life, death, and Life

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Any week spent working nights in a hospital intensive care unit is sure to be memorable, but my first week of ICU nights as a resident physician in 2019 brought a particularly memorable “first.” It was the first time I ever exercised my medical authority over death.   

During medical school and early residency, I encountered several patients who passed away while I was part of their care team, or shortly thereafter. But Ms. G was the first to pass while I was the first-line physician caring for her. Her death was not unexpected. A woman in her 60s, she had dealt with ovarian cancer for years, including one especially problematic metastasis which pressed on the ureter running from her left kidney to her bladder. This led to recurrent severe urinary tract infections, several of which had landed her in the hospital previously, but aggressive medical care had always pulled her through. On this occasion, she had felt weak and short of breath at home and had called an ambulance, but when paramedics arrived they found her minimally responsive, her heart beating dangerously slowly, and then it stopped entirely.  

8 minutes of CPR brought back her heartbeat, and she was intubated and placed on a ventilator to keep her breathing, given fluids and antibiotics to treat her infection, and admitted to our ICU. But then she had several seizures with full body stiffening and convulsions, a very bad sign suggesting that when her heart had stopped serious brain damage may have occurred due to lack of blood flow. The hospital team kept her deeply sedated and cooled her whole body for several days to slow her metabolism and try to minimize neurologic damage, but when she was re-warmed and the sedating medicines were weaned off, she remained unresponsive. An MRI of her head confirmed our fears: widespread anoxic brain injury. Enormous areas of her brain were severely damaged beyond any chance of recovery. While she was not technically brain dead, the most she could reasonably hope to recover would be some rudimentary semi-purposeful movements in response to touch or voice. The higher human functions of language, emotion, reason, and personality had been irreparably disrupted, and there was no realistic possibility of regaining her life as she had lived before. 

We carefully shared this sobering news with her family. Her husband had passed away just a few months earlier, and so her son and daughter were given the heavy task of processing this wrenching prognosis and determining what their mother would want done. It was clear that she would never be fully herself again, and any degree of partial recovery would only happen with many, many months of suffering on a ventilator, as her brain was too impaired to reliably keep her breathing without support. The family decided that Ms. G would not want to go on like that. She had lived a good life, fought long enough with cancer, and now lost her husband, and she would want them to let her go. Extended family gathered from out of town, and plans were made for terminal extubation; to remove the ventilator breathing tube and let nature take its course.[1]  

It took its course at 5:01 a.m. on my night shift, 15 hours after the day team had taken her off the ventilator. She had been kept comfortable and peaceful through the afternoon, evening, and night with palliative medications, and her son and daughter had remained at her bedside the whole time. Around dawn the bedside nurse came into the ICU workroom and informed me that he had just checked on Ms. G and found that she was no longer breathing and had no pulse. I suddenly realized that it now fell to me to officially pronounce her dead.  

Medical training is full of many, “Woah, I’ve never done this before” moments, but this one hit particularly hard. I have authority over death? 29 years old, M.D. diploma less than 1 year old, 1st year neurology resident on my first ICU rotation, and I have power to declare with finality that a fellow human being has, and is, departed? Can I really do that? 

For better or worse, night shift in the ICU allows little time for rumination, so after counseling briefly with an experienced ICU nurse practitioner, I went to the room, alone. Ms. G’s son and daughter stood beside her bed, their grief somewhat subdued by their long night vigil. I quietly informed them of my purpose in visiting, and they chose to remain in the room. I approached the bed, held Ms. G’s wrist and felt for a pulse, and found none. I pulled out my stethoscope, pressed it to her chest and listened for heart and lung sounds, and heard none. She lay utterly still, no response whatsoever to my voice or touch. I drew back, offered my sympathies, and walked back to the workroom. There I dictated a note recording the time of death and describing my exam findings, and entered the final order in Ms. G’s electronic health record: “Discharge as Deceased.” And that was it. 

