up that surgery for money. Who does that? Is that what they teach in medical school? That's not a fine surgeon, that's a bad surgeon, and I can't believe Huntington Hospital associates itself with that, I can't believe they allow it. I'm angry; I am really, really angry; and I hope you're hearing me because I don’t understand why this happened, and I need an answer. Why weren't those teeth taken out as soon as you knew that’s where the infection was? Why was Dr.Tiner allowed to wait like that; what kind of doctor does that?"Dr. Banta sat down on the footstool and started, "Well, don't be angry at just one individual, be angry at the systems, at viruses, at HIV..."Oh, fer Chrissakes... I waved him away; I wasn’t going to listen to that, I certainly hoped he wasn't suggesting it was because of HIV. "I know about HIV, Ross and I have raised money for HIV, I’ve lost friends to HIV, I know about being angry at HIV, and this is not about that. This is about one of your doctors who held up surgery for money and another one who knew about it but brushed it off. This has nothing to do with HIV, nothing; so don't try that with me." Dr. Banta didn’t respond; after a moment's pause, I looked at the interns, "I hope you're learning something here." They were looking down at the floor.Dr. Banta stood up and said they would keep trying, there were still some things they could do, but he couldn't promise anything. I understood that, but stop asking me to give up. Your guy made this mess; now fix it. I told him about the night before, when Ross had been brought out of sedation, that two of their nurses had seen it too, and as long as Ross shows me that, I am not going to give up on him. I know Ross, you don't. He had responded to things that only he and I would know, and you can't ask me to kill him as long as he does that, I won't do it. They left.I know I’m being a pain in the ass, I know that, but this is Ross, and I trusted you to take care of him, and I was expecting to get him back fixed up and good as new, that was the deal but now he’s coming back dead and the doctor in charge who didn’t do anything has the nerve to tell me I can’t make these decisions. Really? Hello? I paid for that surgery - twice! I have credit card statements to prove it. Do I get a refund at least or a new replacement for Ross; does Dr. Tiner’s service come with a money-back guarantee?You think I’m angry now? You haven’t seen angry yet.STANDARD PROCEDUREOne after another from the hospital will stop by to talk during these days, and I will ask that same question. Why the delay for those extractions; why was it held up for payment in advance? One of the Palliative Care specialists (Dr. Abilene Enriquez) sits with me one of these afternoons. I ask her that same question that nobody wants to answer: Why weren’t those teeth removed immediately, what kind of surgeon holds up life-saving surgery for payment in advance? She smiled sweetly as she explained it: “That’s standard procedure.”Is she freaking kidding me? Don’t treat me like a child, not when I’m watching my partner die because of your policies. My response came out as a hiss and a growl: “It is not standard procedure, and you know it is not standard procedure, why would you even say something like that? Do you want me to believe the hospital’s standard procedure is to demand payment in full before they’ll save someone’s life, is that what you want me to think when I walk out of here, can I quote you; should I tell that to all my friends?”She shook her head sadly but said nothing more. At least she knew to stop before she made it worse. Instead she batted her doe brown eyes at me and tried to lean her head on my shoulder in her best attempt to beg forgiveness or approximate empathy; I’m not sure which, but I scooted out of the way. Yeah, I was a jerk about it but I don’t care. If it’s not genuine, I’m not interested. Whatever else you do, don’t lie to me and don’t offer fake sympathy. I’m not here to take care of your feelings now that you all screwed up.Later that day I had a chance to ask her Supervisor that same question..INCOMPETENCEDiogenes had a lantern; all I had is my question but it has become my litmus test for honesty: Why was Dr. Tiner allowed to hold up that surgery for money?Supervisor tells me he’s not on staff at the hospital (got it, it’s not the hospital’s fault), he was brought in as a consultant (which means you hired him), and his billing doesn’t go through the hospital anyways; he’s just a dentist.I’m not sure what it means to be “just a dentist,” but in any case, then he must use a dentist’s billing service, right? Supervisor wouldn’t know about that, he’s just giving me information (translation: he’s protecting the hospital). Okay, but none of that answers my question, and besides (Supervisor must not know this part yet), he’s not a dentist, he’s a plastic surgeon. If he’s “just giving me information,” the least he could do is make sure the information is correct first.Epic Fail.Parents often warn their youngsters: “I already know what you did so just tell me the truth now and it will go easier for you. But if you lie to me now, you’re going to make it a lot worse for yourself.” Palliative Care - charged with bringing comfort and peace to the dying and bereaved - chose to make it worse.What does it mean that I know by now that Dr. Tiner is really a plastic surgeon, but Palliative Care thinks of him as “just a dentist?” Do they really think he’s a dentist, or are they too trying to represent him as one to me? Or did they just not bother to check first? And dentist or not, why does the hospital allow him to delay a life-saving procedure for payment in advance?PROFITS FIRSTWhy does everybody seem to be defending this guy? From Dr. Cohen on down the line, one after the other offers an excuse or an evasion, but nobody offers a medical explanation for the delay and nobody tells me I misunderstood about the payment..All I understand now is that we were misled from the start, then Ross’ concerns had been acknowledged but ignored, I’ve laid out very plainly what I’m thinking now, but nobody wants to address it and correct me if I’m wrong or explain it if I’m right. At this point it looks like they are aware they made a serious mistake, that’s how we ended up here, and now they just want it go away. Ross isn’t dying fast enough and it’s embarrassing and inconvenient and potentially trouble and it needs to disappear; that’s what it feels like to me now, that’s the message I’m getting. Why?Because everybody knows those extractions were delayed for payment, but nobody is willing to say that was wrong.I’m sitting here watching Ross die and I’m expected to be polite and pretend not to notice that everybody else is pretending this is normal.I get it. This is a serious legal problem now. Obviously. You all know it, and I know it; we all know that we all know it. But your guy caused this, not me, not Ross, and he warned you about it and asked you to do something, but you didn’t. Now everybody’s out to protect their own asses, their money, job, reputation, status, license, institution, whatever, and it’s just too darned bad that Ross has to die now, but it’s not our fault. I get it, this has put everybody in an untenable position, but Ross didn’t do that to you and I didn’t do that to you. One of your own did that, he put you all in this horrible predicament, but all of you are protecting him now with your silence. Why?You’ve all taken a vow to heal, save lives and do no harm, but what good is that vow if you don’t hold each other accountable for it?Of all the people I asked that question, not a one of them offered a medical reason for why those extractions hadn’t been done. By the time they were extracted, Ross was in far worse shape and I had been told the day before that treatment should cease. There never was a medical reason for that delay; that’s why nobody can answer it. This was not a medical mistake; it was a financial decision and someone made that decision and everybody is okay with it. That’s what it looks like now.I can’t keep saying it, and I don’t know why they aren’t getting it: but I can’t and won’t end Ross’ life without knowing why.THE DAY I COMPLETELY LOST ITOn Thursday of that week, I leave the hospital at noon to go home and wait for our pharmacy to deliver refills of Ross’ and my own routine prescriptions, one of his antivirals is not available in the hospital’s pharmacy, and he is just about out of them, and I’m almost out of insulin. Plus I can shower, change my clothes and clean up in the meantime. After a couple of hours, the phone rings; it’s the ICU; Dr. Honlee asking me to give verbal DNR approval, that Ross is in distress, and I could spare him this if I approve DNR now. I refuse until I see for myself. He assures me they “expect” to be calling “Code” in the next 15–20 minutes, and they can spare Ross that if I give verbal DNR now.What does that mean, they “expect” to be calling Code? If they can anticipate that in the next 15–20 minutes, why aren’t they doing something about it right now before it gets to that point? Dr. Honlee describes the horrors Ross will endure if they call Code, but I can prevent it with verbal approval: chest compression, broken ribs, electric shocks… This is too much, it’s my fault now that Ross is suffering, and before Dr. Honlee could finish his sentence, I lost it: “This is all Dr. Tiner’s fault, it never should have come to this, this was supposed to be routine but he canceled it and waited until he got paid, that’s why this happened; this is Dr. Tiner’s fault and you all know it, Ross didn’t deserve this, and I want justice for Ross!”Caught off-guard, Dr. Honlee paused for a beat, then his voice dropped, quieter and slower now: “Well… yeah, I know… I know… and I want justice for Ross too...”Then I was right; that is how this happened; someone else sees it too and has said so. I’m not crazy and I’m not imagining it. This nightmare really is what it is, and it’s not over yet.Dr. Honlee is still talking, “…but right now it’s about Ross being comfortable and sparing him any more pain and letting him go peacefully and with dignity.” That’s a little better, it’s about Ross. “Then wait until I get back there so I can say good-bye to him, let me do that, I can be there in 10 minutes.”He didn’t expect that; he is immediately apologetic: “Oh! Well. Yes, of course, of course you should do that, yes, certainly, of course, drive safely.” Arriving at ICU, I expect to see activity around Ross’ room: “Code,” emergency equipment, flashing lights, buzzers, hurried personnel. But there’s none of that. Ross looks exactly the same as he had when I was last there just a few hours earlier. No sign of distress or unusual activity; nobody is there to explain what had happened; nobody waiting with DNR papers for me to sign.What am I supposed to think at this point?What is wrong with you people? Don’t you get it? This is Ross, this is the man I’ve known for 18 years, lived with for 13 years, loved him, trusted him, argued with him, laughed with him, taken him into my house, gone grocery shopping with him, done the dishes with him, replaced the kitchen floor with him, watched movies with him, slept next to him, come home to him, gone on trips with him, been living my life with him… Put yourself in my position for one minute, and try, just try, to imagine it: that’s your wife, husband, child in that coma because the expert, the specialist, “the best at what he does,” demanded payment first before saving his life, and you all know that’s what happened. Do you really think I’m going to give you permission over the phone to stand around and let him die now, just like that; it’s as simple as picking up the phone and ordering a pizza? Have you all lost your minds?I probably owe apologies to a few people for my behavior and attitude that afternoon. I don’t remember everything I said and did, or to whom. I know a lot of it wasn’t nice and probably unfair and undeserved. But a week of evasions, deflections, obfuscating when I’ve been pleading to be given the truth before making this most painful decision; for the unintended suggestion that I’m the one causing Ross to suffer now, when everybody knows how it really got to this point…Yeah, I lost it. I think anybody would.At least Dr. Honlee had agreed, “Yeah, I know, I know… and I want justice for Ross too…” The significance of that was lost on me in the moment but I have to give him credit for that. Had someone pressured him to make that phone call? I don’t know, but if so, then I was unnecessarily harsh with him, and I would apologize to him. What I do know is there seemed to be no reason for that call when I got back to the hospital, and I was just in time for them to have been calling the predicted “Code” and nobody was there to explain it.CHAPLAINCYHuntington has two chaplains on staff. They seem to be somewhat independent of the official company policy; at least, they were more receptive to my thoughts and suspicions which I was no longer holding back. One of them apologized for being unable to comment on anything medical or finance related for not being privy to that information, but offered the observation that if my thoughts were correct, if that was how all this had actually happened, then it was inexcusable, unconscionable, indefensible, and my reaction was utterly justified and I should be making noise about it; it’s not right and something should be done about it. The other chaplain agreed: “You wouldn’t want this to happen to someone else, would you?” No, I wouldn’t, but I don’t want to believe doctors could be so mercenary and uncaring either. “But what if they are? Why don’t you want to believe what you’ve seen with your own eyes?”Chaplain was right: I wasn’t seeing it and accepting it because I hadn’t wanted to see it or accept it. It’s too painful to believe it but it’s true nevertheless. Ross was dying now because two of his doctors just didn’t care enough. That’s hard to take. Dr, Honlee had more or less agreed if not in so many words, and both chaplains have told me to trust my eyes and ears, and what’s wrong is wrong; there are some doctors whose motivations are not as noble as their peers, and that’s the truth. Believe it.Now it’s just about dinner hour when my cell phone buzzes, it’s the pharmacy delivery driver, he’s at my front door, where am I? Oh, jeez, I’m back at the hospital, so sorry, can you deliver here, or can we try again tomorrow?