All Complications Great and Small

It was a good book, but I think it fell short of my expectations after seeing on the cover that it was a National Book of the Year Finalist. The beginning was great, the end really had me turning the pages to see if the case was a zebra or a horse, but the middle seemed to simply contain filler material: Friday the 13th?, rare and idiopathic cases? I guess to me they didn't really fit the title of the book.

The topics you have brought up for discussion have been interesting to consider from the viewpoint of a veterinarian, especially the idea of death panels and "doctorly manipulation".
The first several months that I was in practice I kept a tally of all of the animals that I euthanized, kind of like a fighter pilot might keep a running tally of the enemy planes he shot down. I know that might sound bizarre or morbid, but I guess that was my crazy way of dealing with a very emotionally difficult part of the profession. I have a friend who wanted to be a veterinarian, but she couldn't handle the idea of "putting an animal to sleep." She is now a human anesthesiologist. Ah, the irony.
Related to dealing with euthanasia is the art of "doctorly manipulation." It is amazing how attached people can become to their pets, and yet how removed they can be of the reality of animal suffering. I believe it is often a case of denial. Deep down they know that their cat that is in terminal renal failure is wasting away and is suffering because of it, but they dread letting go of what is more a companion than a pet. And so it is the veterinarian's responsibility to open the eyes of the client. It is a very difficult dance of tactful discussion. Just as difficult are the conversations where there is a treatment available for a patient, but the client is not able to afford the treatment.

On the topic of misdiagnosis and inexperienced physician, I feel that has my name written all over it. There are internships and residencies available to veterinarians, and it is becoming more common for graduating a graduating veterinarian to pursue some area of specialization, but there are still many who go right out on their own after getting their diploma. Such was my route. I remember my first day on the job, I had passed my board exams, but my license had not yet arrived in the mail. I showed up to work a little early in order to make a good impression and make a few preparations for the day. None of the other veterinarians were there yet, so when one of the employees brought in her cat that had been attacked by a dog just before leaving for work, it was to me that she handed the animal. It is hard to put into words the feeling of inadequacy as she looked to me as THE veterinarian that would save her cat. Fortunately it wasn't too bad. I placed an IV catheter help stabilize the animal, and we cleaned up some of its wounds as we waited for the other doctors to show up for the day.
There were other moments where I didn't feel completely up to the task, but I did my best. With difficult cases, referral to a specialist in a neighboring city, wasn't much of an option because of financial restrictions or because of the distance to the specialist. I would sometimes purposefully leave my pen at my desk, so that when I was in the exam room and had little clue as to what I was dealing with, I would go to make a note in the patient's record and then tell the client, "Just a moment, I need to go get my pen," allowing me a couple of minutes to quickly look through one of the medical texts in the office. Another "trick" that I picked up in vet school: one of my professors was faced with a sick cow that required an operation that he had been taught, but had never performed. Just before he began the client asked, "Have you done this kinda thing before?" To which the vet replied, "Oh, I've done a number of them." After relating that story to us during a lecture, the professor grinned and said, "Zero is a number."
I surprised me how forgiving clients could be about my lack of experience. I believe that they understood the challenge in diagnosing a case where the patient can't talk and the resources are limited. I don't feel too much shame in admitting, "I don't know," because most clients don't expect the vet to know everything about every species of animal. Sometimes we have to figure it out as we go. There's a reason we call it "practicing medicine."

Wow, I can't believe how much I have rambled on here. Just one quote from the book before I end this post.
"Conscious learning becomes unconscious knowledge, and you cannot say precisely how." pg 21

2 follow-on comments on Complications

Thanks for all the great discussion on "Complications." Two follow-on points:

Peter - regarding checklists: I am absolutely a proponent of using checklists in medicine. I'm a doctor now, but I was an engineer first. When using humans to perform a task, you improve performance by putting in systems to minimize variation. Intel was great at this; whenever someone made a mistake, our first question was "is this something that could have been prevented by a systems improvement?" This did add sometimes cumbersome layers to a task, but results at Intel are phenomenal.

Back to medicine, this applies directly to Radiology. It can be crucial to have a pre-determined way to approach any given examination. We frequently fall victim to the "satisfaction of search," where a prominent positive finding prevents us from noticing the more subtle abnormalities in a study. Time after time in our M&M conferences, a missed diagnosis comes down to "I guess I just failed to look for _____." I believe that in reviewing a given type of radiology study, the radiologist should take precisely the same steps. I read recently about a hospital (Michigan) who improved radiology reporting by having pre-determined templates for all reports -- basically a checklist of "I checked this, and is was normal, I checked this, and it was abnormal." Many radiologists prefer to dictate their own personalized report, but the standardized report ensures that everything is looked at and reported.

Alvin - Regarding "Death Panels": Actually Becky is the one who came up with this recommendation. A good place to start would be requiring individuals to generate their living will and health care power of attorney documents in order to enroll in Medicare. This would have no effect on many patients, but does take the burden of decision off of the families who find themselves extending care because they don't know what's best for mom or dad, and don't want the burden of having "pulled the plug." And we do see living wills that say "any and all care" on them. Those are fine, too.

Less Complicated and More Anecdotal

In some ways, I think structural engineering and medicine are similar, If we make a mistake, people can die. I like to think that because of that, I have to do a good job. I know, doctors get all the glory, the fame, the TV shows, etc., but the hospitals they work in are designed with importance factors and stuff that makes their work environment safe--so that when other buildings collapse and people get hurt, the ER will be open and ready to help them.

Misdiagnosis
Because the likelihood for misdiagnosis seems to be more likely if the physician has less experience, this means, like many professions, that I want to choose the most experienced physician for what I'm dealing with. Personally, I've been frustrated by the young Physicians Assistants that we have seen that we've had to guide along to the correct diagnosis. I do find comfort in older doctors because it seems like they've seen it all. Surgeons—even more so. I want the guy who does 1000 operations a year as opposed to someone who occasionally does them. I think surgeons are generally aware of their capabilities and I'm glad for that. As an engineer, if I'm not capable of doing something, I recommend that the client uses someone else that can do the job properly. I know when my dad (an eye surgeon) saw a case he wasn't sure about, he'd send them to someone who would be.

