By Dr. Thomas Duffy

My quest or query on the subject of grace in a secular profession has its origins in the circumstances surrounding the care I offered to a patient near the end of his life. The patient was an elderly gentleman with far-advanced leukemia of five years’ duration, during which he had undergone multiple remissions and relapses of his disease. His final hospitalization proved the most harrowing and tortured experience for him as well as for his caregivers. After treatment with an aggressive chemotherapeutic regimen for his recurrent disease, he experienced worsening of his already debilitating physical condition. He developed a bacterial super-infection with Fusarium which had several devastating effects, including blindness and numerous painful ulcerations over his entire body. The recommendation to move from a curing to a caring stance was accepted by the  patient and his family. The decision – his decision – to withdraw therapy was considered appropriate in light of the advanced stage of his disease and the degree of his suffering.

What was unknown to me during this challenging period was a meta-text that was  occurring in parallel to my care of the patient. A hospital chaplain had befriended and counselled him beginning from the onset of his illness and subsequently provided me with an essay describing her experience ministering to him. Her essay describes her painful accompaniment of our patient in word and silent presence as he moved from “roaring against the dying of the light to an acceptance of his journey through the valley of the shadow of death.” She appeared to be empowered and energized from her encounter with the dying patient. In striking contrast, I had come through his illness with feelings of disappointment and defeat, of being bruised and saddened. I was forced to ask why I had come away exhausted and limp whereas the same experience was a source of apparent transcendence for the chaplain. Upon reflection, I entertained the thought that she had access to a resource that I lacked in the encounter.  Her accompaniment had graced the dying of a human being and she had in some way shared in this grace through her actions. Her role as a chaplain afforded her a strength which eluded me. I was left to ponder whether I could share in this resource.  Grace was a fuzzy concept for me. It was an entity that involved the presence of God and a belief in God. And if God is essential for grace where does that leave grace for a non-believer in a secular profession? Had I, in entering that profession, cut myself off from grace and the power it imparted? Is grace an option for non-believers? I couldn’t answer any of these questions until I corrected my woefully inadequate knowledge of grace. This was the initial query which the encounter stirred up and initiated a journey in search of possible sources of grace in the secular procession of medicine.

The first task was to try to understand what grace means. Hemingway’s definition of courage as grace under pressure didn’t quite seem adequate to capture the phenomenon that I had witnessed. Nor was it style in performance, an elegance, poise, or harmony. I recalled grace as a supernatural gift of God and a source of empowerment to perform certain acts. But on further investigation, I discovered that grace in its theological usage has been a theme with a rich and controversial past, appearing in the writings and thoughts of Paul, Augustine, Aquinas, Luther, and numerous other theologians. Through these texts, one discovers that grace has had a plurality of meanings, with each iteration incorporating material from the temporal and historical framework in which the authors defining it had lived. Grace turns out to have been an open concept which initially embraced the whole of God’s transforming gift of himself to humanity, which plays out in infinite ways. For Augustine, the theology of grace is the sacramental union of divine and human will; the core of grace is charity or love, the gift of the Holy Spirit. For Aquinas, grace is not the union but the created gift of mercy which makes that union with God possible. Luther’s conception of grace was a personal relationship with God in Christ – the experience of a God who allows himself to be encountered in a face-to-face relationship.

The interpretations of grace have therefore differed throughout time and the differences were important enough to deeply affect the Protestant Reformation. But amidst all these interpretations, one discovers a central concept: the theme of relationship, of relatedness, between God and humanity in which the human shares the nature of divinity. Reflecting upon grace is reflection upon relationships. The emphasis in this relationship is upon humanity’s participation in the supernatural, a deification which is certainly not compatible with a secular physician’s stance and is in fact seemingly at odds with our quest for a secular grace.

However, the concept of grace has not remained interpretively static since the Reformation. Post-Vatican II theologians challenged this emphasis on grace and rejected the Roman Catholic teachings that grace is a supernatural structure independent of humanity’s conscious, spiritual, and moral life. These interpretations, most prominently and controversially voiced in the writings of the German Jesuit theologian Karl Rahner, called for a re-orienting, a re-directing of the vector of the relationship away from humanity in God to God in humanity. Rahner perceives nature as enveloped in grace and grace bearing upon our inmost reality. For him, the whole of creation becomes a theater of grace. The actualization of grace is in concrete experience. His theology of grace has an echo of North American Indian spirituality and other great wisdom traditions. One experiences grace in felt connection with the universe. Grace is in the world as world – it is in humans as human.