[Side note here: Doctors, nurses, staff… when you have to notify family that their loved one’s death is imminent, don’t call them at home to ask if they’re finally ready to just let it go now. Gently suggest that perhaps they should return to the hospital, or if they would like to say their good-byes, this might be the appropriate time, or… I don’t know what, have the chaplain call them if you don’t know what to say, but don’t ask for permission to stand by and do nothing and just let them die. That’s not showing compassion, that’s covering your ass, and it’s not nearly as compassionate as you’ve convinced yourselves. You see this routinely; it’s just another day at work for you,; you’ve developed an immunity by now, and anyway, everybody dies. Yes, of course, everybody dies someday but you’re not talking to the deceased here; you’re talking to those left behind, who have not built up an immunity to this. And in Ross’ case, Dr. Tiner and Dr. Cohen already did that anyway; it’s why Ross is dying now. Do you think I’m going to give you permission to do it again?]I wanted Ross to come home with me, alive, that’s all, but if he can’t and never will, help me understand why not. He hadn’t done anything to hurt anyone. Why were they allowed to do this to him and why are they allowed to get away with it?THE RIGHT DOCTORThere was one doctor who did say the right thing at the right time. He was one of the cardiologists and he too was no longer directly on the case, but still he’d stop by to see how things were. “I’m just a bystander now,” he had said earlier in the week but at least he was still interested and concerned enough to be there. This was Dr. Mauer, of course. He’d look at the monitors, then at Ross and answer my questions or just observe silently. Never once pressured me to make a decision; he was there to see for himself. A day or two after that phone call from the ICU, Dr. Mauer stopped by again. As he looked over the monitors, his demeanor seemed different this morning, sad but resigned. He leaned his back against the wall, and asked me how I was holding up. I shrugged, I had spent the night again. I was tired. He nodded and looked down at the floor, describing how sad and frustrating this was for the whole team; nobody had expected “this situation;” it had tied the doctors’ hands behind their backs from the start; everybody wished there was something they could do to fix it and make it right, some miracle, but their options were running out now, this was so hard…(Oh, please, cry me a river… No, actually, I wasn’t thinking that at all, I was listening and following; but you’re going to be taking Ross away now, and it’s forever, and those two are going to get away with it. Why? What did we do? I know it’s not staff’s fault but don’t ask me to pretend this is okay, Dr. Mauer, it’s not okay. That’s not fair. How would you like it if that were your wife or child in “this situation?”)He was still looking down, describing how “this situation” had put all of them, the doctors and even the hospital itself now in a bad spot, between a rock and a hard place, this situation was bad for all of them and there seemed to be no way out or around it… then he looked at me again: “But I can’t imagine how hard this must be for you; I can’t imagine having to go through that; I just can’t imagine how hard that would be.”Out of all those doctors and staff, he was the only one who stepped up and said that.I had nothing to add; he had said it all. I merely nodded and mouthed the words, “Thank you.” Someone had finally understood and sympathized. He waited another moment or two silently looking at Ross, then he turned and left.So different from “not really” and how this had been “dumped” on me and “it won’t be premature.” How snide and cocky; who says something so dismissive and condescending to someone who is losing his partner and best friend after entrusting him to you, and you looked the other way and allowed this to happen on your watch after you had been asked to do something about it? Dr. Cohen couldn’t wash his hands of this mess fast enough, but had to insult me first on his way out. “so ein Feig.”Dr. Mauer didn’t have to be there now anymore than Dr. Cohen, but he was, and he didn’t try to dodge the issue; he didn’t hide behind distractions; no irrelevant red herrings such as HIV; no deflecting with what else might have happened; no hint of “risky” or “costly;” no pretending this was business as usual.; no bullshit about “standard procedure;” none of the poisonous dismissal in “not really.” The exact opposite of all that defensiveness; an exposed and humble acknowledgment that as awkward and precarious for them, how unimaginably horrible for Ross and myself. He put himself in my position and he got it, and he didn’t try to pretend. That’s what real empathy looks like and a doctor who does that is “ein echter Mensch.” He’s the one you can trust.I imagine the hospital won’t be happy to hear it, I can imagine the hospital would rather he not have said any of that, but I can’t put in words what a relief it was to finally have someone be honest with me, to tell me what was really going on behind the scenes, and not make me feel I was being unreasonable or crazy. I hope he isn’t reprimanded or penalized for it; he should be rewarded; and I’ll be the first to stick up for him. He kept alive the last flicker of faith I had in Huntington Hospital; it had almost been snuffed out after so many obvious attempts to obfuscate, each one making it worse than the one before. In my view, he shot right to the top alongside Dr. Rosenberg and Dr. Shriner for saying it.Sunday, March 15. I sat next to Ross on the little footstool, stroking his arm and holding his hand, leaning over the side rail of the bed. It was a matter of hours or even minutes, I knew it was coming and not far off. A little after 12 noon, the charge nurse came in with a respirator technician; seeing the position I was in, she offered to lower the side rail; that might be more comfortable for me. No, that’s okay, I told her; I could barely get the words out, but I wanted to ask her something: would it be alright if I moved some of the tubing and drip lines out of the way, could I clear a little space on the side so I can lay next to Ross; would it be alright if I hold him while he goes through this? She dropped her head and looked away for a moment; the technician turned his back. The charge nurse turned back toward me again and nodded, saying, “Yes, I think we can do that. Let’s do it like this,” and she and the technician quickly cleared a little space on Ross’ right side of the bed and she showed me how to do it safely. They drew the curtain and stepped out of the room. It was just about 12:30. I crawled into the bed alongside Ross, careful of the tubes and wires, and slipped one arm underneath his head and the other across his chest and held him for the last time, feeling his heart beat grow fainter and slower. Around 12:45 his heart must have stopped, it was so quiet and calm, I didn’t even realize it until the nurse came in and told me: Ross is gone.REQUIEM AETERNAMChair. Sit. Staring. Numb. There on the bed, flat, first time in weeks. White sheet, head at one end, ankles and feet at the other. Quiet now.Ross, I’m sorry, I am so, so sorry, I tried but….There is a knock on the wall behind me, and the curtain is parted. “May I?” Yes, of course, come in. She’s wearing a doctor’s white coat, stethoscope - do they still use those? - she’s carrying a clipboard and flashlight. Before she starts, she says, “I’m very sorry for your loss. This won’t take but a minute. You can stay if you like, or you can step outside if you prefer.” Thanks, I’m fine. I’ll stay. I’m too tired to move anyway, I may as well watch.She moves quickly, efficient but respectful. She checks the eyes. She listens for a heartbeat, runs through a few other checks. Two or three times she glances over at me. She looks familiar, I know her from somewhere; I’m sure of it. On the far side of the bed, she is bending forward, her hair falls forward around her shoulders; long brown hair that hangs halfway down her back. When she straightens up and brushes it back, now I remember… she was with Pontius Pilate that morning; she was Dr. Do-Nothing’s witness.Now she’s at the foot of the bed, almost done. I wonder if she heard about my outburst on the phone the other day; I’m sure I was on the agenda before morning rounds this past week. Our eyes meet; of course she’s heard about it. She sees death every day; is she also going to play along and pretend this is all normal? I have had no interaction with her at all until now; I have no idea what to expect from her.She starts to say something, but stops, then asks how I’m doing.I don’t have a word for this, I’m running on empty, just blank, I don’t really know how I’m doing, so I shrug my shoulders instead; that’s all I have left.A moment’s pause, then she says it too: “I can’t imagine…”SOME OBSERVATIONS:Not one person answered my question with a medical explanation for that initial delay, and not one person told me I must have misunderstood about prepayment. I didn’t misunderstand it; I prepaid for it twice! The very premise was never questioned; it was assumed, taken for granted. Palliative Care (of all departments!) even told me it is “standard procedure.”Huntington Hospital has always had a stellar reputation, and they’ve earned it… as long as things go well. But when someone makes a bad decision in bad faith? They can’t or won’t own up to it, probably thinking they have to protect that reputation, and not realizing that it’s having the opposite effect. What respect I had had for them prior to this has evaporated now and they did that to themselves. I want to be clear about that: I didn’t lose respect for them because Ross died. I lost respect for them because they would not be honest with me about how it happened and rather than explain it or apologize, they protected the person(s) who did it. In my eyes that makes the hospital complicit and culpable, morally and ethically if not legally.This wasn’t a medical failure, it wasn’t a misdiagnosis or a botched surgery or a flawed procedure. It was a failure of priorities and character; profits before people, and fear of admitting the truth. Ross died of endocarditis and heart failure following a decision where finances took precedence over his life. They can come up with all kinds of forensic explanations to explain the biology of it all, but that won’t erase the sequence of events that led up to the final outcome. Dr. Tiner delayed treatment until he was paid first, Dr. Cohen did nothing about that; and the hospital’s lack of financial oversight created an environment that allowed it.And the final slap in the face: Ross died for $1,750, which would have been paid by his insurance plan. I paid it out of pocket so Ross could come home again, alive. Instead I have a cardboard box with his ashes now. I would have preferred a proper burial and resting place for him; $1,750 would have let me do that. Instead, I did what I could afford, cremation for $975 and no urn - half the cost of the surgery that came too late. Added together, that’s $2,725. It seems crass to reduce the tragedy to this, but that’s two mortgage payments for us. I’m right back to where we started, but now without Ross.The hospital refuses to give me copies of the records I need to submit a claim for reimbursement from the insurance company… a claim that wouldn’t have been necessary if the hospital had properly vetted Dr. Tiner to begin with. A claim that Ross would have submitted if he had survived. But since I don’t have standing, and since I can’t really make those decisions for Ross, now I can’t have copies of the medical records that are required to be reimbursed. It was suggested that I write it off as a gift, a charitable donation, but that also requires records and proof.Nobody objected when I paid for Ross’ surgery in advance; only when I asked for the proof that it happened.“Can they do that, if we don’t have the money, would they really just let me die?” It’s what happened, they didn’t do anything when he asked, so I guess they would just let him die. They can say what they like, but that is what happened.Since first telling Ross’ story, I have received countless emails and comments from others who have been put through similar and worse experiences. Hundreds of thousands of dollars, bankruptcies, foreclosures, lives and homes lost. In comparison, I have to consider myself fortunate to some degree; $2,725 is pennies compared to so many others. But those pennies took priority over a person’s life. That is standard procedure far too often; Palliative Care’s explanation was accurate in ways that weren’t intended.We rely on the good faith of those who have taken a vow to heal us and do no harm. No such oath is required of our insurance industry, nor of the administrators, accountants and managers who have fiduciary responsibility for the health care industry. That gap between the physicians and the providers and the administrators fostered an environment that punishes honesty and encourages silence and obfuscation even when honesty is healing and silence does harm.There is a gaping hole in our health insurance industry. Consumers are required to carry health insurance, or else pay a fine. But health care providers are not likewise required to honor our health insurance plans. Why are we required to carry it if they are not required to honor it? Who set up such a lop-sided system where money goes in, but does not always come back out? Politicians, lobbyists and the private, for-profit insurance companies.I am going to tell Ross’ story whenever and wherever I can. I have to. For me to remain silent would mean I too have become complacent and complicit in Ross’ death.DAY OF WRATH, DAY OF JUDGMENTIt may be presumptuous of me to offer these, but it’s impossible to go through a tragedy like this and not come away with some thoughts about what went wrong, what might have prevented it and what could have led to a happier outcome.There should be a federal law that makes it illegal to require prepayment for any emergency or life-saving medical procedures, including procedures that must precede or follow emergency procedures. I would call it “the Tiner law” and name it for the person whose actions necessitated it. When telling Ross’ story I had one person ask, apparently in defense of Dr. Tiner: “But you expect to get paid for your work, don’t you?” My answer was, of course I expect to get paid… after I’ve done what I was hired to do.Colleagues in the medical profession should be mandated to report practitioners who require prepayment for emergencies. Failure to report should be treated as complicity. Doctors should not protect colleagues who violate professional ethics. The “Cohen law” would be named for the person whose lack of action necessitated it. If it were up to me, those names would be associated with the reasons those laws are necessary. That would be one form of justice for Ross, and it wouldn’t be premature.The resolution process must invite and include open dialogue and follow-up with the patient when a patient expresses misgivings about his practitioner. “Yes, there have been some problems with him, but I’ve spoken to him and he’s the best and he’s the one we use” is not a resolution; that’s dodging the issue. Ross had a right to know what those previous problems had been and how they were resolved before entrusting his life to that