Almost anyone can inspect an immobile body and conclude that the person is dead, but as a physician, when I say a person is dead, it’s official. It goes on records kept by the hospital, city, state, and country, and usually nobody questions my authority on the matter. But where did I get that authority? Where does authority over death even come from? Spending years studying the workings of the human body and its myriad processes and dysfunctions, followed by decades observing, examining, and treating patients gradually gives experience which justifies some authority to speak and act on matters of health and illness. Along the way this medical authority is made official by various stamps of approval: Doctor of Medicine, License to Practice Medicine, Completion of Residency, Fellow of the American Academy of Psychiatry and Neurology, Maintenance of Certification, etc. And that seems sensible. But what about authority over life and death? That is not the same thing. 

For one thing, what is death? In declaring Ms. G dead, I used the cardiopulmonary standard: death is the irreversible cessation of heart and lung function. Since prehistoric times, humans have noted that many organs can cause problems if damaged, but if the heart and lungs stop working, the rest of the body permanently stops working. It’s a clear definition, and it’s as simple to apply as my exam of Ms. G. But then humans invented ventilators which breathe for the patient, and cardiac devices which pump blood for the patient, and now we have extracorporeal membrane oxygenation (ECMO) which does both. For patients who are on these sorts of life support and are severely neurologically injured, physicians sometimes apply the neuro-respiratory standard of brain death: death is the permanent loss of capacity for consciousness, spontaneous breathing, and brainstem reflexes.[2] Applying this definition is a little more complex and involves testing various brainstem reflexes that control eye movements, coughing, and breathing, but it allows us to say objectively whether or not a patient is “brain dead.” But then there exists a broad spectrum of patients who are somewhere between consciously living and brain dead: severely and irreversibly brain damaged, but maintaining some basic brain functions and reflexes. And there is a far larger group of “chronic critical illness” patients, whose brains are relatively intact but who have a lengthy and growing list of severe incurable diseases with multiple organs failing, and who are only kept partially functioning by medical interventions which grow steadily more aggressive, invasive, and frequent. Are these patients dead? Not according to either of these 2 standard definitions which physicians use. And thanks to ventilators and many other remarkable machines, barring a crisis we can keep patients semi-stable in such states for a very, very long time.  

And by default, we do. Physicians most often exercise their authority over death by fighting against it. We ponder and struggle over which treatment to apply to critically ill patients, but the question of whether to apply a treatment may be forgotten, ignored, or actively rejected. Part of this reaction arises from a genuinely noble determination to “do everything” to relieve disease, pain, and suffering. But part of it is less noble and more human. Treating disease is the default course of action in medicine, and human psychology always leans toward sticking with the default rather than making a deliberate choice to deviate from it.[3] A doctor may also have built their identity on being a savior of lives, with death framed as failure and defeat. And a doctor who has not come to terms with their own mortality may see it reflected in the eyes of a dying patient, and react desperately in fighting against it. 

And then there are the pleas of the patient and family: can’t you do something? Isn’t there still a chance? Keep doing everything, we can’t just let Mom die. In the modern culture of exalted science, hospitals have become the temples of healing where the ill and dying come seeking scientific blessings of renewed life from priests in white robes. It is the same impulse that has always driven humans to call upon higher powers: in a world of uncertainty we yearn desperately for something certain, reliable, and powerful in which to place our trust. But science makes a poor deity, for it is founded in questions rather than answers, and at its glorious best it is a patchwork of theories, corrections, contradictions, and uncertainties, where fragments of glimmering truth are agonizingly difficult to identify in a sea of competing hypotheses. 

The great physician William Osler wrote, “Medicine is a science of uncertainty and an art of probability.” [4] Nowhere is scientific uncertainty more prominent than in medicine, where the fundamental uncertainty of physics is amplified through layers of chemistry, biology, physiology, and behavior into the beautiful complexity of a human being, whose individual response to treatment can be known only by passage of time, and whose only certainty is eventual death. But a caring doctor doesn’t want to burden the suffering patient with the full weight of medical uncertainty. The patient might panic. They might lose hope. They might lose faith in their licensed clinicians and turn to far more dubious healers. And so we try to balance acknowledging the unknown with presenting our best coherent explanations and recommendations for treatment. 