Doctorly Manipulation:
“There are times when a doctor has to steer patients to do what's right for themselves.” and “Patients don't want the freedom we've given them.” I agree. I think it's often quite silly to give patients freedom. Again, as an engineer, if I say structure needs to be there, it needs to be there. If it isn't, when the office has a party and people dance where the structure isn't, they'll fall to their deaths (Hyatt Regency catwalk collapse). When I meet with a client who doesn't want the structure, I tell them they need it. I expect a doctor, usually more expert than me in medicine, to tell me when I need something. For example, we had a breech baby last time, and the doctor said, “we're going to do an ECV [turning the baby] and then induce”. My wife said, “well, we were thinking about doing the ECV and then letting the baby come naturally.” The doctor said, “ok” and would have let it end at that. But after asking him some more questions, we chose to do exactly what he initially recommended, and it was a good thing too.

I enjoyed the book very much. Thanks Doug.

The road, the man, and life

Some belated thoughts on the road:

I listened to this while on the road from Vegas to SLC. It was a dreary day, and the landscape through Nevada is very post-apocalyptic. Then the whole family got sick. I had a temporarily deep voice, and found myself talking like the narrator's voice for the man.

It made me think how even in the face of death (you ARE dying), we strive to live. Why? I don't think it's the fear of death—I'm not really scared of death, but I do want to live. Mostly because I enjoy life. I don't know if I would have this same desire if life weren't enjoyable. Because I really believe the next life is a continuation of this, often I find myself thinking, "oh, it would be okay if I died." I'm sure I would feel differently if I were the only source of protection for my children. It seemed the man had a stronger desire to live. It sure wasn't for himself, it was definitely to take care of the boy.

But the movie looks too scary for me.

Why'd You Have To Go And Make Things So Complicated?

Church was cancelled today due to icy conditions at 7 AM that were fine by the time church starts at 11, but it gives me some time to write. I really enjoyed the book Complications and Doug's thoughts. I will just add my comments on the topics Doug put out there.

1. The uncertainty in medicine - I enjoyed how the book portrays doctors as human, whereas we often give them superhuman powers in our minds. As Peter points out, we also do this with General Authorities, and to a lesser degree, I also catch myself doing this with car mechanics, reality TV stars, and politicians.

Before the US went to war in Iraq, I supported the action under the assumption that President Bush knew something that I didn't, something top secret that he just couldn't share with me. Similarly, I often assume that General Authorities know more than I do or have seen something that I haven't and thus they have more power to be spiritual. I thought plumbers knew more than I do, too, that I could never change a sink, until it was pointed out to me that they don't have advanced degrees. They just have more experience and the right tools. It's empowering to realize that I have just as much power and ability to do all of these things, IF I apply myself to learn the relevant skills and use the right tools (or if I invite Glenn over to help me change the sink).

2. Autonomy, consent, and the role of the patient - I have very conflicting feelings on this point. I believe that, as described by Gawande and Doug, patients often make very poor decisions, and particularly at the end of life, a lot of resources are wasted. Survival at all costs is not necessarily best for the community or the patient. Unfortunately, the only solution to this seems to be the dreaded 'Death Panels'.

As I read this book, I often thought about how the roles of doctors and patients compare to the roles of parents and children. Children often don't realize how human their parents are and how much uncertainty there is in what we do. And children may often make poor decisions, but after a certain age all parents can do is offer advice. Right now, my children are so young that my word is the law, but eventually, I'll have to grant them their agency and allow them to make poor choices, even if it's a waste of resources.

3. Top performers and practicing - That really is a great quote. I think Malcolm Gladwell (who was quoted on the book jacket of my copy of Complications) says something similar in his more recent book, Outliers. I think both Gladwell and Gawande are lucid, interesting writers.

4. Learning on the job - There is a lot of learning on the job and uncertainty in my profession, too, but the big difference is that I don't have a direct impact on the life or death of another person. (I may have an indirect impact in the approval or disapproval of a medical device, but I don't have to face them directly.) There may be mistakes in the learning process, but I don't see how the medical profession could do it any other way.

Speaking of my profession, though, I was happy to see that Gawande's attempt to use Decision Analysis didn't work because I think it's a bunch of bunk. It makes the process of arbitrarily assigning probabilities to different events seem scientific, when it's not. My boss is trying to get the FDA to use Decision Analysis on a wide scale, and I'm avoiding the meetings and hoping the movement dies quickly. I do believe that statistics has and will continue to help improve medical decision making, just not though Decision Analysis.

5. Medical errors and liability suits - I keep reading in multiple books how poor the litigation system is in preventing doctors from making mistakes. The worst doctors don't have the most lawsuits, and the best doctors still make mistakes. In the book, "Nudge", the authors suggest that people should be able to waive their right to sue in order to get lower insurance premiums, but the courts and lawmakers for some reason don't think that people should be allowed to waive their rights to sue.

This is the issue that drives me the most crazy about the whole health care debate. If Democrats are truly serious about reducing the cost of health care, then putting a cap on the amount people can sue for seems like an easy way to start (the studies on this issue seem pretty unambiguous), but this issue hasn't even been part of the debate. It just makes me think that Democrats aren't really trying to help fix health care, that it's just politics as usual. (Note: On a broader note, I'm open to universal health care, though I'm skeptical of the government's ability to efficiently distribute health benefits.)

6. The man who couldn't stop eating - Doug says, "If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves?" I guess I'm more sympathetic than Doug to those that are not self-disciplined. I have a compulsion to play games/waste time when I should be working on my unfinished PhD research. Having tried and failed to change myself multiple times, you begin to stop trusting yourself when you say things are going to be different this time. If there were a surgical option such that I could get myself to always do what I thought was right, I would seriously consider it. (Of course, that may be Satanic of me to want to force myself to do good.)

And like the blushing example he gave, sometimes what outsiders perceive as a need to be more mentally disciplined is something rooted in a physical problem. Maybe we weren't born messed up, but perhaps the learned behaviors in childhood become hard-wired. I agree that as a society we are fat and lazy, as Doug said, and admittedly, whenever I see a morbidly obese person (there's one at work) I shudder and think, "Get a grip, Man!" Still, on paper, I'm hesitant to judge anyone too harshly.

Again, thanks Doug for the good read. I look forward to hearing everyone's comments.

Making a list, checking it twice...

I really enjoyed Gawande's book. I may read his follow-up Better: A Surgeon's Notes on Performance.

I agree with Doug that the central theme of the book is the essential human-ness of medicine, even surgical medicine. I have a couple thoughts on that front:

First, although Gawande talks about the dramatic improvement in mortality numbers among anesthesiologists, he doesn't to my recollection mention safety checklists (which is a bit odd, since Gawande has been a vocal advocate of such checklists; maybe he came to it after writing the book).