person.Third party billing for in-hospital procedures must stop. All in hospital work should be funneled through the hospital’s billing department without exception. The hospital must be made aware of how its facilities are used, and how they are to be paid for. One billing system with oversight and familiar with insurance providers would have known that the extractions were covered by Ross’ insurance plan.Care workers should be rewarded for calling out ethical violations, not intimidated into silence. The reason I kept asking questions was to figure out who I could trust now that Ross’ life had been held up for payment and I had been told I could not make decisions for him even after I had paid for an operation that hadn’t happened. Nobody was willing to say that the way it happened was wrong: the real “standard procedure” apparently was to remain silent and look the other way. That destroys trust and credibility and creates the appearance of complicity.Two other concerns remain unresolved for me.In the absence of sufficient socioeconomic information about a patient, for a doctor to decide on his own whether that patient will be treated or left to die… I can appreciate it as an academic ethical dilemma for its philosophical discussion points, but I’m left wondering what the parameters are in a real-life situation, or if there are any. “Risky and very costly” is too ambiguous for me. It is putting a price-tag on a patient’s head. How much is “very costly” and for whom? And what could be riskier than dying? As difficult as it is to have to make that decision for someone you know and love, at least you have familiarity enough with the person who has trusted you to make that ultimate decision. But to make that decision for a stranger about whom you know nothing? Maybe others can, but I couldn’t do it; it’s not my place. I didn’t give that stranger life; what right do I have to take it away? That was one of the most frightening rationalizations I’ve ever heard, and to have it presented under such circumstances as this, with such nonchalance. What would have happened if I had been out of town, or overseas, or under a Covid-19 quarantine, or unconscious myself in another hospital…? It was horrifying enough to have made me faint.This last one is the most bewildering to me.Federal law requires us to have medical insurance but it does no good when a hospital provides someone who doesn’t take that insurance and offers no other solution, especially in an emergency or life-threatening situation. If that is to be permitted, then why do we have insurance at all? This was not an elective, it was not planned, it was not plastic or cosmetic surgery. The need here was to remove the source of an infection before it proved fatal; a clock was ticking, but there was no sense of urgency. Payment took priority.I don’t understand how that was allowed to happen. It’s a crack in our health system. Ross had the proper insurance but when he fell into that crack and hollered for help, none of the rescuers paid attention to his cries, and he disappeared forever. Would somebody please explain that to me?And to be clear, I am not asking about the cause of death; I am not asking about endocarditis or strep infection. I am asking about how a pittance of payment was permitted to take priority over his life, and when he objected to that, nothing was done; it was defended instead. That wasn’t a medical mistake, it was a decision.CONCLUSIONSThere are some people I need to thank, and point out the goodness and give credit where credit is due.As I said before, the nursing staff, the technicians and floor workers were all of them outstanding. Whoever hires and trains those groups is doing it right, and that person deserves a great deal of credit for Huntington’s reputation.Dr. Honlee’s intentions were, I think, in the right place when he rephrased his request for DNR to clarify it was for Ross’ sake, to prevent Ross from suffering further. That wasn’t immediately clear because of the pressure placed on me to make a decision over the phone, after everybody had to have witnessed how desperately I had been fighting for Ross in person for more than a week. And to arrive and find Ross in exactly the same condition as just hours before was baffling. But then again, Dr. Honlee did say, “and I want justice for Ross too.” That counts for something.From the first time I saw him interact with Ross until the very end, it was clear that Dr. Mauer’s concern was real and genuine and human. I don’t know how to explain it but I just know. We all know the difference in how our doctors treat us, sometimes it’s easy and other times it’s harder to define, but we know. Dr. Mauer was the one, the only one, who gave me a clear picture of how Ross’ case was affecting people behind the scenes, and as bad as it was, how much more horrible for me and Ross. That’s empathy. And courage. It takes courage to be honest and exposed at the hardest times. I can’t thank him enough. He saved what was left of Huntington’s reputation in my mind.The chaplains who empowered me to trust my eyes and ears and instincts, and to do something about it. If it’s broken it won’t get fixed until someone points it out, otherwise it will happen again. With one of them I had a talk about ethics and morals and psychology theories, along with my father’s background (he was a liberal Lutheran minister and had begun his career as a hospital chaplain), and with the other I had a long talk about my Harvard education and the summer of 1974, after my high school sophomore year when I had been an exchange student to East Germany, one of the first U.S. students allowed to do so. I had been teaching Ross some basic German phrases over the last several months. That had been fun, and he was getting pretty good at it.And the medical examiner, with whom I had very little interaction to speak of, but as the last one to be with me and Ross in that room that last day, to simply say that she too could not imagine… after she had also been there as Dr. Cohen’s witness only 10 days before. That meant a lot.And of course, Nurse Maria, for that first morning, for publicly and without hesitation scolding Dr. Cohen’s “not really.” (I don’t think he has any idea how poisonous that was; I think it was blind, self-protective instinct on his part.) If Maria had not been there and said what she did in that instant, who knows… I owe her immeasurably.But then there are the other, unanswered questions and contributors.Ross’ fate will haunt me for a long time to come. I am always going to have that unanswered question: why didn’t they do anything when they knew the danger? Were they really as inhuman and indifferent as Ross had feared when he asked, “What if we don’t have the money, would they really just let me die?” It’s hard to affix a motivation for it; but nevertheless, that is exactly what happened.Yes, there was a bacterial agent, and yes, there were microscopic events, but those were known and foreseeable. And possibly preventable. But now we’ll never know. What we do know is that there was a protocol, and that protocol was never given a proper chance, because we didn’t come up with $1,750 in time.Huntington Hospital accepts government subsidies and support via Medicare, Medi-cal, Covered CA, and the like. Yet they provided a surgeon who does not or would not accept those insurance plans from the patient, even after the patient warned about that and asked for something to be done about it. How is that possible, legal, ethical, sound business or medical practice? It is a clear violation of EMTALA law. How was that allowed to happen, at a hospital with a reputation as sterling as Huntington Memorial?Because I don’t have “standing,” this is, as one lawyer told me, “a clear-cut case, but one without a client.” I believe this is why Dr. Cohen sounded so relieved: if I can’t pursue justice for Ross, who can?I can’t get rid of the thought that Ross was treated poorly because he was perceived to be poor and therefore he could sit on the back burner and wait, not worth the risk or the cost; poor people die all the time and he was just another one. Focus on the profitable patients. I don’t think it’s conscious and deliberate so much as it is systemic, a mindset that has crept into our health care system because the system is driven by profit.What is leading me to think that?Dr. Tiner’s insistence on payment in full in advance because he had trouble collecting in the past;Dr. Cohen minimizing Ross’ concerns about that;the rationale to not treat elderly or homeless people if “risky and very costly;”knowing this infection is serious but no sense of urgency;having the medical examiner at the ready that morning,that Ross’ situation had been “dumped” on me (excuse me ?!?);the inconsistent responses to my question about how and why this happened,my repeated question of how a hospital allows a doctor to delay a life saving operation for advance payment was never refuted or corrected; it was assumed; I was told it was “standard procedure.”What am I supposed to conclude?I have yet to hear a medical explanation for that delay. I asked plenty of times. The silence leads me to conclude that there is no explanation; that Ross was ignored because he was thought to be poor and payment took priority over his life, and everybody was complacent with that, it was business as usual until disaster struck. That’s my experience of what happened here; I don’t know what else to make of it and with no other explanation forthcoming, I am expected to pretend that this was okay..Yes, he may have died anyway. I know that. But the fact remains, nothing was done about a routine but necessary preliminary surgery until payment had been received first. That is the question on the table.It was known that this was a life-threatening infection, and though the source of that infection had been identified, it was allowed to remain in place for nearly two weeks because we didn’t have the money in time, and the procedure was finally done only after it was too late to do any good. How can anyone be expected to conclude that this is sound medical practice?It’s really hard to sit with your partner after he has been moved from the cardio wing to the ICU because he had a stroke the night before, and to have that inevitable talk about what might happen next and what he wants you to do if it should come to that. The hardest part - and I wouldn’t wish this on anyone - was looking into his eyes when this would not have happened if I hadn’t paid the mortgage so early or if I had used the right credit card or if I had… But he knew me and he knew what I was thinking and he said it wasn’t my fault. So when the unthinkable came to pass, to be told that I can’t really make these decisions, to have my questions circumvented and unanswered, to be asked to let it go instead… after discovering this did not have to happen, insurance does cover it but nobody did anything when he had asked… “would he really let me die, just like that?”Yes, apparently so, and worse, everyone seemed to be okay with that; after all, everybody has to die someday, right? Ross is just one more. Oh, well. Standard procedure.Huntington Hospital is frequently recognized as a five-star, first class hospital… and it probably deserves that reputation when all ends well. Based on my personal past experience, I’ve always thought they earned it and it was well deserved. But how are they when it comes to admitting a mistake, or answering questions in order to heal an injury they or their associates have caused? One associate, and only one, made the attempt and he did so voluntarily and on his own. The rest failed, miserably so; they made it worse. I wouldn’t be telling what happened to Ross and still looking for answers if it were otherwise.Doctors, nurses, medical staff… we know honest mistakes happen, but we know the difference between an innocent mistake made by a doctor who cares, and wanton negligence, blatant greed and bored indifference. We figure that out by what you say and do, by the words you use and the actions you take on our behalf, as well as what you don’t say or do, and the actions you don’t take on our behalf. Everybody knows that our current health insurance system has flaws. and because of that, doctors and hospitals must guard against frivolous lawsuits, that you have to be careful about what you say. But when $1,750 is valued more than a patient’s life, who really is the frivolous one?So many violations and ethical failures:,EMTALA violationsFailure to treat in a timely mannerFailure to treat due to billing or payment issuePatient abandonmentPracticing outside scope of licenseAiding and abetting practice outside scope of licenseBut the perpetrators can escape exposure, correction or punishment because we did not have a specific piece of paper to make our relationship official. Think of the ramifications of that. A single person could experience the exact same sequence of events, with nobody to fight for his case. Indeed, that is what Dr. Cohen himself professed to do when he deemed proceeding to be “risky and very costly.” Best friends, roommates, life-long pals, business partners, and so on… those most immediately affected, most able to make a decision, but unable to do so, or to intervene to prevent a similar situation.Dodging, avoiding, covering up, evading and distracting look like complicity and complacency. This was failure to treat due to a billing issue, a report-able ethical failure (yes, I looked it up), and while everybody seemed to know that, nobody would say this was wrong and should not have happened. What do you imagine a person fighting for his partner’s life is going to conclude from that? If you’re not against it then you are permitting it. It’s a crucible for you certainly, but remember your oath to do no harm. It means nothing if you remain silent knowing one of your own violates it. Your silence causes harm.ROSSI knew Ross for nearly two decades, and he was, first and foremost, a humanitarian. He was always the first to pitch in and help anyone who needed it; he volunteered with numerous agencies and charities; he supported the underdogs of society and stood up for them.One time we were riding our bikes and passing through a not so great neighborhood. Ross was not a big or intimidating guy, about 5′ 9″ and medium build, but he could be fearless when pushed. He was pedaling about half a block ahead of me. On the sidewalk even further ahead was a young couple, arguing loudly and it was rapidly escalating, and then the pushing, slapping and fists started. Ross zoomed right over on his bike, “Hey! Cut it out, right now! Don’t you hit her!” The guy was clearly drunk when he turned to see who was challenging him, but Ross charging straight for him on his bike distracted him enough that she broke loose and ran. “Leave her alone, you coward!” Ross hollered at him, circling back around. I followed her to make sure she got far enough away while Ross kept the other one at bay. That