But it is important to point out that for Rahner this gift does not become a truly secular or godless grace – these concrete experiences occurring in nature touch the very center of the religious subject and through them the subject has an experience of God. However this transcendence is not restricted to individuals who believe in God. All persons have the capacity to participate and respond to grace. Rahner posits a so-called supernatural existential, a form of uncreated grace, that exists in all humans. Its transforming efficacy is not limited to those who know grace as grace but, in Rahner’s words, all human experience contains moments in which persons are called to live with an openness to what lies beyond the observable. Those who respond to such experiences by being so open allow themselves to live not only with the hope that there is something beyond the everyday, but also with the gifts granted to them by this ineffable presence. When man experiences this openness by looking outside himself, in the process he passes outside himself and participates in grace.

Rahner’s theology of grace appears compatible with our query regarding a form of secular grace. He also incorporates the godless or non-believer whom he claims is inhabited by t

he supernatural existential. He calls them “anonymous Christians,” a potentially offensive appellation. Still, Rahner’s teachings situate grace in the lived lives of humans. At the core of his definition of grace is the theme of relationship, with the vector of that relationship shifting from humanity in God to God in humanity and in nature. Grace is therefore accessible in our daily lives and we must ask where there is evidence of such grace in our lives. When do we encounter experiences that contain elements of things that go beyond the observable and the everyday? How do we recognize them when they enter our lives?

This task of identifying grace and its sources in our lives is facilitated by following the examples of others who have identified grace in other venues. Especially helpful in this regard is the work of Peter Hawkins in his book The Language of Grace. This book shares our quest of addressing the theme of grace in a secular society. He uses the works of three mid-twentieth century authors – Flannery O’Connor, Walker Percy and Iris Murdoch – as mediums in which to pursue this question. All three writers believe that access to grace exists in our everyday lives but a secular society no longer has the means to recognize its presence. Percy created characters whose lives embodied this theme in a tragic manner, characters who failed to rise above the everydayness of their lives. O’Connor was incensed by a godless society which she described as being populated by “wingless chickens.” She uses shock tactics in her stories to rouse the reader from a slumber of ignorance and creates a body of literature which locates the mystery of grace in the reader’s own experiences. Her characters undergo religious experiences as they encounter the bizarre, the grotesque, and the violent in their lives.

In O’Connor’s book Wise Blood, a malevolent character called Hazel Motes has attempted to establish a new church – the Church of Christ Without Christ – and in his religious fervor burns out his eyes with lye. The story concludes with his landlady, Mrs. Flood, bent over his lifeless body and peering into his burned-out eye sockets. 

She shuts her own eyes and sees a pinpoint of light, feeling as though she is at the entrance of something that is moving further and further away into the darkness. O’Connor uses this strange encounter of two ordinary human beings to convey the message that Mrs. Flood is re-discovering Christ while looking into the eye sockets of a dead man. She connects the pinpoint of light to the star that appears on Christmas cards, and through it she moves backwards in time to Bethlehem. Hazel Motes’ death and the darkness are the beginning of a re-birth for Mrs. Flood and for the reader as well. A thunderbolt, a jolt, has been tossed that forces both Mrs. Flood and the reader to consider what is more than the observable and to move outside themselves when witnessing the suffering of another human being.

Admittedly, Wise Blood traffics in the violent, the grotesque, and the bizarre. At times, physicians travel in that same territory when ministering to their patients. One of my patient encounters resembles O’Connor’s story: the tale of Isaiah, an elderly retired railroad worker, who had been admitted to the hospital with massive gastrointestinal bleeding. His treatment included a now-discarded and appropriately discredited device, the Wangensteen balloon. This device, inserted through the nose into the stomach, was perfused with ice cold alcohol that would constrict his blood vessels and halt the bleeding. However, Isaiah’s balloon migrated up into his esophagus, shutting off his airway and threatening asphyxiation. Upon arrival at the bedside after hearing the alarm, I promptly intervened by deflating the balloon that anchored the device in place. Unfortunately, I was unable to remove the device, which left Isaiah close to death from lack of oxygen. I leapt upon the bed and while straddling him – one knee on his sternum and my hand upon his head – I yanked the tube with all my strength. The balloon came out at last, but with it came the patient’s nasal septum and a gush of blood. From my cat-bird perch, I looked into Isaiah’s eyes as blood covered his face and saw his terror which mirrored my own. His eyes were questioning, attempting to make sense of this act of violence on the part of his healer. Obviously there was no pinpoint of light moving back to Bethlehem, but there was no question but that I had moved outside of myself by undertaking this violent act that ultimately saved Isaiah’s life.

Another example of grace in literature with resonance for those working in medicine comes from John Steinbeck’s famous tale of woe, The Grapes of Wrath. Rose of Sharon and her family find refuge in a barn after Rose delivers a dead infant in the midst of a rising flood. They come upon a young boy and his starving father. The text describes Rose of Sharon looking down at the wasted face and wide eyes of the frightened boy, and suckling him with the milk originally intended for her dead child. She looks across the barn and a mysterious smile comes to her lips. Rose, devastated by the loss of her baby, now shares in a measure of transcendence by offering her milk to a starving stranger. The act is an epiphany in the midst of human suffering and is easily recognized as an act of grace for both Rose and the boy.