I was wondering what you think of checklists, Doug? My impression (and its nothing more than that) is that most surgeons view them as a hassle, something that is nice in theory but lousy in practice, not worth the effort, etc. And understandably so; I know the highly formalized type of check-list activities I do for work are an annoyance.

But I think the bigger issue is that perhaps doctors feel it is juvenilizing to have to run the checklist, that pride or ego maybe gets in the way. And not just for individual doctors, but sociologically within the subculture, making it difficult even for doctors who wouldn't mind running a checklist before surgery to do so in the face of colleague disapproval. I don't know; maybe all this is off-base, constructed more from fictionalized views of medicine than reality, but if it is reality I think it's a very understandable one, and one that fits with Gawande's larger narrative.

Second, I was talking with a ward member the other day about the book. Her husband is starting a two-year internship in pediatric radiology at Children's hospital in Boston. I wondered whether Americans have a tendancy to mythologize Doctors more than other cultures do, and thus have less tolerance for the human element of medicine. She said that she certainly feels that to be the case. She said she feels exactly the same sort of mistaken expectations when she tells people that her husband is a surgeon as when she tells people that her father-in-law is a General Authority.

I think we do mythologize doctors, and I think Gawande would like to temper that to some degree, and I think it is healthy to do so. I also think, however, that doctors (and society in general) also receive some benefits from that mythologizing inclination. Specifically, I think people are more likely to trust and have faith in doctors than they otherwise might. This goes to the patient autonomy question, I suppose. As Doug says, in some ways patients are terrible decision makers when it comes to their treatment options. Given the trend toward patient autonomy, eroding the myth of The Doctor could lead to even worse decisions on the part of the patient as they come to see doctors more and more as imperfect, fallible human beings. Perhaps this is why Gawande calls for a move back to the old model of doctors largely deciding what is in the patient's best interest.

One thing that Gawande didn't talk about that I think is particularly timely is the intersection of medicine and public policy. I was recently chatting with a friend who is an Air Force doctor. He went on at some length about the ways in which specialization is increasing, how it is driving policy more and more, and how general practioners are getting squeezed out as a result. His statement, if I remember correctly, is that because the Medicare advisory board is dominated by specialists, they are able to set rates that they feel are appropriate, which means the finite pot of money is increasingly split up with a bias toward recompensing specialists. This has echoes in the health care debate today as they talk about different payment models, like paying per positive patient outcome rather than per procedure. Anyway, not really on topic but something I find fascinating.

Thanks for the great read, Doug.

We've now reached the end of the second book club round. I think we should all take December off and start up again with a January selection. Anyone not on the following list who would like to make a selection, let me know either in the comments or via email: Peter, Alvin, Paul, Glenn, Rob, Doug, Jesse, Karl (Jesse and Karl, I know you've been quite busy with other things and haven't followed along with the book club this round. But if you have time I'd love to keep you in as making one selection, even if that's the only month in which you're able to participate. If you don't feel like you can do that, just let me know and we'll skip you this time around).

I'll give it until next week sometime for anyone who wants to to amend the list, then I'll use my patented, handy-dandy randomegizer to choose an order for the participants.

Glenn's thoughts on Millet's book

I really enjoyed the posts from you guys. I considered your comments and had drafted some responses to them, but that draft disappeared. If I find it someday I may post it. For now I will share with you things that I took note of during the first part of the book. Before I do so, let me just say that I was surprised when I started into the book, how general and broadly applicable the ideas were. I was expected Bro. Millet to say, "Now, when you get asked this by your non-member co-worker, this is what you should say." It's true that the book does contain some of that in later chapters, some of which I found interesting, some of which I have already forgotten. The most useful thing in the book, in my opinion, is that he suggests how to answer a question rather than trying to give us a script to use when answering a question. Teach them correct principles ...

Here are some quotes about faith and testimony that resonate with me, and are of value to me, especially since burying myself in research:

"A testimony is not something you either have or do not have. Rather, it is an impression of the Spirit about the truthfulness of eternal things, an inner awareness that ranges along a spiritual continuum from a simple peaceful feeling to a perfect knowledge" - pg 30

"I believe because of the epiphanies, small and large, that have intersected my path -- small discrete moments of grace when I have sensed a kind of superinteding presence outside of myself. I believe because these moments ... are too precious to discard, and I choose not to trivialize them by reducing them to rational explanation. I believe because, for me, the alternative to belief is far too daunting." - pg 34


I finished Complications this morning. I will read through Doug's post and try to get something equally worthwhile up here soon.

Complications

November's book: Complications, A Surgeon's Notes on an Imperfect Science

The first time I read this book I was pretty early in my medical training. It was fun to read it again after a few years, this time with a much different perspective. I have been there for many of the scenarios that Gawande describes, being as he was a resident. Anyway, I have my own medical opinion of what he has produced. I am interested to know how the rest of you felt about the points he made. Here are some topics of discussion, with my thoughts:

1)"The core predicament of medicine -- the thing that makes being a patient so wrenching, being a doctor so difficult, and being a part of a society that pays the bills they run up so vexing -- is uncertainty." (pg 229)

---This seems to be the theme of the entire book. Other than the "mystery" chapters where he details some rare and bizarre conditions, Gawande mostly seems to be explaining just how human modern medicine really is. In spite of all the advances of science, medicine comes down to a fallible doctor in a room with a patient -- and several unknowns.

Personally, I tend to agree. I of course have been working rather diligently (happy birthday, Alvin) for the past several years to learn things most people don't know. I think it's safe to say that I'm better than the rest of you at being a doctor. But in the end, I'm not really perfect at this -- nor will I ever be. I'm basicaly the guy with a competetive advantage for this field.

I remember prior to my mission, I thought there were people who spoke French and people who didn't. It was incredibly naive, but there it is. I remember listening to my MTC instructors use the language so freely, and I did my best to copy them. Even after I got to the country, I thought the more experienced elders were using perfect French. Only with time and experience (and actually a lot of dedicated study) could I recognize that probably 2/3 of the missionaries were finishing their mission with sub-standard French, and markedly American accents.