was Ross.A few years after we had been living together, I was diagnosed with diabetes. It runs in the family on my dad’s side; all his brothers had it, as did a few of his sisters, so it wasn’t that surprising. In fact, a few months later, one of my brothers was diagnosed and another found he was borderline. I struggled to bring it under control, a combination of not knowing what I was doing, not paying attention and not monitoring it, along with denial of how serious this could be, and it was going in the wrong direction. After several months of this, Ross announced he was taking over the groceries and meals, and he was brutal about it. Breakfast, lunch and dinner were planned, measured and monitored; he wouldn’t even make lunch or dinner until I had done my blood test; he was that strict and committed. Within three months he brought my stats down from dangerous to merely high, and soon afterwards, from elevated to acceptable. Yes, I grumbled about it the whole time, but he paid no attention and it worked. I owe him, and to be told now that I can’t make these decisions for him, not really, was beyond the pale.He demanded one thing of everybody he encountered: that they treat every other human being with respect. Whether you like them or not, get along with them or not, agree with them or not, you respect them for their humanity until they prove themselves undeserving of it, and you forgive them for a mistake if they learn from it. That was Ross.He did not deserve what happened to him here, he was a victim of what he deplored: lack of concern for another human being. It wasn’t deliberate or planned; there was no conspiracy to murder him here; that’s not what happened. But it seemed clear to me that Thursday morning that neither Dr. Cohen nor Dr. Tiner had any idea or interest in who Ross was as a person. He was Medi-cal. It’s small comfort, but at least he was spared the insult and indignity of having to listen to the excuses and distractions and obviously bullshit answers for why he was ignored to death.However, Ross was not a vengeful type. I know that he could and would forgive if the people involved learned from it and turned his tragedy into something positive. He was more generous and forgiving than I could ever be.I have never asked readers to share one of my answers, but this is one time I feel I must. For Ross’ sake, please take that extra step and share or let someone know about his story. The best way I can memorialize Ross is to do everything I can to make sure this never happens to anyone again.One last way I want to memorialize Ross, is to remember him in happier times. On Day 3 of the 2008 Ride to End Aids comes the notorious long, steep hill known as “Quadbuster.” Many riders dismount and walk their bikes up that last half mile. Not Ross.Here he is, having the time of his life, triumphantly reaching the crest of Quadbuster.I miss him.

If I could, I'd give every college student a copy of the enduring essays "What Are You Going to Do With That?," by William Deresiewicz and "The Case for Breaking Up With Your Parents," by Terry Castle, stay with them until they read both essays completely, and tell them to re-read them on a yearly basis (I do), because I think that's almost all of what they need to hear. Scratch that, I'd pass copies to everyone and anyone:What Are You Going to Do With That?The question my title poses, of course, is the one that is classically aimed at humanities majors. What practical value could there possibly be in studying literature or art or philosophy? So you must be wondering why I'm bothering to raise it here, at Stanford, this renowned citadel of science and technology. What doubt can there be that the world will offer you many opportunities to use your degree?But that's not the question I'm asking. By "do" I don't mean a job, and by "that" I don't mean your major. We are more than our jobs, and education is more than a major. Education is more than college, more even than the totality of your formal schooling, from kindergarten through graduate school. By "What are you going to do," I mean, what kind of life are you going to lead? And by "that," I mean everything in your training, formal and informal, that has brought you to be sitting here today, and everything you're going to be doing for the rest of the time that you're in school.We should start by talking about how you did, in fact, get here. You got here by getting very good at a certain set of skills. Your parents pushed you to excel from the time you were very young. They sent you to good schools, where the encouragement of your teachers and the example of your peers helped push you even harder. Your natural aptitudes were nurtured so that, in addition to excelling in all your subjects, you developed a number of specific interests that you cultivated with particular vigor. You did extracurricular activities, went to afterschool programs, took private lessons. You spent summers doing advanced courses at a local college or attending skill-specific camps and workshops. You worked hard, you paid attention, and you tried your very best. And so you got very good at math, or piano, or lacrosse, or, indeed, several things at once.Now there's nothing wrong with mastering skills, with wanting to do your best and to be the best. What's wrong is what the system leaves out: which is to say, everything else. I don't mean that by choosing to excel in math, say, you are failing to develop your verbal abilities to their fullest extent, or that in addition to focusing on geology, you should also focus on political science, or that while you're learning the piano, you should also be working on the flute. It is the nature of specialization, after all, to be specialized. No, the problem with specialization is that it narrows your attention to the point where all you know about and all you want to know about, and, indeed, all you can know about, is your specialty.The problem with specialization is that it makes you into a specialist. It cuts you off, not only from everything else in the world, but also from everything else in yourself. And of course, as college freshmen, your specialization is only just beginning. In the journey toward the success that you all hope to achieve, you have completed, by getting into Stanford, only the first of many legs. Three more years of college, three or four or five years of law school or medical school or a Ph.D. program, then residencies or postdocs or years as a junior associate. In short, an ever-narrowing funnel of specialization. You go from being a political-science major to being a lawyer to being a corporate attorney to being a corporate attorney focusing on taxation issues in the consumer-products industry. You go from being a biochemistry major to being a doctor to being a cardiologist to being a cardiac surgeon who performs heart-valve replacements.Again, there's nothing wrong with being those things. It's just that, as you get deeper and deeper into the funnel, into the tunnel, it becomes increasingly difficult to remember who you once were. You start to wonder what happened to that person who played piano and lacrosse and sat around with her friends having intense conversations about life and politics and all the things she was learning in her classes. The 19-year-old who could do so many things, and was interested in so many things, has become a 40-year-old who thinks about only one thing. That's why older people are so boring. "Hey, my dad's a smart guy, but all he talks about is money and livers."And there's another problem. Maybe you never really wanted to be a cardiac surgeon in the first place. It just kind of happened. It's easy, the way the system works, to simply go with the flow. I don't mean the work is easy, but the choices are easy. Or rather, the choices sort of make themselves. You go to a place like Stanford because that's what smart kids do. You go to medical school because it's prestigious. You specialize in cardiology because it's lucrative. You do the things that reap the rewards, that make your parents proud, and your teachers pleased, and your friends impressed. From the time you started high school and maybe even junior high, your whole goal was to get into the best college you could, and so now you naturally think about your life in terms of "getting into" whatever's next. "Getting into" is validation; "getting into" is victory. Stanford, then Johns Hopkins medical school, then a residency at the University of San Francisco, and so forth. Or Michigan Law School, or Goldman Sachs, or Mc­Kinsey, or whatever. You take it one step at a time, and the next step always seems to be inevitable.Or maybe you did always want to be a cardiac surgeon. You dreamed about it from the time you were 10 years old, even though you had no idea what it really meant, and you stayed on course for the entire time you were in school. You refused to be enticed from your path by that great experience you had in AP history, or that trip you took to Costa Rica the summer after your junior year in college, or that terrific feeling you got taking care of kids when you did your rotation in pediatrics during your fourth year in medical school.But either way, either because you went with the flow or because you set your course very early, you wake up one day, maybe 20 years later, and you wonder what happened: how you got there, what it all means. Not what it means in the "big picture," whatever that is, but what it means to you. Why you're doing it, what it's all for. It sounds like a cliché, this "waking up one day," but it's called having a midlife crisis, and it happens to people all the time.There is an alternative, however, and it may be one that hasn't occurred to you. Let me try to explain it by telling you a story about one of your peers, and the alternative that hadn't occurred to her. A couple of years ago, I participated in a panel discussion at Harvard that dealt with some of these same matters, and afterward I was contacted by one of the students who had come to the event, a young woman who was writing her senior thesis about Harvard itself, how it instills in its students what she called self-efficacy, the sense that you can do anything you want. Self-efficacy, or, in more familiar terms, self-esteem. There are some kids, she said, who get an A on a test and say, "I got it because it was easy." And there are other kids, the kind with self-efficacy or self-esteem, who get an A on a test and say, "I got it because I'm smart."Again, there's nothing wrong with thinking that you got an A because you're smart. But what that Harvard student didn't realize—and it was really quite a shock to her when I suggested it—is that there is a third alternative. True self-esteem, I proposed, means not caring whether you get an A in the first place. True self-esteem means recognizing, despite everything that your upbringing has trained you to believe about yourself, that the grades you get—and the awards, and the test scores, and the trophies, and the acceptance letters—are not what defines who you are.She also claimed, this young woman, that Harvard students take their sense of self-efficacy out into the world and become, as she put it, "innovative." But when I asked her what she meant by innovative, the only example she could come up with was "being CEO of a Fortune 500." That's not innovative, I told her, that's just successful, and successful according to a very narrow definition of success. True innovation means using your imagination, exercising the capacity to envision new possibilities.But I'm not here to talk about technological innovation, I'm here to talk about a different kind. It's not about inventing a new machine or a new drug. It's about inventing your own life. Not following a path, but making your own path. The kind of imagination I'm talking about is moral imagination. "Moral" meaning not right or wrong, but having to do with making choices. Moral imagination means the capacity to envision new ways to live your life.It means not just going with the flow. It means not just "getting into" whatever school or program comes next. It means figuring out what you want for yourself, not what your parents want, or your peers want, or your school wants, or your society wants. Originating your own values. Thinking your way toward your own definition of success. Not simply accepting the life that you've been handed. Not simply accepting the choices you've been handed. When you walk into Starbucks, you're offered a choice among a latte and a macchiato and an espresso and a few other things, but you can also make another choice. You can turn around and walk out. When you walk into college, you are offered a choice among law and medicine and investment banking and consulting and a few other things, but again, you can also do something else, something that no one has thought of before.Let me give you another counterexample. I wrote an essay a couple of years ago that touched on some of these same points. I said, among other things, that kids at places like Yale or Stanford tend to play it safe and go for the conventional rewards. And one of the most common criticisms I got went like this: What about Teach for America? Lots of kids from elite colleges go and do TFA after they graduate, so therefore I was wrong. TFA, TFA—I heard that over and over again. And Teach for America is undoubtedly a very good thing. But to cite TFA in response to my argument is precisely to miss the point, and to miss it in a way that actually confirms what I'm saying. The problem with TFA—or rather, the problem with the way that TFA has become incorporated into the system—is that it's just become another thing to get into.In terms of its content, Teach for America is completely different from Goldman Sachs or McKinsey or Harvard Medical School or Berkeley Law, but in terms of its place within the structure of elite expectations, of elite choices, it is exactly the same. It's prestigious, it's hard to get into, it's something that you and your parents can brag about, it looks good on your résumé, and most important, it represents a clearly marked path. You don't have to make it up yourself, you don't have to do anything but apply and do the work­—just like college or law school or McKinsey or whatever. It's the Stanford or Harvard of social engagement. It's another hurdle, another badge. It requires aptitude and diligence, but it does not require a single ounce of moral imagination.Moral imagination is hard, and it's hard in a completely different way than the hard things you're used to doing. And not only that, it's not enough. If you're going to invent your own life, if you're going to be truly autonomous, you also need courage: moral courage. The courage to act on your values in the face of what everyone's going to say and do to try to make you change your mind. Because they're not going to like it. Morally courageous individuals tend to make the people around them very uncomfortable. They