The medical counterpart to this story does not have a rising flood as its backdrop but rather a diagnosis of active tuberculosis in a young woman, the mother of two children. After presenting to the hospital with a fever and blood-filled phlegm, she quickly received a diagnosis of tuberculosis; she was placed in an isolation room and started on appropriate medications. However, during the night she leapt from her sixth floor room for unknown reasons and her body landed in a courtyard below. A code was called, and a young house officer responded by scaling a containing wall and proceeding to offer mouth-to-mouth in a futile attempt at resuscitating/resurrecting her shattered body. Just as Rose of Shannon had given her milk to a starving man, a physician gave his breath to a lifeless young woman. The gifts of a mother’s milk and of a young doctor’s breath are both examples of grace in a secular setting.

It would therefore appear appropriate to accept that physicians participate in a way of life which is Rahner’s theater of grace. Rose of Shannon has this one moment of transcendence in her encounter with a starving man. The physician, as he assists in births and caring for the sick and dying, has repeated opportunities to experience grace. People like Hazel Motes, Mrs. Flood, Isaiah, Rose of Sharon, the woman with tuberculosis, and the courageous physician are all part of daily life in the world of medicine. It is fitting to conclude that grace exists in a secular profession – that more is granted to us from realms of existence beyond the everyday –  but is it always in the violent, the grotesque, and the bizarre aspects of our lives? Or are there other occasions of grace as we live our daily lives in medicine? Is grace a rare punctuation in a physician’s life, or is there access to grace in the everydayness of patient encounters?

Review of our journey to this point identifies common themes in our understanding of grace. Classical interpretations identified relationships between man and God as a central component of grace.  Rahner describes it as a process of moving outside ourselves when looking at our lives and those of others. Hazel Moats and Isaiah suggest that it is the act of looking upon or into another human being which is the occasion of grace. Rose of Sharon and the young physician participate in grace through offering unselfish attention to another human being. All of these themes converge in the theology and philosophy of Simone Weil, Iris Murdoch, and Emmanuel Levinas. Weil posits a non-religious transcendence that is achievable in looking with loving tenderness upon another human being. This attention to others represents for her an ethical act wherein one re-directs one’s gaze from self to other; it is an intentional practice of opening one’s mind to the reality of strangers and attending in concrete ways to their greatest good. Murdoch shares the same beliefs as Weil and trumpets the offering of attention as the proper mark of an active moral agent. For Murdoch, attention is a form of non-dogmatic prayer that occurs when the “avaricious tentacles of the self are freed up in the act of paying attention to another human being.” This requires an awareness of others, the ability to accurately and sensitively read their situation. It is a substitution for prayer, an embracing of the full humanity of the other, a cultivation of empathy.

These same beliefs are echoed in the words and works of the twentieth century theologian/ philosopher, Emmanuel Levinas. He has described the “call of the other” which occurs in any face-to face encounter in which there is a re-orientation of our natural focus on ourselves to a focus on the other. Levinas believes that moral transcendence, the good life, is achievable in this simple but profound act of recognizing the hunger of others. His theory, his font of empowerment and moral transcendence, is present in the very act of looking upon others, which for physicians means looking upon their patients. This act of gazing upon others has a reciprocity in the call of the other; we become responsible for the other when we look upon them. His message is particularly pertinent for physicians since nowhere is this act more quintessentially present than in the act of looking upon another human being who is suffering or dying, especially when one has the tools and expertise to relieve at least some of that suffering. For Levinas, as well as for the rest of us, attending to the material needs of the other fulfills our spiritual needs.

The implications of this are profound for physicians; one can reasonably conclude that in the daily living of one’s life as a physician there is a constant opportunity to receive grace, to be empowered, to open up instead of burning out. Access to grace in the act of looking upon others provides sustenance for the spirit. William Osler believed that in becoming a doctor, one no longer lived simply as man or woman, husband or wife, but instead as a physician. One was to live a life beyond the ordinary. This journey to identify secular grace in the medical profession leads to the conclusion that grace is empowerment to live a life beyond the ordinary through the daily tasks of looking upon and ministering to our patients. This attending to, waiting with, and gazing upon was the source of the chaplain’s strength and grace when she peacefully accompanied our patient to his death, and the same portal to grace exists within all patient encounters. It is a source of ennoblement that is within every physician’s reach if he or she can realize the grace inherent in the act of caring for a stranger.

Thomas Duffy is an Emeritus Professor of Medicine/ Hematology at Yale University School of Medicine. He is a graduate of Johns Hopkins School of Medicine where he completed his Internal Medicine training and fellowship. He has been a faculty member at Yale for over four decades where he has been a part of its Bioethics Community since his initial involvement in helping establish its Ethics Committee in early 1980.