I think much of America has the naive thinking I used to have about language ability: "A board-certified physician is qualified to be my doctor." In reality, there are widely disparate levels of ability, care, and dedication - to say nothing of the unknowns we encounter no matter our ability. Back when I got into medical school, there were several people who advised me to work hard but not too hard -- "What do they call the guy who gets last place in his medical school class? . . . Doctor." That may be true, but the title only means so much. This goes to the malpractice comment later, but people expect doctors and medicine to behave like a robot and a factory. It's not that easy. "We look for medicine to be an orderly field of knowledge and procedure. But it is not." (page 7)

2) Autonomy, consent, and the role of the patient.

"The decision was Lazaroff's." (pg 210)
"Could it have been a mistake, then, even to have told him about the surgical option?" (pg 216)
"patients frequently don't want the freedom that we've given them." (pg 219)

---I'm curious how you feel about today's world of patient autonomy and informed consent. This idea, that the patient should approve all medical decisions, is strictly taught in our medical schools. It's one of the basic tenets of ethical medical practice -- as much as beneficence and nonmalfeasance. I personally met with about 30 patients yesterday to have them sign "informed consent" paperwork for interventional radiology procedures. The basic principle is that the patient must be of sound mind and aware of the risks, benefits, and alternatives of a procedure before allowing the doctors to proceed.

This all sounds great on paper, or in a courtroom. But personally I don't really like it. I essentially walk into room after room and say (not really here, folks; I'm using hyperbole to make a point...) "Mrs So-and-so, your doctor has asked us to place a stent in your liver. I'm going to ask you to sign a sheet that says we might kill you, but that you want us to proceed anyway. Of course we never try to kill people in our department, but there's always that one you didn't see coming..." That way, when the patient does die, we can point to our document as protection.

But only in extremely rare cases does the patient grasp what may or may not happen on our table today. And almost nobody can objectively detach themselves from the numbers. I can tell patients the odds that we'll cause internal bleeding, infection, and even death. Still, it almost never means they understand the best course of action. In the end, I get two types of people. 1- the patients who look at me with a carefree smile and say "where do I sign?" and 2- the patients who are shocked by all the complications I am forced to mention and sign with "if you really think this is the best thing for me." Interestingly, I have never personally encountered a patient who refused consent for a medical procedure that was recommended by their physician.

OK so there are some patients who are crazy and who refuse consent, but I mean normal people.

So I'm not saying that we should hide facts and decisions from patients. I do believe our current "autonomy" and "informed consent" framework is built around lawsuit protection rather than patient care. I think a more reasonable approach is to discuss the procedure with the patient, in as much detail as they desire, leaving the words "cardiac arrest," "brain injury," "loss of life," and others out of the discussion.

One other (very real today) problem with the "Patient Autonomy" movement is cost. We let patients dictate how much care they do or do not receive.

Wait... pause... My personal code of ethics and even religion are going to come out in this paragraph. Just bear that in mind; I would not and cannot force my feelings on someone else.

Where was I? We are all going to die. All of us. And experienced doctors can tell when you are on your way out. Almost universally, though, we don't recommend stopping care. We sugar coat things and give patients (or families) the sense that there is a better chance of recovery than there really is. So we talk to patients or their families about these expensive and likely futile options, again having the informed consent discussion. We basically leave it up to them if we continue "agressive" care or not. My experience is that almost no one can choose to give up. Either the patient doesn't want to give up(naturally), or the family doesn't want to live with the burden of "not having done everything we could." So the medical costs in the last year of life skyrocket.

Enough about that...

3) "Top performers dislike practicing just as much as others do. But more than others, they have the will to keep at it anyway."

---just like that quote.

4) "We find it hard, in medicine, to talk about this with patients." (page 23)
"No matter how accomplished, surgeons trying something new got worse before they got better." (page 30)

---Basically, I just like how he describes the learning process within medicine. Would you accept a "trainee" performing your procedure? Are you brave enough to ask your doctor how many of the procedures he or she has done, and would the answer change your willingness to let them proceed?

So for me personally, I take it as my professional responsibility not to touch a patient unless I know what I'm doing. So if I tell you I'm going to cut you open, you can rest assured I know how to do it right. It is true, though, that I don't have the experience that others may have. And when a rare complication occurs, my first move will be to find someone more experienced. This is also not fundamentally a problem of students/residents vs. certified physicians. I listened this morning to a discussion between a junior and senior faculty member in my department. A patient was scheduled with the younger doctor for a procedure he has not done often. The discussion dealt with whether to tell the patient of the doctor's inexperience or recommend the senior faculty member perform the procedure, among other options.

5) "To the public - and certainly to lawyers and the media - medical error is fundamentally a problem of bad doctors." (page 47)
"And a patient's liklihood of winning a suit depended primarily on how poor his or her outcome was, regardless of whether that outcome was caused by disease or unavoidable risks of care." (page 57)
"We are all, whatever we do, in the hands of flawed human beings. That fact is hard to stare in the face." (page 105)

---My wife is already wondering when I'm going to emerge from this entry, and you probably are too. Let me be brief:

When our oldest was born, my wife was given 10 times the correct dose of a medication. Her heart was overloaded, she went into "flash pulmonary edema," and spent the next day and a half on a ventilator. It was a blatant, clear-cut, medical error. My aunt, a hospital administrator, summed up several people's comments when she said that we should get our hospitalization for free, and could get a whole lot more.

We did nothing. Not because we were not harmed, but because I believed that everyone makes mistakes. The doctor, who was indeed responsible, was legitimately contrite. That was enough for me. In the moment, we were concerned about the long term implications -- not just for my wife but also for our family size due to the emergency C-section that was required. But even with all those emotions, I was more prepared to forgive than to litigate.

But, as the book does point out, people love to sue when the outcome is poor. And (some, not all) lawyers love to help them along.

6) The Man Who Couldn't Stop Eating

OK; we could do a whole discussion on obesity and appetite, but let me just say this much. I agree that some people have a pathologic compulsion to eat. That being said, I am not a fan of gastric bypass surgery. The bottom line is that you make it so painful to eat that the patient retrains themselve. Or rather, some patients. Far too many gastric bypass patients learn to accomodate the change and end up worse than before. In the meantime, you are taking some of the worse possible candidates to the OR and undergoing a surgery with a very real risk of death or disability.

If a person is so desparate to change, can they not dig deeply and find the motivation to change themselves? Gawande gives anecdotal reports of patients who could not possibly have improved without the surgery. I would counter his anecdotes with many others who (in the absence of a successful obesity pill) believe that surgery is easier than fixing their broken lifestyle.