don't fit in with everybody else's ideas about the way the world is supposed to work, and still worse, they make them feel insecure about the choices that they themselves have made—or failed to make. People don't mind being in prison as long as no one else is free. But stage a jailbreak, and everybody else freaks out.In A Portrait of the Artist as a Young Man, James Joyce has Stephen Dedalus famously say, about growing up in Ireland in the late 19th century, "When the soul of a man is born in this country there are nets flung at it to hold it back from flight. You talk to me of nationality, language, religion. I shall try to fly by those nets."Today there are other nets. One of those nets is a term that I've heard again and again as I've talked with students about these things. That term is "self-indulgent." "Isn't it self-indulgent to try to live the life of the mind when there are so many other things I could be doing with my degree?" "Wouldn't it be self-indulgent to pursue painting after I graduate instead of getting a real job?"These are the kinds of questions that young people find themselves being asked today if they even think about doing something a little bit different. Even worse, the kinds of questions they are made to feel compelled to ask themselves. Many students have spoken to me, as they navigated their senior years, about the pressure they felt from their peers—from their peers—to justify a creative or intellectual life. You're made to feel like you're crazy: crazy to forsake the sure thing, crazy to think it could work, crazy to imagine that you even have a right to try.Think of what we've come to. It is one of the great testaments to the intellectual—and moral, and spiritual—poverty of American society that it makes its most intelligent young people feel like they're being self-indulgent if they pursue their curiosity. You are all told that you're supposed to go to college, but you're also told that you're being "self-indulgent" if you actually want to get an education. Or even worse, give yourself one. As opposed to what? Going into consulting isn't self-indulgent? Going into finance isn't self-indulgent? Going into law, like most of the people who do, in order to make yourself rich, isn't self-indulgent? It's not OK to play music, or write essays, because what good does that really do anyone, but it is OK to work for a hedge fund. It's selfish to pursue your passion, unless it's also going to make you a lot of money, in which case it's not selfish at all.Do you see how absurd this is? But these are the nets that are flung at you, and this is what I mean by the need for courage. And it's a never-ending proc­ess. At that Harvard event two years ago, one person said, about my assertion that college students needed to keep rethinking the decisions they've made about their lives, "We already made our decisions, back in middle school, when we decided to be the kind of high achievers who get into Harvard." And I thought, who wants to live with the decisions that they made when they were 12? Let me put that another way. Who wants to let a 12-year-old decide what they're going to do for the rest of their lives? Or a 19-year-old, for that matter?All you can decide is what you think now, and you need to be prepared to keep making revisions. Because let me be clear. I'm not trying to persuade you all to become writers or musicians. Being a doctor or a lawyer, a scientist or an engineer or an economist—these are all valid and admirable choices. All I'm saying is that you need to think about it, and think about it hard. All I'm asking is that you make your choices for the right reasons. All I'm urging is that you recognize and embrace your moral freedom.And most of all, don't play it safe. Resist the seductions of the cowardly values our society has come to prize so highly: comfort, convenience, security, predictability, control. These, too, are nets. Above all, resist the fear of failure. Yes, you will make mistakes. But they will be your mistakes, not someone else's. And you will survive them, and you will know yourself better for having made them, and you will be a fuller and a stronger person.It's been said—and I'm not sure I agree with this, but it's an idea that's worth taking seriously—that you guys belong to a "postemotional" generation. That you prefer to avoid messy and turbulent and powerful feelings. But I say, don't shy away from the challenging parts of yourself. Don't deny the desires and curiosities, the doubts and dissatisfactions, the joy and the darkness, that might knock you off the path that you have set for yourself. College is just beginning for you, adulthood is just beginning. Open yourself to the possibilities they represent. The world is much larger than you can imagine right now. Which means, you are much larger than you can imagine.The Case for Breaking Up With Your ParentsShall I be ashamed to kill mother?—Aeschylus, The Libation BearersTime: last year. Place: an undergraduate classroom, in the airy, well-wired precincts of Silicon Valley University. (Oops, I mean Sun-Kissed-Google-Apps-University.) I am avoiding the pedagogical business at hand—the class is my annual survey of 18th-century British literature, and it's as rockin' and rollin' as you might imagine, given the subject—in order to probe my students' reactions to a startling and (to me) disturbing article I have just read in the Harvard alumni magazine. The piece, by Craig Lambert, one of the magazine's editors, is entitled "Nonstop: Today's Superhero Undergraduates Do '3000 Things at 150 Percent.'"As the breaking-newsfeed title suggests, the piece, on the face of it, is anecdotal and seemingly light-hearted—a collegiate Ripley's Believe It or Not! about the overscheduled lives of today's Harvard undergraduates. More than ever before, it would appear, these poised, high-achieving, fantastically disciplined students routinely juggle intense academic studies with what can only seem (at least to an older generation) a truly dizzy-making array of extracurricular activities: pre-professional internships, world-class athletics, social and political advocacy, start-up companies, volunteering for nonprofits, research assistantships, peer advising, musical and dramatic performances, podcasts and video-making, and countless other no doubt virtuous (and résumé-building) pursuits. The pace is so relentless, students say, some plan their packed daily schedules down to the minute—i.e., "shower: 7:15-7:20 a.m."; others confess to getting by on two or three hours of sleep a night. Over the past decade, it seems, the average Harvard undergraduate has morphed into a sort of lean, glossy, turbocharged superhamster: Look in the cage and all you see, where the treadmill should be, is a beautiful blur.I am curious if my Stanford students' lives are likewise chockablock. Heads nod yes; deep sighs are expelled; their own lives are similarly crazy. They can barely keep up, they say—particularly given all the texting and tweeting and cellphoning they have to do from hour to hour too. Do they mind? Not hugely, it would seem. True, they are mildly intrigued by Lambert's suggestion that the "explosion of busyness" is a relatively recent historical phenomenon—and that, over the past 10 or 15 years, uncertain economic conditions, plus a new cultural emphasis on marketing oneself to employers, have led to ever more extracurricular add-ons. Yes, they allow: You do have to display your "well-roundedness" once you graduate. Thus the supersize CV's. You'll need, after all, to advertise a catalog of competencies: your diverse interests, original turn of mind, ability to work alone or in a team, time-management skills, enthusiasm, unflappability—not to mention your moral probity, generosity to those less fortunate, lovable "meet cute" quirkiness, and pleasure in the simple things of life, such as synchronized swimming, competitive dental flossing, and Antarctic exploration. "Yes, it can often be frenetic and with an eye toward résumés," one Harvard assistant dean of students observes, "but learning outside the classroom through extracurricular opportunities is a vital part of the undergraduate experience here."Yet such references to the past—truly a foreign country to my students—ultimately leave them unimpressed. They laugh when I tell them that during my own somewhat damp Jurassic-era undergraduate years—spent at a tiny, obscure, formerly Methodist school in the rainy Pacific Northwest between 1971 and 1975—I never engaged in a single activity that might be described as "extracurricular" in the contemporary sense, not, that is, unless you count the little work-study job I had toiling away evenings in the sleepy campus library. What was I doing all day? Studying and going to class, to be sure. Reading books, listening to music, falling in love (or at least imagining it). Eating ramen noodles with peanut butter. But also, I confess, I did a lot of plain old sitting around—if not outright malingering. I've got a box of musty journals to prove it. After all, nobody even exercised in those days. Nor did polyester exist. Once you'd escaped high school and obligatory PE classes—goodbye hirsute Miss Davis; goodbye, ugly cotton middy blouse and gym shorts—you were done with that. We were all so countercultural back then—especially in the Pacific Northwest, where the early 1970s were still the late sixties. The 1860s.The students now regard me with curiosity and vague apprehension. What planet is she from.But I have another question for them. While Lambert, author of "Nonstop," admires the multitasking undergraduates Harvard attracts, he also worries about the intellectual and emotional costs of such all-consuming busyness. In a turn toward gravitas, he quotes the French film director Jean Renoir's observation that "the foundation of all civilization is loitering" and wonders aloud if "unstructured chunks of time" aren't necessary for creative thinking. And while careful to phrase his concerns ever so delicately—this is the Harvard alumni magazine, after all—he seems afraid that one reason today's students are so driven and compulsive is that they have been trained up to it since babyhood: From preschool on, they are accustomed to their parents pushing them ferociously to make use of every spare minute. Contemporary middle-class parents—often themselves highly accomplished professionals—"groom their children for high achievement," he suspects, "in ways that set in motion the culture of scheduled lives and nonstop activity." He quotes a former Harvard dean of student life:This is the play-date generation. ... There was a time when children came home from school and just played randomly with their friends. Or hung around and got bored, and eventually that would lead you on to something. Kids don't get to do that now. Busy parents book them into things constantly—violin lessons, ballet lessons, swimming teams. The kids get the idea that someone will always be structuring their time for them.The current dean of freshmen concurs: "Starting at an earlier age, students feel that their free time should be taken up with purposeful activities. There is less stumbling on things you love ... and more being steered toward pursuits." Some of my students begin to look downright uneasy; some are now listening hard.Such parental involvement can be distasteful, even queasy-making. "Now," writes Lambert, parents "routinely 'help' with assignments, making teachers wonder whose work they are really grading. ... Once, college applicants typically wrote their own applications, including the essays; today, an army of high-paid consultants, coaches, and editors is available to orchestrate and massage the admissions effort." Nor do such parents give up their busybody ways, apparently, once their offspring lands a prized berth at some desired institute of higher learning. Lambert elaborates:Parental engagement even in the lives of college-age children has expanded in ways that would have seemed bizarre in the recent past. (Some colleges have actually created a "dean of parents" position—whether identified as such or not—to deal with them.) The "helicopter parents" who hover over nearly every choice or action of their offspring have given way to "snowplow parents" who determinedly clear a path for their child and shove aside any obstacle they perceive in the way.•Now, as a professor I have had some experiences with "hel­icopter" parents, and were weather patterns on the West Coast slightly more rigorous, I'm sure I would have encountered "snowplow" parents as well. Indelibly etched on my brain, I tell the class, is a phone call I received one winter break from the aggrieved mother of a student to whom I had given a C-minus in a course that fall. The class had been a graduate course, a Ph.D. seminar, no less. The woman's daughter, a first-year Ph.D. student, had spoken nary a word in class, nor had she ever visited during office hours. Her seminar paper had been unimpressive: Indeed it was one of those for which the epithet "gobsmackingly incoherent" might seem to have been invented. Still, the mother lamented, her daughter was distraught; the poor child had done nothing over the break but cry and brood and wander by herself in the woods. I had ruined everybody's Christmas, apparently, so would I not redeem myself by allowing her daughter to rewrite her seminar paper for a higher grade? It was only fair.While startled to get such a call, I confess to being cowed by this direct maternal assault and, against my academic better judgment, said OK. The student did rewrite the essay, and this time I gave it a B. Generous, I thought. (It was better but still largely incomprehensible.) Yet the ink was hardly dry when the mother called again: Why wasn't her cherished daughter receiving an A? She had rewritten the paper! Surely I realized ... etc. One was forced to feign the gruesome sounds of a fatal choking fit just to get off the phone.Did such hands-on parental advocacy—I inquired—trouble my students? My caller obviously represented an extreme instance, but what did they think about the wider phenomenon? Having internalized images of themselves (if only unconsciously) as standard-bearers of parental ambition—or so Lambert's article had it—their peers at Harvard didn't seem particularly shocked or embarrassed by Ma and Pa's lobbying efforts on their behalf. According to one survey, only 5 to 6 percent of undergrads felt their parents had been "too involved" in the admission process. Once matriculated (there's an interesting word), most students saw frequent parental contact and advice-giving as normal: A third of Harvard undergraduates reported calling or messaging daily with a parent.Yet here it was—just at this delicate punctum—that I found myself reduced (however briefly) to speechlessness. Blindsided. So how often do my students—mostly senior English majors, living in residential dorms—text or talk to their parents? Broad smiles all around. Embarrassed looks at one another. Whispers and some excited giggling. A lot. Well, how much exactly? A lot. But what's a lot? They can't believe I'm asking. Why do I want to know? I might as well be asking them how often they masturbate. And then it all comes tumbling out:Oh, like, every day, sometimes more than once.At least two or three times a day. (Group laughter.)My father e-mails me jokes and stuff every day.My mother would worry if I didn't call her every day. (Nodding heads.)Well, we're always in touch—my parents live nearby so I go home weekends, too.Finally, one student—a delightful young woman whom I know to be smart and levelheaded—confesses that she talks to her mother on the cellphone at least five, maybe six, even seven times a day: We're like best friends, so I call her whenever I get out of class. She wants to know about my professors, what was the exam, so I tell her what's going on and give her, you know, updates. Sometimes my grandmother's there, and I talk to her too.I'm stunned; I'm aghast; I'm going gaga. I must look fairly stricken too—Elektra keening over the corpse of Agamemnon—because now the whole class starts laughing at me, their strange unfathomable lady-professor, the one who doesn't own a television and obviously doesn't have any kids of her own. What a freak. "But when I was in school," I manage finally to gasp, "All we wanted to do was get away from our parents!" "We never called our parents!" "We despised our parents!" "In fact," I splutter—and this is the showstopper—"we only had one telephone in our whole dorm—in the hallway—for 50 people! If your parents called, you'd yell from your room, Tell them I'm not here!"After this last outburst, the students too look aghast. Not to mention morally discomfited. No; these happy, busy, optimistic Stanford undergrads, so beautiful and good in their unisex T-shirts, hoodies, and J.Crew shorts; so smart, scrupulous, forward-looking, well-meaning, well-behaved, and utterly presentable—just the best and the nicest, really—simply cannot imagine the harsh and silent world I'm describing.