I could hear the cussing from inside the room and noted the awkward glances of nearby nurses and staff who turned to look and gawk.  Even though I only sat a few feet outside the door, I ignored the increasingly loud litany of expletives and deliberately focused on the screen in front of me.  He was my patient and I was doing my best to concentrate on his rapidly evolving list of medical problems, the electronic progress note already ballooning in front of me as I tried to prioritize multiple terminal conditions competing for attention.  I scrolled through pages of old notes that were littered with repeating instances of phrases such as “lost to follow up,” “did not comply with therapy,” “uncooperative,” and the ever favored, “signed out against medical advice.”  I paused and watched as a freshly berated specialist walked out of the room, sat down at a nearby computer, and dictated into his own note the word “belligerent.”  The diction snob inside me was pleasantly surprised to hear a new and applicable word and so I inserted it into my note as well.

Last week my pastor asked me, “How do you keep from becoming cynical?”  The question caught me off guard; it occurred in the context of a series of conversations on the struggles of caring for people in both spiritual as well as physical matters.  My reply was somewhat flippant as I didn’t have a good response.  The question was unintentionally pointed; Pastor Tom is a quick-witted man and one of the many reasons why I respect him so much is that even though he appreciates a dry and sardonic sense of humor, he intentionally suppresses it.  By contrast, I relish in lengthy conversations about all things dark and cynical.  In college I would rant about the evils of systems of poverty, child slave labor, sex trafficking.  Nowadays I rant about urban violence, health disparities, child abuse, racism, Donald Trump.  I am not shy about these views and justify vocalizing them as a mechanism for challenging injustice, but the genuine and curious nature of Pastor Tom’s question left me unexpectedly exposed to scrutiny.  After all, what is justice and how does that apply in medicine?  What is the root of cynicism and why are criticism and sarcasm so satisfying?

Healthcare providers are trained to treat all patients with dignity, honor, and respect.  The duty and obligation is as old as the profession itself:

Whatsoever house I may enter, my visit shall be for the convenience and advantage of the patient; and I will willingly refrain from doing any injury or wrong from falsehood, and (in an especial manner) from acts of an amorous nature, whatever may be the rank of those who it may be my duty to cure, whether mistress or servant, bond or free. – Hippocratic Oath

However the very nobility of the aspiration is an indication of how unnatural it truly is (if it were natural, there would be little need for the oath).  It is counterintuitive because the daily experience of tragedy and illness warps our sense of justice.  I have watched pieces of people roll through the trauma bay, decayed and neglected bodies of Alzheimer’s patients turn up in the ER, shaken babies seize.  In those times I have said to myself and others, “No one deserves that,” as the collective expression of our grief and compassion.  But I have also watched the IV drug abuser turn up for the 15th bloodstream infection, the withdrawing alcoholic get strapped to the bed while cussing out and swinging at staff, and the abusive pedophile convulse from shock therapy.  At those times, I have wondered to myself, “Did they deserve that?”

The Boston Globe wrote up a series of interviews of nurses who took care of Dzhokhar Tsarnaev, the surviving Boston Bomber.  It is an honest and raw description of conflicting emotions:

All of the nurses asked by supervisors to care for Tsarnaev agreed, the hospital said. The Globe interviewed seven of them, and all said that the ethical bedrock of their profession requires them to treat patients regardless of their personal history. They are sometimes called upon to nurse drunk drivers, prisoners, gang members, but this assignment was the ultimate test of Florence Nightingale’s founding ideals…

While moving Tsarnaev one day, another nurse, Irene, reflexively said: I am really sorry “hon.’’ It’s the sort of thing nurses say dozens of times a day to other patients, but it felt weird with an alleged terrorist, she said.

Afterward she and Marie made a pact. They would alert each other if either used an endearment, so they could stop.

“You see a hurt 19-year-old and you can’t help but feel sorry for him,’’ said Marie, who like other nurses referred to him as a boy. Yet, she said, she “would not be upset if he got the death penalty. There is no way to reconcile the two different feelings.’’

Some nurses said they felt no sympathy for Tsarnaev…

“When you’re in the room, it’s just a patient. You’re here to . . . make sure they’re feeling better,’’ said Michele, a 29-year-old nurse who cared for Tsarnaev the first night. “When you step away, you take it in. I am compassionate, that’s what we do. But should I be? The rest of the world hates him right now. The emotions are like one big salad, all tossed around.’’…

The greatest source of solace turned out to be confiding in one another.

I think much of the cynicism that pervades medicine comes from an inability to cope with perceived injustice.  We have no trouble wanting to see good people get better; there is no shame or shortage of goodwill towards kids with cancer or the Special Olympics or the “deserving poor.”  But felons and ex-convicts?  Child molesters?  Drug abusers?  In our most generous moods, we try to conjure excuses or reasons for the way they are: they themselves were abused, they are the victims of addiction, they are products of poverty and circumstance.  And when we exhaust those reasons, we assert that we provide care because it is a reflection of our moral character, our Oath, our respect for the image of God and humanity that they bear.  But in our more honest moments, we will secretly acknowledge and approve that no one is lining up to collect donations or build charities for them, the depraved, the scum of the world.

In his letters to the Corinthians, the Apostle Paul occasionally writes about idolaters, slanderers, murderers, thieves, the sexually immoral, etc.  He does not have endorsements or words of consolation for them, typically saying, “For what have I to do with judging outsiders?  Is it not those inside the church whom you are to judge? God judges those outside.“

In fact, his harshest invective is reserved for those inside the church, the ones who claim to be Christian.  In 1 Corinthians 4, he delivers a particularly stinging and sarcastic rebuke to Christians who lord their spirituality over others and flaunt their perceived spiritual stature and financial “blessings” as indicators of God’s favor.  He finishes this criticism with this plain description of the “true” apostles’ public regard:

“ To the present hour we hunger and thirst, we are poorly dressed and buffeted and homeless, and we labor, working with our own hands. When reviled, we bless; when persecuted, we endure; when slandered, we entreat. We have become, and are still, like the scum of the world, the refuse of all things.” – 1 Corinthians 4:11-13

It is bewildering and offensive to think that the phrases “scum of the world” and “refuse of all things” in scripture are not used to describe those commonly thought to be despicable but rather as badges of honor for Christians who suffer because being treated as such places us in the gracious company of Jesus Christ.  Peter expands on this in his own letters:

Honor everyone. Love the brotherhood. Fear God. Honor the emperor.

Servants, be subject to your masters with all respect, not only to the good and gentle but also to the unjust. For this is a gracious thing, when, mindful of God, one endures sorrows while suffering unjustly. For what credit is it if, when you sin and are beaten for it, you endure? But if when you do good and suffer for it you endure, this is a gracious thing in the sight of God. For to this you have been called, because Christ also suffered for you, leaving you an example, so that you might follow in his steps. He committed no sin, neither was deceit found in his mouth. When he was reviled, he did not revile in return; when he suffered, he did not threaten, but continued entrusting himself to him who judges justly. He himself bore our sins in his body on the tree, that we might die to sin and live to righteousness. By his wounds you have been healed. – 1 Peter 2:13-24

If I am honest with myself, I will admit that the root sin of my festering cynicism is a meritocratic, self-aggrandizing pride.  I see this because I soak up praise when given accolades but nurse my wounds when criticized, especially by those whose suffering I would like to imagine is divinely sanctioned.  But what these instances really should become are visions of the cross of Christ, where the living and loving God himself was treated (by me) like the refuse of all things that I might find freedom and life and liberty and satisfaction.  Somehow, in ways I still do not fully understand, the only way in which to defend against cynicism is remember that I too am the scum of the world.