We were not nearly as fat as a country 20 years ago, and again less so 40 years ago. I do not believe that appetite is new to our generation. We have just become too indolent to take care of it ourselves.

-------------

Anyway, I enjoyed this book. Share what you thought; feel free to use my discussion points or not.

For the Birthday Boy

Today is Alvin Cutler Van Orden's birthday. I'd intended (and still intend) to send him a package with three gifts. Since I got sick last week, the package is yet waiting to be assembled. In lieu of said package, I have assembled a simple cipher detailing the promised presents. I've embedded it in the absurdly forced paragraph below.

"Who enjoys bingo, war, uno, obsessive uno, DJs, and jedi-ing puzzles of risks? Alvin! Going jedi pleases, and so jump on your not-actual gift (if you can open it). Best, PBJ."

Sorry for the ridiculousness, but it seriously took me forever to come up with something into which I could embed the cipher. I also checked my journal for what I thought of Alvin back in the day. Here's what I had to say:

"Alvin is quiet, humble, intelligent, active spiritual and a great example...He's a really great guy and I've learned a lot about stretching my limits and magnifying my calling from his challenges to do push-ups, read scriptures, sing hymns, etc. He's a wonderful roommate."

Happy birthday, Alvin. Hopefully you crack the code before the present itself arrives.



P.S.- Here are a few cipher parameters that will simplify the decoding process: I/IV/I.

Canon, Doctrine, Truth and all that

I've been teaching Sunday School for the past year and half, and several of the issues raised in the discussion so far have come up repeatedly in class. I'll give my thoughts on just a couple.

1) Canon, doctrine and truth:
Millet, as Rob points out, gives a fairly simple test of what is "doctrine." Is it in the standard works? Is it in the teaching materials? Is it in recent conference talks? This is, to me, somewhat interesting. In his conception, "doctrine" is a superset of "canon" (which I take, I feel with good justification, to be the four standard works). He doesn't include (at least not explicitly) numerous other materials generated within the church like non-general conference talks (talks given at regional or stake conferences, for instance), church publication articles, books written by general authorities, Michael McLean soundtracks, and a host of other materials available from the church distribution center (with an easy to use order form sent out with your Ensign :)). He rather explicitly excludes arcane teachings, like the troublesome statements in the Journal of Discourse.

So, Millet proposes a two-tiered approach to the acceptability of teachings which I personally feel is over-simplifiedl; it's doctrine or it's not, with not much gray area in between. Perhaps he doesn't really feel this way, but believes its the simplest method of dealing with Christians unfamiliar with the various forms of church discourse, but I think it misses important points. Other Christians are very familiar with the "authoritativeness" questions; they get questioned again and again about why some verses in the Bible are "more true" than others. They also have to balance teachings of modern preachers against personal interpretations of scripture. It seems to me like approaching questions about arcane teachings of past prophets with that common framework is a better way to bridge gaps than to simply say "we don't teach that, so it isn't doctrine (even if one of our prophets once said it)."

2. Institutional versus Personal Revelation:
This builds a bit off the last point. The question often arises about where Truth lies, and how we can get at it. Rob mentions the promise, based on Sec 107 and backed up by many presidents of the church, that if you follow the majority of the twelve you will not go astray. That's comforting inasfar as it goes, and I have no intention of ever deviating from following the Apostles and Prophets. But...

Personal revelation must needs be in constant tension with institutional revelation. In theory it seems truth should be truth, regardless of how it is received. And we should always be able to pray and receive confirmation of revealed truths. Except often I've met sincere people who have struggled with contradictory revelations. Faithful members who pray and receive revelation that homosexuality is not a sin. Investigators who pray and receive revelation that the Book of Mormon is not true. And because of the primacy we give in the church to personal revelation I often have no recourse in such discussions but to bear my own testimony (that homosexuality is a sin, that the Book of Mormon is true) and assure them that somehow both things must be simultaneously true.

I could go on at length about truth and certainty and probably sneak in some Bayesian probability theory, but I won't.

3. Can truth change?
Faced with prophetic teachings about blackness and the mark of Cain or the essentiality of polygamy for exaltation or any number of other doctrines that were once widely believed by the church (including by its leaders) to be true and now are not, it seems to me that simply saying "that's not doctrine since we no longer teach it" is insufficient.

With regards to the practical aspects and policy positions of the church, I can understand how they might change. Men of African descent weren't given the Priesthood; now they are. There's no necessary contradiction between that and an unchangeable God revealing his will through Prophets if we accept that practices are often defined by the time in which we find ourselves (c.f. Word of Wisdom). I can reconcile things being "alright" at one point and "not alright" at another; their fundamental nature didn't change, but the environment surrounding them did, and the "goodness" or "badness" is inherently a factor of the interaction with the environment, not the object itself. Wow...that's way too unclear, even for me. Really I just mean that practices may change because of differences in the world where they occur, rather than with God.

But doctrinal statements aren't like practice (or, IMO they shouldn't be). I usually conceive of them as existing in a non-physical plane. So, for example, Millet's explanation that prophetic teachings of blood atonement were just overheated rhetoric originating from mid-19th century Mormon revivalism doesn't sit well with me. It cheapens doctrine, in a sense, making it instrumental rather than primal, as if the point of prophetic teachings isn't to illuminate, only to persuade to action. Maybe that's the right way to view it, but it will take me a lot of thinking and questioning before I'm willing to accept that model.

So this post makes it sound like I spend all my time questioning the fundamental epistemological soundness of the Church. I don't. Really, I think I've come to the same uneasy equilibrium as most of you. Some things don't make sense to me, but that's because of my limited perspective, and I'll just do my best to follow both the Prophets and my own conscience and hope they don't conflict too often. And if/when they do, I'll do my best to choose what's right and trust in God to deal with me justly.

If it ain't broke

I haven't read the book, but these posts have been intersting and refreshing to me, and I wanted to thank everyone for sharing.  I'd like to try to put into words my approach to handling tough gospel questions, which I'm sure bears some commonality with the approaches you all have shared.

I think I've gradually come to a position that is best described as a cross of "by their fruits you shall know them" and "if it ain't broke, don't tinker with it."  That is to say, I follow the gospel because I've seen it work countless times in so many lives--most importantly, my own.  To spend much time wrestling with peripheral church history or doctrinal issues is, for me, counter-productive.