•At the time, I wasn't sure why this conversation left me dumbfounded, but it did. It stayed with me for weeks, and I told numerous pals about it, marveling again at the bizarreness of contemporary undergraduate life. One said she talked to her mother five times a day! In the moment, the exchange had awakened in me a fairly dismal psychological sensation I'd sometimes felt in classes before (one hard to acknowledge, so out of step with official norms does it seem): namely, that teaching makes me feel lonely. Not all the time, but enough to notice. Lecturing before students, I will suddenly feel utterly bereft. A cloud goes over the sun. Though putatively in charge, I'm estranged from my charges—self-conscious, alone, in a tunnel, the object of attention (and somehow responsible for everything taking place) but unable to speak a language anyone understands. I feel sad and oppressed, smothered almost, slightly panicky. It's a sensation one might have in an anxiety dream—the sort in which you feel abandoned and overwhelmed and without something you desperately need. They've gone away and left me in charge of everything. At least in my own head, it's the sensation of orphanhood.One rallies, of course. Professor Freakout soldiers on and the feeling dissipates. The business of the day returns. But the psychological cloud can remain for a while, like a miasma. By asking my students a lot of intrusive and impertinent questions, I concluded afterward, I'd obviously brought this grisly mood on myself. Their charming, fresh-faced, matter-of-fact responses—yes, they were just as busy as their Harvard counterparts, but, yes, they also managed to stay in (surprisingly) close touch with parents (i.e., they loved and were loved in return)—had somehow triggered my orphan-reflex. I had only myself to blame. I chastised myself for having temporarily forgotten that students today—not just those at Harvard or Stanford, of course—live in a new, exciting, exacting "24/7" world, one utterly unlike (mentalité-wise) the one I inhabited as an undergraduate. They seem reasonably content with their lot; in fact appear to take the endless "connectivity" for granted—the networking, blogging, Skyping, Facebook posts, Twitter feeds. And why shouldn't they? Have they ever known anything else? None of it made me happy, but neither was I particularly happy with myself.Now, lest one wonder, I should say upfront I am not an orphan—or at least not in the official sense. At the time of writing, both my parents are still alive—in their mid-80s, but frail, beginning to fail. They don't live together. In fact, despite residing less than a mile apart, they haven't laid eyes on one another for almost 40 years. Not even by accident in the Rite Aid store. Don't ask. They've had five rancorous marriages between them. I haven't seen my father more than 10 or 12 times over the past decade. That my recurrent sense of psychic estrangement—not to say shock at my students' hooked-in, booked-up, seemingly bountiful lives—might be in some way connected with these Jolly Aged P's is a topic that would no doubt require a posse of shrinks to explore thoroughly. But even without reference to private psychodrama, I think I now at least half-grasp the reason why my students' overscheduled lives, so paradoxically conjoined (I felt) with intense bonds with parents, discombobulated me so thoroughly.Unsurprisingly, orphanhood—that painful thing—has everything to do with the case. Orphanhood conceived, that is, in the broadest sense: as a metaphor for modern human experience, as symbol for unhappy consciousness, as emblem of that groundwork—that inaugural experience of metaphysical solitude—that Martin Heidegger deemed necessary for the act of philosophizing. About orphanhood conceived, in other words, as a condition for world-making—as both the sorrow and creative quintessence of life.Now that's a bit of a mouthful, I realize, so let me explain it in simpler terms. If you teach the history of English and American literature (as I've done most of my life), it's safe to say you will end up, among other things, a state-of-the-art Orphan Expert. Not that it's that hard. You don't need to go back very far in literary history, after all, to find a plethora of orphaned or quasi-orphaned protagonists. At the outset of the play bearing his name, Hamlet, poor mite, might best be understood, after all, as a sort of half-orphan—indeed, a half-orphan with an unconscious wish to become a full-service orphan. If not downright matricidal, he seems aggrieved enough by his mother's perceived betrayals to wonder if hastening her demise might not make life at Elsinore Castle rather more enjoyable for everybody concerned.And what is Milton's Paradise Lost if not one of Western culture's great parables of self-orphaning? Along with the Oresteia and the Oedipus plays, it's a sort of poetical primer on how to forfeit the love and care of one's Creator in a few outrageous, easy-to-follow steps. Satan's not really to blame for the mess: He's just a figment, the kid who sticks chewing gum on the table leg. Adam and Eve know perfectly well what they are doing when they eat the fruit of the Tree of the Knowledge of Good and Evil. They want to eat it. And when they are seen, misery-ridden, leaving life in the Garden behind ("They, hand in hand, with wand'ring steps and slow,/ Through Eden took their solitary way"), they carry with them all the pathos of suddenly abandoned children. They have no mother, presumably, and their Father is dead to them. Worse yet, they are wise orphans; they recognize their own culpability in their loss. Cosmically amplifying their sorrow is the sickening, banal, no-way-back knowledge that they've brought their banishment on themselves. Daddy took the T-Bird away. But we should never have been driving it in the first place.Yet for English speakers, it's in classic Anglo-American fiction—in the novel, say, from Daniel Defoe, Aphra Behn, Samuel Richardson, and Henry Fielding to Dickens, Eliot, Twain, James, Woolf, Hemingway, and the rest—that the orphaned, or semi-orphaned, hero or heroine becomes a central, if not inescapable, fixture. Something about the new social and psychic world in which the realistic novel comes into being in the late 17th and early 18th centuries pushes the orphan to the foreground of the mix, makes of him or her a strikingly necessary figure, a kind of exemplary being. (By "orphan" I likewise include those characters—call them "pseudo-orphans"—who believe themselves to be orphans, but over the course of the narrative discover a mother or father or both.) So memorably have these "one of a kind" characters been drawn, we often know them by a single name or nickname: Moll, Tom, Fanny, Becky, Heathcliff, Jane, Pip, Oliver, Ishmael, Huck, Dorothea, Jude, Isabel, Milly, Lily, Lolly, Sula.Even if you haven't read the books in which these invented beings appear, you've probably heard of them and their stories; may even have a rudimentary sense of what they are like as "people" (self-reliant, footloose, attractive, curious, quick-thinking, lucky, tricky, a mischief-maker, the proverbial black sheep ... and so on). Alarmingly enough, orphaned protagonists appear regularly in stories written explicitly for children: Witness Little Goody Two-Shoes, Pollyanna, Heidi, Little Orphan Annie, Kim, Mowgli, Bilbo, Frodo, Anne (of Green Gables), Dorothy (she of Toto and Auntie Em), Peter (as in Pan), Harry (as in Potter). And needless to say, these parentless juveniles are usually the heroes or heroines of the books in which they appear. They may be wounded or fey or uncanny (what do we make of the vacant circles that Little Orphan Annie has for eyes?), yet they are also resilient, charismatic, oddly powerful.•Thus the first of two big lit-crit hypotheses I'll advance here: More than love, sex, courtship, and marriage; more than inheritance, ambition, rivalry, or disgrace; more than hatred, betrayal, revenge, or death, orphanhood—the absence of the parent, the frightening yet galvanizing solitude of the child—may be the defining fixation of the novel as a genre, what one might call its primordial motive or matrix, the conditioning psychic reality out of which the form itself develops.Now, even though I've made a talking point of it, what's important here is not merely the frequency with which orphaned heroes and heroines appear in fiction since the 18th century. Yes, from Ian Watt's The Rise of the Novel onward, the phenomenon has inspired some brilliant commentary. In one of the most profound books on fiction ever written, Adultery in the Novel, Tony Tanner associates the orphan trope with the early novel's tendency toward diagetic instability—its ambiguous, unsettled "ongoingness" and resistance to closure:The novel, in its origin, might almost be said to be a transgressive mode, inasmuch as it seemed to break, or mix, or adulterate the existing genre-expectations of the time. It is not for nothing that many of the protagonists of the early English novels are socially displaced or unplaced figures—orphans, prostitutes, adventurers, etc. They thus represent or incarnate a potentially disruptive or socially unstabilized energy that may threaten, directly or implicitly, the organization of society, whether by the indeterminacy of their origin, the uncertainty of the direction in which they will focus their unbonded energy, or their attitude toward the ties that hold society together and that they may choose to slight or break.Like the Prostitute or Adventurer, the Orphan embodies the new genre's own picaresque "outlaw" dynamism.Precisely because the 18th-century orphan-hero is usually untried, unprotected, disadvantaged (not to mention misinformed or uninformed about his or her parentage), he or she can function as a sort of textual free radical: as plot-catalyst and story-generator—a mixer-upper of things, whose search for a legitimate identity or place in the world of the fiction at once jump-starts the narrative and tends to shunt it away from didacticism and any predictable or programmatic unfolding of events.A flagrant example of such jump-starting occurs in Defoe's Moll Flanders (1722). Here it is precisely the eponymous heroine's putative orphanhood (she knows only that her mother, whom she presumes to be dead, was a thief and gave birth to her in Newgate Prison) that catalyzes, among other scandals, one of the novel's most titillating (if outlandish) episodes: Moll's shocking marriage-by-mistake to her own brother. (Only well into their marriage, after she and her brother have several children, will Moll realize that her chatty mother-in-law, his mother, is also her mother—long ago transported to America, but still alive and flourishing.) Defoe purports to moralize in Moll Flanders—in his Preface he describes his narrative as free of "Lewd Ideas" and "immodest Turns"—a work "from every part of which something may be learned, and some just and religious inference is drawn." Yet bizarrely, through some inscrutable narrative magic, the very mystery in which Moll's birth is shrouded triggers one of the novel's most perverse and sensational incidents. What on earth are we meant to "learn" from it? Don't ever get married, in case your spouse is really your long-lost brother or sister?Yet Moll Flanders also illuminates a perhaps more profound aspect of the orphan narrative: its austere embedding of a certain hard-boiled psychological realism. Even when the hero or heroine recovers a lost parent, that person can shock or mortify. The "orphan mentality" can persist, alas, post-reunion. Thus Moll finds out that, yes, as she's been told, her mother is a raddled old Newgate jailbird, with the livid mark of the branding iron on her hand. Now, for most of us, such a revelation—even barring incestuous ramifications—would be disillusioning, to say the least. Imagine: After years of loneliness, of longing for a tender maternal embrace, you finally, miraculously, locate your birth mother: She turns out to be a convicted felon. A whore. A liar and check-kiter. A crystal-meth addict. No help there; she's way worse off than I am.•Freud famously described the "family romance" as the childhood fantasy that one's parents aren't,in actuality, one's real parents—that one was switched in the cradle, left in a basket on the doorstep, found under a cabbage leaf or the like, and that one's real father and mother are persons of great wealth, beauty, and high station, a king and queen, perhaps, who will someday return to reclaim you and love you in the way you deserve. He thought such fantasies especially likely to develop at the birth of a sibling, when anger at the parents—for introducing a presumably odious rival into the family circle—is at a height. Real parents are disparaged; imagined parents idealized. The scenario in Moll Flanders reads like a sendup of the Freudian romance: almost a spoof on it. It's not simply that the lost-and-found parent turns out to be disappointingly "trashy." She's quite shockingly trashy—sneaky, disingenuous, a terrible old crone with false teeth, sleazier than you even thought possible. But you're stuck with her, it seems, for life, unless you can find a way to write her back out of your story.If one wanted to be fancy, one might dub this familial antiromance the "emotional drama of the post-Enlightenment child." Moll does not cease to be "orphaned" having rediscovered her mother; on the contrary, she abandons her (and the brother-husband), and resumes her solitary adventuring. And while she will re-encounter the brother later—indeed inherit the Virginia plantation he and the mother have established—Moll never sees her mother again. The maternal reappearance alters little or nothing in the heroine's inner world: Psychologically speaking, Moll is as alone at the end of the fiction as she was when she started. She's what you might call a self-orphaner, an orphan by default. Evasive, secretive, deeply intransigent—one of life's permanentorphans.In the broad, even existential, sense of the term I deploy here, orphanhood is not necessarily reducible to orphanhood in the literal sense. At least metaphorically, virtually any character in the early realist novel might be said to be an orphan—including, paradoxically, many of those heroes and heroines who have a living parent (or two), or end up getting one, as Moll Flanders does. A feeling of intractable loneliness—of absolute moral or spiritual estrangement from the group—may be all that it takes. You don't need to have been abandoned by a parent in the conventional sense, in other words, to feel psychically bereft.Indeed, from a certain angle—and thus my second big lit-crit hypothesis—the orphan trope may allegorize a far more disturbing emotional reality in early fiction: a generic insistence on the reactionary (and destructive) nature of parent/child ties. The more one reads, the more one confronts it: Whatever their status in a narrative (alive, dead, absent, present, lost, found), the parental figures in the early English novel are, in toto, so deeply and overwhelmingly flawed—so cruel, lost, ignorant, greedy, compromised, helpless, selfish, morally absent, or tragically oblivious to their children's needs—one would be better off without them. You might as well be an orphan.Julia Kristeva remarks somewhere (my wording may not be exact) that "in every bourgeois family group there is one child who has a soul." And thus we meet them, in novel after novel: not only those who go literally motherless and fatherless, but also the children "with souls" who, for precisely that reason, will be persecuted by their foolish parents or parental stand-ins; ostracized, abused, made to submit to some hellish moral and spiritual reaming-out. Ruthlessly, imperviously, the realistic novels of the 18th and 19th centuries compulsively foreground this "orphaning" of the psyche; shape it into parable, and in so doing (I think) dramatize the painful birth of the modern subject—that radically deracinated being, vital yet alone, who goes undefined by kinship, caste, class, or visible membership in a group.Witness, for example, the predicament of the eponymous heroine at the outset of Samuel Richardson's august and appalling masterwork, Clarissa. (Published in 1748, Clarissa, for those of you who haven't read it, is the greatest novel ever written in any language.) Now although the young and virtuous Clarissa Harlowe has grown up, presumably happily, at Harlowe-Place surrounded by her "friends"—i.e., both of her parents, two siblings, and several uncles—as the novel opens, she's just been "orphaned" in the emotional sense: profoundly, inexplicably, and shatteringly rejected. (Ironically, the word "friend" in the 18th century can not only mean someone outside the family circle whom one likes or loves, but also a member, simply, of one's immediate family circle.) When Clarissa refuses to marry the man of her father's choice, a rich and grasping Gollum-like creature named Solmes (one always imagines him with webbed feet), her "friends" morph abruptly, and nightmarishly, into domestic dungeon-masters. They revile Clarissa and threaten to disown her; they lock her up in her room for days and refuse to see her or read her letters; they forbid her contact with anyone who might help her; her father curses her. As they prepare to marry her off to Solmes "by force," she seems ever more like one of the victim-children in fairy tales, the designated family sacrifice.Now Richardson critics over the past few decades have tended to skate past these terrifying opening scenes in order to concentrate on Clarissa's sufferings later at the hands of Lovelace, the charming sociopath and would-be rescuer who seduces her. Yes, Lovelace's depredations later are spectacular and obscene—he kidnaps her, drugs her, rapes her while she is drugged, and ultimately hounds her to death. Yet even before Lovelace enters the novel (or so I have always felt), Richardson has already saturated the novelistic mise-en-scène with an even more unnerving and absolute kind of horror. "Home" is the primordial horror-show in this novel—a place of dehumanization and soul-murder from which the child, to save herself, must somehow escape. Count the Harlowes, likewise, among the ghastliest fictional parents outside Greek tragedy—all the more so because they speak the language of sentimental bourgeois feeling. Even as they subject their daughter to unspeakable torments, they "love" Clarissa, they say; that is why she must be so brutally forced to obey.Yet one finds these dire mamas and papas everywhere in early fiction—even comic fiction. They are omnipresent in works by Fielding, Smollett, Burney, Horace Walpole, Mary Shelley, and Ann Radcliffe. Even Jane Austen, arguably, offers an indictment of parents as harsh as that in the Gothic fiction of Shelley or Radcliffe. Witness the foolish, manipulative, greedy, or otherwise profoundly unsatisfactory mothers and fathers in Northanger Abbey, Pride and Prejudice, Mansfield Park, Emma, Persuasion. Austen typically veils the inadequacy, even malice, of her fictional parent-figures by festooning them with comic trappings: We laugh at the absurd Mrs. Bennet, the whinging Mr. Woodhouse, even the monstrous Sir Walter Elliot—the vain, pomaded, rank-obsessed father of Anne Elliot, heroine of Persuasion. (Mothers are often long-dead in Austen, and as in many other works by women from the period, the heroine is obliged to live with a cold, oppressive, or dissociated father.)In real life, having any of these narcissistic nongrown-ups for a parent would be a nightmare come true. They induce bewilderment and a sense of genetic incommensurability. How can Emma—brilliant, coruscating, kind—be the child of the dull, mewling, psychotically self-centered Mr. Woodhouse? Austen's heroines, in particular, are often especially changeling-like—sleek, witty, perceptive misfits, who appear oddly unintegrated into whatever (usually reduced) version of the family unit the novelist has devised for them.What to do with the parents who fail us so abysmally? Perhaps the most drastic solution is to imagine a fictional world from which parents have simply been erased—psychically blanked out—absolutely, and long in advance of any narrative unfurling. Charlotte Brontë's books are a terrifying case in point. They project worlds in which estrangement, loss, and silence about the past seem the precondition for narrative itself. Brontë omits the "back story"—or provides only a fatally impoverished one. Neither of her best-known narrators, Jane Eyre and Lucy Snowe, has a living father or mother: Jane's parents have died of typhus; of Lucy's we know nothing at all. Both heroines seem to emerge out of, and continually slip back into, an amorphous, staggering, irrevocable loneliness. One senses in their aphasia about the past some suppressed horror. Reading Lucy's glassy-eyed narrative, in particular, is like listening to someone who's had a head injury, or suffers from post-traumatic amnesia.We quickly learn not to expect any answers; some submerged trauma is itself the given, the starting point. Crucial information will never be forthcoming. For these are orphan-tales, drawing us, ineluctably, into a domain of emptiness and pain. Yes, Jane Eyre and Lucy Snowe may know their own names—first and last both. (Many fictional orphans don't.) But, affectively speaking, everything else has gone blank. The system crashed long ago. Not only have they no parent or guardian to point to, they seem to have no idea—emotionally, spiritually—what words like "mother" and "father" might mean.•So what—you may be wondering—has all this gloomy business to do with my frantic, ambitious, madly multi-tasking students? With helicopter Moms and Dads? With so-called Velcro parents? The ones who keep messaging 24/7? Surely I don't wish to link all the ultra-depressing things one encounters in literature—O, the horror, the horror, etc.—with the banal, addictive, anodyne back-and-forth of contemporary student life? Hello, you have 193 new messages. Checking for software updates. Your start-up disk is almost full. Hey, it's Mom. I was just wondering if you'd had time yet to. ...Or do I?My answer must be both circumspect and speculative. I don't wish, on the one hand, to sound like someone nostalgic for pain—a relic, a loneliness-junkie, a cheerleader for real-world orphanhood, or (when you get right down to it) a proponent of Orestes-style matricide or patricide. (Not usually, anyway.) On the other hand, I can't help but wonder if we haven't lost the thread when it comes to understanding part of what a "higher education" ideally should entail. Pious college officials yammer on about the need for students to develop something they (the officials) call "critical thinking" and thereby gain intellectual autonomy: a foothold on adulthood. But I'm wondering if it isn't time to reaffirm an idea that "critical thinking" begins at home, or better, withhome—which is to say, that each of us at some point needs to think (dispassionately, daringly) about the "homes" from which we emerge and what we really think of them.Do you owe your parents your obedience? Your deference? Your love? Your phone calls? The questions sound harsh because they are. But our Skype-ridden times may require a certain harshness.Some of the primal myths of our culture—as the greatest artists and writers have always intuited—seem to authorize violence, real or emotional, between the human generations. Francisco Goya's sublime and horrific masterpiece, "Saturn Devouring His Son" (ca. 1819-23), depicts a shocking event in Greek mythology—the cannibalistic murder by the primeval Titan god Kronos (Saturn, in the Roman version) of one of his children. Having received a prophecy that he will be overthrown by one of his own offspring, Kronos devours each of his five children at birth. His wife Ops manages to save their sixth child, Zeus, only by hiding him away on Crete and feeding Kronos a stone in swaddling clothes in place of the newborn. Kronos is fooled and later, this same Zeus, father of the new Olympian gods, overthrows his father, as predicted.An image to shock and awe, undoubtedly, but also one of the great paintings made in that period we call the Enlightenment: that revolutionary era (say, roughly, 1660-1820) during which—for better or for worse—Western culture began to shake off some of the more baleful and stultifying aspects of the Judeo-Christian past and reimagine itself as "modern."The central insight of the period? It's so familiar to us, perhaps, that we have lost sight of its momentousness: that individual human beings are endowed with critical faculties and powers of moral discernment, and as a result, have a right, if not the obligation, to challenge oppressive, unjust, and degrading patterns of authority. Over the course of the 18th century and into the 19th, more and more educated men (and a few brave women) felt intellectually empowered enough to criticize previously sacrosanct "received ideas": traditional religious beliefs, established forms of government, accepted modes of social, legal, and economic organization, the conventional dynamics of family life, relations between men and women, adults and children—all those cognitive grids through which we customarily make sense of the world.At its most potent, the critique was severe—world-changing. A host of Enlightenment freethinkers—Voltaire, Diderot, Rousseau, Hume, Mary Wollstonecraft, Adam Smith—articulated it in passionate and various ways: that the venerable cognitive models human beings had mobilized over the centuries to explain "the nature of things" were often nothing more than self-reinforcing and barbaric "superstition." Taken for dogma, these man-made belief systems had produced a host of ills: savage religious and political strife, the commercial exploitation of the many by the few, the enslavement and genocidal killing of masses of people, the degradation of women, children, animals, and the natural world—century upon century, in fact, of unfathomable global suffering.In his iconic essay of 1784, "What is Enlightenment?" Immanuel Kant put it thus:Enlightenment is man's emergence from his self-incurred immaturity. Immaturity is the inability to use one's own understanding without the guidance of another. This immaturity is self-incurred if its cause is not lack of understanding, but lack of resolution and courage to use it without the guidance of another. The motto of enlightenment is therefore: Sapere aude! Have courage to use your own understanding!Not that Kant imagined any cultural enlightenment to be easy or bloodless—especially given the seemingly intractable human proclivity for business as usual:Laziness and cowardice are the reasons why such a large proportion of men, even when nature has long emancipated them from alien guidance, nevertheless gladly remain immature for life. For the same reasons, it is all too easy for others to set themselves up as their guardians. It is so convenient to be immature! If I have a book to have understanding in place of me, a spiritual adviser to have a conscience for me, a doctor to judge my diet for me, and so on, I need not make any efforts at all. I need not think, so long as I can pay; others will soon enough take the tiresome job over for me.I confess: I first read those words over 25 years ago, and they have never ceased to thrill me.I understand the orphan-narratives of literature the same way I do Goya's painting and Kant's exhortation: as imaginative vehicles designed to shock us into "critical thinking" about those Titan figures we call our parents, and the larger psychosocial forces they so often (wittingly or unwittingly) represent. The intimate authority of parents is, after all, the first kind of authority most of us experience; the parental command the first utterance we recognize as that which must be obeyed. Pain and