This is not to say that I turn a blind eye to any and all hard questions, but rather to clarify that questions of historical authenticity and leadership fallibility tend not to worry me much, because my testimony of the gospel has almost nothing to do with either issue.

This perspective makes many members of the church uncomfortable.  As a church, we are brought up investing so much of our testimony in the tenet that God guides this Church directly through his prophets, that to question an apostle or even a general authority seems sacrosanct--as if we're questioning God Himself.  After all, if you start to question one thing that one prophet said, it's only natural to question other things other prophets said, including Joseph Smith.  It's a slippery and dangerous slope.

But that's where I find myself at times.  I have way too much trouble, for instance, justifying the withholding of the priesthood from blacks with some sort of hypothetical cost/benefit consideration that finally shifted 30 years ago.  Could there have been cost/benefit considerations at play in the mind of the Lord?  Yes.  But it seems equally likely to me that our prophets and apostles were/are susceptible to errors in judgment.

I don't believe that errors in judgment necessarily constitute fraud, even if an individual attributes the judgment to the Lord.  I think that all individuals, no matter who they are, have trouble differentiating sometimes between divine guidance and personal feeling.  And perhaps in some cases, the Lord achieves great works through individuals who are somewhat mistaken about what it is they are doing--e.g. is there any harm to the belief that, while Joseph Smith thought he was translating papyrus, in reality he was simply a conduit for scriptural material that the Lord wanted us to have?  Then again, I would not be surprised to find out that orthodox versions of problematic events are in fact authentic.  For example, I think there are enough plausible explanations out there that any rational person could reasonably entertain the idea that Joseph Smith actually translated the Book of Abraham.

So how do you know what is error and what is not?  Well, in many cases, it's irrelevant.  For example, how the Book of Abraham came to be does not change the real-life effect that the Book of Abraham has on me right now.  And therefore, it does not matter to me how the Book of Abraham came to be.  I do not need to have faith that the Book of Abraham is an 100% authentic translation, rather I just need to have faith in the teachings found therein.

What happens if I find myself at odds on a position that requires some sort of action (see my Prop 8 posts from last year).  Do I give the benefit of doubt to church leaders, even though my gut instinct is that they are wrong?  Or do I trust my gut and assume the leadership is wrong?  In either case, I think the willingness to admit to oneself that "the Church being true" is not synonomous with church leaders always being correct actually facilitates a very healthy response, as long as one is also willing to 1) admit as much or even more doubt in one's own opinion; and 2) not let the issue become a distraction from following more important teachings.

What would I do if I was at odds with a position that had a more personal impact?  I have, after all, core beliefs that I don't see myself ever changing.  And by core, I mean beliefs that have a real-life, personal impact, such as "thou shalt love thy neighbor as thyself."  I think it goes without saying that I would have to leave the Church if it ever expressly taught us not to love our neighbors.  I just have faith that I, personally, will never be at odds with the Church over those core beliefs.  But I know some people who have core beliefs that are fundamentally at odds with the Church, and I would think less of them if they stayed in the Church while having those beliefs.

Could the effect I perceive the gospel as having in my life be, as Alvin warns, a placebo effect?  I think any rational person has to admit this possibility.  Even though I have faith that the gospel isn't a placebo, it would be dishonest to myself not to leave my mind open to the possibility that my faith is misplaced.  But the anecdotal evidence seems to point to the fact that it isn't a placebo effect, and  I see no compelling reason to change my beliefs just to find out if there is a difference.

The biggest challenge to me has been figuring out how, approaching the gospel from this angle, I should approach interactions with others, both inside the church and outside.  How do I tell a new member, for instance, that of course the Book of Mormon is true, but it doesn't matter whether Joseph was really translating the Book of Abraham?  Do I just offer plausible explanations, and hope that they take one of those and run with it, or is there a way to help them see that the issue is, in reality, nothing more than a distraction?

"Finally" Getting at the Truth

I always seem to end up in conversations about my faith and its practices. Most often the discussions are amiable and uplifting. Occasionally they take a wrong turn and I or the other person take something personal and get a little defensive. When people ask me difficult to answer questions...I love it! My faith and understanding has increased and has become more deeply rooted. I seem to recognize God's hand more powerfully in the lives of people of other beliefs.

Ryan and Bro. Millet are good examples of reaching out to those of other faiths and building on common beliefs. I appreciate that aspect of this book a great deal. One of the principles that this book taught me, and which I fall back on all the time, is "what is our doctrine?" I like the limits of what our doctrine really is according to Millet...what is in our standard works, what is taught in our church curriculum today, and what is taught at general conference today. All the mysterious things that Brigham Young said or taught, that currently are not taught, are off limits to anti-Mormon's for criticism, because they are not still being taught. Does that mean Bro. Brigham was wrong? Maybe, maybe not.

Another aspect of this book I really liked was his conversation with his Baptist friend about accepting Jesus and knowing the Bible is true. How does one come to this point? Often in the church we are caught up in explaining the Holy Ghost by using the metaphors related to "feelings". My lawyer Church of Christ friend says that we crazy Mormons are just confused about our "feelings". I have stated to her that the Holy Ghost is so much more than feelings, but that our language is often limited to metaphors, and that is why we describe spiritual confirmations to others as feelings. I asked her how she came to know Jesus was her Savior. She said, "The Bible tells me so." How do you know the Bible is true? "Because there is empirical evidence that it is true." ...this from an attorney!? I tell her that I feel bad that she doesn't accept her witness of Christ as having been a personal witness and manifestation of the Holy Ghost. I have talked with other Catholic and Baptist friends who have had deep personal spiritual witnesses that Christ is their Savior. I know they really had those experiences. We LDS don't have a corner on the market for spiritual experiences...we just have the fullness of the Gospel for them to come and build upon.

I have used this book for the last couple of years as a reference tool along with many other sources like the standard works, other church publications, and even fairlds.org to help answer difficult gospel challenges. It has been richly rewarding.

responding to challenging questions about church

Hi,
I haven't been participating for awhile, sorry about that. I enjoyed reading Alvins little post on the book by Millet, which I haven't read. But I have thought about the points about difficult questions about the church. My perspective is that before delving into all the these details and weighing evidence, etc, it's useful to ask, "Can the Church be proven to be not true". I like this question. When I ask it to Mormons the answer is almost always "no". If the answer is no, then it's really no use in losing much sleep over doctrinal issues or disturbing historical facts, etc. If the answer is yes, then before you make a serious study of these things, you have some idea of what kind of fact would prove the church isn't true. I haven't been able to come up with one that is very good. One person recommended to me that if the church ever asks me to do something that is wrong or bad, then that would show it's not true. But this isn't very satisfying to me. I could be a Methodist all my life without being asked to do something wrong.

So at this point, my working hypothesis is that it's impossible to prove the church wrong, and we live in a world of faith, and a world of hope, doing the best we can. I believe that we, humanity, are waiting for something more. From my reading of the scriptures and my understanding of what science is, I believe that the strongest truth claims are those that allow themselves to be proven false when contrary evidence arises. I think this is beautifully illustrated in the story of Elijah. The sin of the priests of Baal was that their belief in their false gods could not be proven wrong, regardless of any physical evidence that Elijah was able to show. If Elijah had failed to bring the fire from heaven, then he would have less cause for condemning the priests for their unbelief. there are many examples in the scriptures in which the prophets put themselves on a limb and say effectively, "if such and such doesn't happen then you don't have to believe me." I'm thinking of Nephi and prediction of the death of the chief judge, and samuel the lamanite saying that Christ would come in 5 years.

Similar patterns hold in Science. The laws that we are most certain of are those that we know how to disprove. I know how to disprove the law of energy conservation, I just have to find one repeatable experiment where it doesn't hold. Relativity makes predictions, precision calculations that can be quantified. These can be used to predict future events with precision. These predictions can be brilliant like when somebody (Einstein I think?) predicted that relativity predicted that some astronomical event would be late by like 3 minutes or something. And he was right! Prophets in the scriptures have claimed the ability to make accurate predictions of the future, to heal people, to transport people large distances, to see into people's minds and hearts, to save and take life in large quantities, etc. Our prophets of today set a really high standard for themselves by claiming an equal footing with the prophets of the past. Today we see all of these "powers" being performed by "Godless" scientists. Many in the church would say that the scientists are inspired by God without knowing it. Maybe that's true, but if all of this great science is inspired by God it's important not to be dismissive about it. For example one should take evolution seriously, and not dismiss it as nothing. Evolution is a great example of something that does raise profound questions about God and faith and what it means to be human, but most Mormons are convinced that these questions are irrelevant to their existence, and I think this is unfortunate. Joseph Smith was a great prophet because he took the major dilemmas of the day, the really big problems, and he made sense of them, he resolved the problems for those peoplpe. How can we proselyte to the world when we refuse to even understand the questions that they are asking? How can we learn if our attitude is that "If we don't understand it, then it isn't important." This latter belief is taught quite often in church, if you listen carefully.

I've written much, and I should stop, but I'll add one more point: I've studied how scientists work and I live it, and the methods and values of science are very different from the methods of faith, as I've learned them in the church. I could write for a long time about these differences, but not here.

Also, I would like to say something about outreach, I have been attending a bible study group at a methodist church with a bunch of older men, mostly retired. Many are former academics. The discussion is frank and honest and I really have been enjoying it, learning how others think, and it has developed my faith. In some ways it is more nurturing to my faith as a Mormon than listening services at my own church. It took a lot of courage for me to get involved with this group, so if you are thinking about doing something similar, I would highly recommend it.

Thanks for reading this, and have a great day!
Ryan Larsen

Responding to Difficult Questions

With apologies to Bro. Mortensen, I'm going to start the September book discussion (on Nov. 3) before my ancient brain forgets any more.

I took a class from Robert Millet at BYU, and the one lecture I remember is when he played a radio clip of some pastor from another church. Millet thought this radio pastor had particularly insightful comments on the Mary and Martha story. I can still hear the pastor loudly proclaim, "The Master was in the house!!" My point is that Millet is sincere in his beliefs about outreach between our church and others (in case you doubted). I certainly agree that we (Mormons in general) do need to get out more.

I enjoyed the book, though I really had to force myself not to skim over large sections of the book where Millet discussed questions to which I felt I already had an answer. In fact, I read the book not seeking to see how I could answer other people's questions, but how I could answer some of my own questions. I don't think I've ever been asked truly difficult questions from non-Mormons, but I have been asked some tricky questions from Mormons and ex-Mormons.

There were a couple of questions that Millet raised that I wish he had explored further, and since he didn't I'm going to raise them here. I can't quote him exactly because I no longer have the book.

1. Why should we trust feelings/answers to prayers as a means for knowing the truth? Millet makes an excellent point about how he feels sorry for those that don't have that feeling. That knowledge without the spirit is empty. I agree. We need to feel what is right and be able to get answers. BUT, I think that's an incomplete answer.

For my job, I tell people every day about the dangers of the placebo effect. It's powerful, and people can clearly feel things because they think they're supposed to or because they want to, etc. We have many examples in early church history of false revelations. People thought they were following the spirit, but Joseph told them it was a false or evil spirit. Even today in the church I often see members feel impressed to do something they didn't want to do, and it turns out poorly.

Yes, we must have the feelings of the spirit to really know what is truth. However, our feelings can be, and often are, misinterpreted, so I guess it seems like a sandy foundation. Having had a good friend that came to church for years, had the discussions, prayed and didn't get an answer, I wish there was a good back-up plan.

2. What about the Book of Abraham and the scrolls found in a museum? Millet asserts that the scrolls found could not be the originals because they aren't long enough and don't fit the descriptions in church histories. This was the first time I heard this theory. I had been told in a BYU institute class that the scrolls found were the same scrolls that Joseph Smith had. The teacher (a BYU religion professor) said the scrolls found had some sketches of temple plans on the back. The institute teacher's theory was that the translation of the scrolls was much like Joseph Smith's translation of the Bible. It wasn't really a translation at all. The scrolls just served as something to trigger Joseph Smith to receive inspiration from the Lord. I must say that I like Millet's theory better. It certainly cleans up a lot of other questions. Any thoughts on this one way or the other?

3. How do you account for the church's changing positions and early church history? Now, I'm a bit hazy now on what Millet said on this, but I do want to bring it up as a point of discussion. Personally, I don't lose a lot of sleep over blacks and the priesthood, polygamy, and more recently, changes to the temple ceremony. All of the changes have been changes for the better. If I remember right, Millet said that none of these changes were doctrinal changes, defining doctrine as something in the standard works.