suffering, we soon learn, will result from our disobedience.And soon enough, most of us become adept at shaping our wishes according to a system of superimposed demands. We learn as young children to control the way we eat, drink, and eliminate waste; we learn to clean our own bodies; we learn under what circumstances it is appropriate to yell or scream or cry, and when we must be silent. Later on, "adult" society will impose further, ever more complex demands. Thus we internalize all those second-order codes of behavior associated with the educational, political, religious, and economic domains within which we all attempt to function, with lesser or greater success.Yet might it not be the case that true advances in human culture—the real leaps in collective understanding—typically result from some maverick individual action—some fundamentaldisobedience on the part of the individual subject? Such maverick actions often disturb—precisely because they need to get our attention. We have to be jolted out of complacency. The greatest artists invariably disrupt and disturb in this way. Like many of the novelists I've been describing, Goya gives us a shocking scene of intergenerational violence—but he does so, precisely, I wager, to force us to confront some of the deepest and hardest feelings we have—about parental authority and its rightful scope, about family violence, about the power of the old over the young, about the role of paternalism in society and government, about whether or not, indeed, those people we designate as "fathers" (priests, doctors, political leaders, scientists) or "mothers" (nurturers, apple-pie makers, self-sacrificing soccer moms, iPhone FaceTime partners, Mama Grizzlies, Tiger Mothers) really Know Best, about whether it is incumbent upon us to exert ourselves against them.You don't have to be a professor, I think, to see Goya as a radical naysayer—a human being horrified by a certain bestial and soul-destroying kind of parental authority. The focus in the "Saturn" painting is on paternal despotism; but elsewhere in Goya's oeuvre we find, too, a frightful bevy of murderous mothers—notably in Los Caprichos (1799), a suite of fantasy-engravings depicting monstrous witches, crones, goats, and owls engaged in child-torture of different sorts. The questions Goya raises remain awful and unremitting, more than 200 years later. Is the rule of life eat or be eaten, even if what you consume is your own child? (One of the most terrible things about "Saturn Devouring His Son" is surely the fact that the headless, half-eaten "child" has the proportions not of a newborn infant, but of an adult human being.) Should we resist our creator's authority? When and how and why? Or should we let ourselves be murdered in his name? When and how and why?Such questions lie at the heart of great literature too. What the early novel dramatizes, it seems to me, is nothing less than a radical transformation in human consciousness—the formation of a new idea. For better or worse, the ferocious, liberating notion embedded in the early novel is that parents are there to be fooled and defied (especially in matters of love, sex, and erotic fulfillment); that even the most venerated traditions exist to be broken with; that creative power is rightly vested in the individual rather than groups, in the young rather than the old; that thought is free. The assertion of individual rights ineluctably begins, symbolically and every other way, with the primal rebellion of the child against parent.So where are we today? Are we in the midst of some countertransformation? A rolling back of the Enlightenment parent-child story? Are we returning to an older model of belief—to a more authoritarian and "elder centric" world? The deferential-child model has dominated most of human history, after all. Maybe the extraordinary Enlightenment break with the age-old commandment—honor thy father and thy mother—was temporary, an aberration, a blip on the screen.My own view remains predictably twisty, fraught, and disloyal. Parents, in my opinion, have to be finessed, thought around, even as we love them: They are so colossally wrong about so many important things. And even when they are not, paradoxically, even when they are 100 percent right, the imperative remains the same: To live an "adult" life, a meaningful life, it is necessary, I would argue, to engage in a kind of symbolic self-orphaning. The process will be different for every person. I have my own inspirational cast of characters in this regard, a set of willful, heroic self-orphaners, past and present, whom I continue to revere: Mozart, the musical child prodigy who successfully rebelled against his insanely grasping and narcissistic father (Leopold Moz­art), who for years shopped him around the courts of Europe as a sort of family cash cow; Sigmund Freud, who, by way of unflinching self-analysis, discovered that it was possible to love and hate something or someone at one and the same time (mothers and fathers included) and that such painfully "mixed emotion" was also inescapably human; Virginia Woolf, who in spite of childhood loss, mental illness, and an acute sense of the sex-prejudice she saw everywhere around her, not only forged a life as a great modernist writer, but made her life an incorrigibly honest and vulnerable one.In a journal entry from 1928 collected in A Writer's Diary, Woolf wrote the following (long after his death) about her brilliant, troubled, well-meaning, tyrannical, depressive, enormously distinguished father—Sir Leslie Stephen, model for Mr. Ramsay in To the Lighthouse and one of the great English "men of letters" of the 19th century:Father's birthday. He would have been 96, 96, yes, today; and could have been 96, like other people one had known: but mercifully was not. His life would have entirely ended mine. What would have happened? No writing, no books—inconceivable. ...The sentimental pathology of the American middle-class family—not to mention the mind-warping digitalization of everyday life—usually militates against such ruthless candor. But what the Life of the Orphan teaches—has taught me at least—is that it is indeed the self-conscious abrogation of one's inheritance, the "making strange" of received ideas, the cultivation of a willingness to defy, debunk, or just plain old disappoint one's parents, that is the absolute precondition, now more than ever, for intellectual and emotional freedom.

Almost 50% of US specialists presently report rewarding patients through telemedicine (otherwise called telehealth), as per an ongoing overview by Merritt Hawkins in a joint effort with The Physicians Foundation. Telemedicine isn't really another thing; specialists have been offering phone discussions for quite a long time. Be that as it may, the COVID-19 period has brought telemedicine to the cutting edge of medicinal services. Until there's a demonstrated treatment or antibody for the new coronavirus, getting clinical guidance, looking at indications, or going for a test remotely may be a reality for huge numbers of us. This is what specialists who practice telehealth need you to think about it.What is telemedicine?Telehealth is more straightforward than it sounds. Fundamentally, you get a meeting or a meeting with your PCP via telephone or by means of an online video stage like Skype, FaceTime, or Zoom. Consider it a "virtual visit" with your medicinal services supplier.Before COVID-19, New York City-based gynecologist Rebecca C. Brightman, MD, colleague clinical teacher of obstetrics, gynecology and conceptive medication at the Icahn School of Medicine at Mount Sinai, offered telephone counsels to patients. Be that as it may, since the episode, she's offered the two conferences and arrangements through telephone or webcam. "I offer both to my patients—it's up to them whether they need the up close and personal cooperation," she tells Health.Orthodontist Heather Kunen, DDS, prime supporter of dental practice Beam Street, in New York City, is another specialist who has grasped telehealth. "Before the COVID-19 pandemic, my office had been thinking about joining virtual Invisalign conferences as a component of our rundown of administrations," she tells Health. "The lockdown/stay-at-home requests roused us to formally actualize the virtual assistance utilizing Zoom."Most medicinal services suppliers are truly adaptable with regards to advanced stages. "Utilizing FaceTime is a basic choice for those with an iPhone, and Skype works extraordinary too," pediatric urologist Jay Levy, MD, who is a clinical executive at Aeroflow Healthcare, tells Health. "Numerous suppliers additionally offer an electronic clinical record framework, as Home, where patients can check in on the web and interface with their primary care physician."Different social insurance stages are accessible to interface patients remotely with the correct clinical suppliers, for example, Walgreens Find Care, which likewise offers a virtual drug store to the individuals who need to have their solutions filled and conveyed.What do I have to do telemedicine arrangements?In case you're content with a telephone meeting, all you need is a telephone. On the off chance that you'd lean toward an eye to eye counsel, you'll need a cell phone, tablet, or a PC with a webcam. To guarantee a positive, profitable telemedicine experience, Dr. Duty says the most significant thing is to check your WiFi is working appropriately. "Perhaps the greatest issue is an arrangement being diverted at last dropped because of helpless WiFi availability," he says.Similarly as you have a private, calm space when you meet with your human services supplier in their office, it's a smart thought to do likewise at home. Dr. Duty recommends a sufficiently bright space where you're not prone to be upset. On that note, it's a smart thought to give others access your home know early that you'll be inaccessible during your arrangement time period.Some other planning, for example, checking your weight or your temperature, truly relies upon the particular wellbeing addresses you have. To give your primary care physician a precise wellbeing history, observe any indications and their span, Kevin Ban, MD, boss clinical official at Walgreens, tells Health.Do all insurance agencies spread it?Not really. "As telehealth has gotten considerably increasingly basic to help address clinical requirements during the coronavirus episode, the administration, wellbeing plans, and suppliers have started organizing new approaches and mechanical advances to make it progressively open to patients the country over," says Dr. Boycott. For example, the government as of late passed enactment extending the accessibility of administrations gave through telehealth under Medicare.At the point when you call the specialist's office to make or affirm an arrangement date and time, staff will confirm your protection, make any essential updates and, if appropriate, take installment for your co-pay via telephone, Dr. Toll says. All things considered, avoid any and all risks by asking your medicinal services supplier or their office staff about inclusion before you plan an arrangement, or what the all out cost will be.What occurs during a telemedicine arrangement?During a telehealth interview, Dr. Brightman asks her patients inquiries about their clinical history and current side effects to choose the best course of treatment. She never requests that a patient undress, however they can send her a photograph (with no identifiers) in the event that they are worried about an obvious finding. "This can assist me with making a determination and work out whether it very well may be dealt with remotely or requires an office visit. "Ordinarily, no one else is available when I have a telemedicine visit," she includes.In the event that she concludes that a patient needs a test, she urges them to go to the workplace, where the sum total of what safety measures have been taken with respect to social removing, hand cleanliness, and individual defensive gear (PPE) where proper.Dr. Kunen begins a Zoom interview by asking her patient what their main concern is. She at that point looks at their teeth and dissects their chomp before giving a conclusion. "I clarify the Invisalign item and procedure to the patient and answer any inquiries they may have," she says. After the counsel, the training's treatment organizer contacts the patient to talk about financials and the following stages.When would it be a good idea for me to stay with an IRL visit?"Telemedicine can bolster numerous intense consideration needs and diseases, yet it's not fitting in certain conditions," says Dr. Boycott. "For instance, patients can't experience methodology or get imaging tests remotely." And telemedicine is never a swap for an in-person arrangement for patients who are very sick and require earnest clinical consideration, or who have side effects that could demonstrate a genuine and pressing issue.Dr. Brightman has performed conferences by means of telemedicine for the administration of menopausal side effects and excruciating periods and family arranging, just as to treat urinary tract and different diseases. Some obstetrics visits should likewise be possible basically, with ladies checking their circulatory strain and weight at home. However, Dr. Brightman says there are times when an in-office visit is fundamental, for example, unusually substantial draining and STI screening.With regards to dentistry, practically all techniques will require an in-person visit at some phase to let the dental specialist complete any physical work that should be finished. While minor crises like a messed up section or a jumped out wire can frequently be settled briefly at home by means of virtual direction by an orthodontist, point by point clinical perception and explicit conclusion must be done face to face, says Dr. Kunen.What are the disadvantages?While telemedicine offers eye to eye communication with human services suppliers—which is vital at a time this way, when necessities are fundamentally high because of the COVID-19 pandemic—recollect that it has impediments."Doctors can depend on patients to take their temperature, anyway things, for example, pulse and lab work all depend on nursing staff," says Dr. Toll. "It's additionally difficult to reproduce the hands-on component of a standard office visit. Without the capacity for the specialist to contact or feel the patient, it is once in a while progressively hard to figure out what the real issue is."Dr. Kunen concurs that telemedicine solutions might be fairly constrained as far as what can be cultivated, yet she trusts it's "a brilliant aide to present day practice." And during this remarkable time, when numerous individuals will most likely be unable to (or need to) go to an in-person visit, a virtual one is an extraordinary option as a rule. "Going ahead, I think telehealth will stay a significant segment to every clinical practice," she says.