While this isn't an issue for me, it is an area where I start to get defensive. The 'Are Mormons Christians?' questions don't phase me at all, but when I get serious questions about our beliefs on polygamy, I get uncomfortable. Non-Mormons will usually drop the issue if you just explain we don't believe that any more, but my good friend that is semi-Mormon has more persistent questions about it. For example, why did Joseph Smith marry someone that was already married and why was he so secretive and why don't we teach the full truth about these things in Sunday school... Again, I don't lose sleep over these things, but I do think there are a lot of issues that don't have clean answers. I think this book can make you think there are good answers to every question, but if there are, I haven't heard them all yet.

Doug, my county didn't have your book, but fortunately, I also have a library card for the county next door and I'll be picking up the audio book on Thursday. I'm looking forward to it.

November 2009 Book

So for November's book, I propose that we read "Complications," by Atul Gawande. The book was a National Book Award finalist, so I'm assuming it should be readily available. It's a quick read, but I think very interesting and full of good insight about health care today. Besides, I want you guys to get a peek into my world.

Also, there have been few posts lately. It might be good if you all reply to this post so that we get an informal count of who is engaged with the PVS at present.

Happy reading, and careful with that scalpel...

The Future of the PVS Book Club

While we're waiting for Robert to collect his thoughts on the September book of the month, can someone (Peter?) tell me who is in charge of picking the books for October/November, and December?

The Road less traveled (thank goodness)

I listened to this from start to finish on Saturday. It was a bit intense and fairly disturbing. Long ago I read The Running Man, by Stephen King writing as Richard Bachman. The Road brought back memories of Running Man, probably because of the sense of hopelessness that the author creates around his character. I was glad that this book had a happier ending than Running Man.

Thoughts, in no particular order:

• The thought that went through my head as I read about the bomb shelter with the food storage and other emergency supplies was, "I wonder if they were Mormon?" I look back and laugh that I actually thought that.
  
• When the father and son visited the childhood home of the father, the father mentions a Christmas passed. I expected the son to ask, "What's Christmas?" but he doesn't. Did that surprise anyone else? I can't envision them having had celebrated a post-apocalyptic Christmas.
• Speaking of religion, the topic comes up a few times in the book, especially towards the end. The man seems to have had some religious upbringing, but it didn't seem like he had passed on much in the way of doctrine to the boy, though his son certainly had a solid moral compass.
• Like Alvin, I pictured the boy being about 8 years old. I'm not sure how long it look them to get to the coast, but the boy seemed to mature during the coarse (intentionally misspelled) of their journey. He started getting uncomfortable with his did staring at him. He would be irritable or uncommunicative at times. To me this indicates either maturity accellerated by scenes and experiences that children shouldn't have to endure, or the approach of adolescence (10-12). This role has to potential to launch the career of the next Haley Joel Osmet. I just did an imdb search on the movie; I hadn't heard of Kodi Smit-McPhee, but I'm guessing Hollywood will see more of him int he future.
• The saddest/scariest part of the book for me was when the dad was trying to explain when/how to commit suicide. That should NOT be part of a father to son talk.
  

Not the bio I was looking for

I was expecting something more along the lines that Sister Dewey wrote about Gordon B. Hinckley. This book was more of an analysis of the Church with David O. McKay as a point of reference. The first and the last chapters were more of the biography that I was looking for. Perhaps if it was written more linearly rather than categorically, I might have been satisfied. Part of the problem for me was that some things were repeated as they crossed over into the history of multiple topics (eg. the chapter on communism, the chapter on politics).

Some things that surprised me were similar to what others have already mentioned: McKay's tolerance of others' viewpoints, the collisions of opinions between General Authorities (while reading the book I wondered if these clashes made it difficult for some of them to be involved with certain prayers in the temple), Ernest Wilkinson ('nuf said), Ezra Taft Benson's persistance in certain matters and McKay's change of decision from Benson's influence. Some of the authors' depictions made the leadership in the church appear to me like the top level management of a large corporation.

I look forward to talking with my Dad about this book and his recollections of this period. Like Peter, I wonder if the members of the Church viewed things as Miss Middlemis did. Given her proximity to things, I'm sure that they didn't.

A question I have, and maybe one of you can add some insight, is about a comment the authors made in the chapter about The Church and Blacks. The book claims that Joseph Smith ordained some blacks to the priesthood, but the authors left no supporting reference.

September book of the Month?

Hopefully there are still a few people thinking about commenting on The Road, but I'm ready to turn my attention to the September book.

Bob, I think it's your turn to choose; do you have anything in mind?

"The Road"

Finishing that book was like waking up from a bad dream. I'm not saying the book was bad, but quite the opposite. The writing style was very different than anything I've read before, even the lack of apostrophes and chapters. For whatever reason it sucked me in as if I was "the man" and I saw my own son was "the boy". Maybe that is way McCarthy left them unnamed; so that we could more easily see ourselves in their place.

Back in my high school wrestling days, I would often go three days without food and very little water to "make weight". During those days I remember my mind and body going into a catatonic state. I went through the motions of life, but I felt I had no life in me. I remember one winter night after practice sitting on our living room coach wrapped up in blankets zoned out in front of the TV. I was so cold, with no fat or calories to burn and dry cotton-mouth was my every day reality. That night a Sprite commercial came on and I watched as the cool refreshing beverage was poured over that delicious crystal ice. I was just about ready to give up everything in life just to have a sip of that. Anyway...this book brought me back into those same feelings.

I read the entire book in one sitting working my uneventful flooring customer service part-time job at RC Willey. I was compelled to eat my dinner early while reading because I couldn't bear to "go without" again. Maybe that's why I'm getting more and more on the hefty side. I just have a hard time going into that mental state of being without food and water, especially without a spiritual purpose to support me through it.

I enjoyed the father and son relationship shown in this book. I loved the goodness of the boy shown in his tenderness with with the man who called himself "Ely" and for the mercy he showed toward the thief at the beach. I sensed the boy's frustration with his father's apparent hypocrisy. The father told stories of good deeds, but when it came down to it, the man was more concerned with protecting his son's life than extending the kindnesses he preached.

The harsh possibilities of human nature are portrayed in horrific imagery...the suicide of the man's wife rather than face the futile struggle to live in such a world...the pregnant woman seen and then shortly after the headless baby cooking over the fire...the imprisoned people in the basement being cannibalized one body part at a time.

What it comes down to is the basic good versus evil. How would I be in this same situation? I would I carry the fire of goodness and hope or would I devour my fellow human beings and long for death.