Understandably, many patients and families given this balanced presentation ask for more certainty: will this get better? Will it get worse? How long do I have left? In response I try to provide reliable data from the medical literature, but I emphasize that medicine does not offer certainties, only probabilities, and these drawn of necessity from large groups of patients who are similar enough to be statistically useful and yet varied enough to undermine prediction of outcomes for any individual. When patients accept that I as a physician have very limited ability to predict the future, it always seems to include some degree of disappointment. They came looking for answers, and while a diagnostic explanation for their symptoms and a plan for their treatment is nice, I often sense the larger questions pushing from behind the curtain: why did this happen to me? How is this going to affect my life? Will this end my life? If so, what happens after that?  

I feel obligated to stick to my white-coated role of medical scientist, but when I sense those larger questions looming behind patients’ inquires and concerns, I feel constrained, like Jacob Marley’s ghost from Dickens’ A Christmas Carol. When Scrooge is confronted by a haunting vision of the afterlife and asks in distress, “Tell me more, speak comfort to me, Jacob!” his deceased, chained business partner replies, “I have none to give. It comes from other regions, Ebenezer Scrooge, and is conveyed by other ministers”. [5] My patients are far worthier than Scrooge to receive answers and comfort, but when it comes to life and death, in my role as physician I have no more ability to provide eternal answers and true comfort than damned Jacob Marley. Any patient who seeks to understand life and death in a medical clinic or hospital is in a terrible predicament: confronting the abyss surrounded by those who have nothing useful to say about it. [6] I can politely ask what sources they have turned to for comfort and spiritual strength in the past, but when such sources seem to be lacking or absent, it makes me want to take the white coat off, set it aside for a few minutes, and share where I go looking for answers and comfort, what I have learned, and invite them to learn for themselves. So far I haven’t figured out how to appropriately work this into my medical practice without crossing boundaries and disrupting care, but here is what I might say if I could: 

I sense that what you are really asking for isn’t another medical statistic. You are looking for certain answers about life, suffering, death, and purpose. As a doctor I don’t have the answers to those kinds of questions, but I have personally learned that there is a God who does. God is the true authority over life and death. God formed your physical body and understands it completely. God knew you before you came to Earth, and is intimately aware of what you are going through right now. God sent you here to provide you opportunities to learn, make choices, gain experience, and overcome challenges. Knowing this would be impossible to do by yourself, God sent Jesus Christ to teach truth, exemplify goodness, experience the worst of all human suffering, and overcome death. While our bodies will gradually break down and eventually pass away, through Jesus Christ you will be resurrected, your body restored to life and raised to a new Life that can never die. Life continues on, not in metaphor or memory or mystical essence, but in physical reality, for that is the only way you could still be you. 

I know this is true, not through my medical training, but by inspiration from God through the Holy Spirit. I was taught about Jesus Christ and the resurrection by my parents, but I learned for myself in April 2010 while listening to an inspired speaker, Thomas S. Monson. He spoke of seeing the painting “A Hopeless Dawn” in the Tate art gallery, [7] which shows a woman mourning the loss of her husband at sea: 

Monson spoke: “Among all the facts of mortality, none is so certain as its end. Death comes to all; it is our ‘universal heritage; it may claim its victim[s] in infancy or youth, [it may visit] in the period of life’s prime, or its summons may be deferred until the snows of age have gathered upon the … head; it may befall as the result of accident or disease, … or … through natural causes; but come it must.’ It inevitably represents a painful loss of association and, particularly in the young, a crushing blow to dreams unrealized, ambitions unfulfilled, and hopes vanquished. 

“What mortal being, faced with the loss of a loved one or, indeed, standing himself or herself on the threshold of infinity, has not pondered what lies beyond the veil which separates the seen from the unseen? Centuries ago the man Job—so long blessed with every material gift, only to find himself sorely afflicted by all that can befall a human being—sat with his companions and uttered the timeless, ageless question, “If a man die, shall he live again?” … 

Monson then recounted God’s plan of salvation, the life, suffering, and crucifixion of Jesus Christ, and said: “No words in Christendom mean more to me than those spoken by the angel to the weeping Mary Magdalene [at the tomb] … ‘Why seek ye the living among the dead? He is not here, but is risen.’ 

“Our Savior lived again. The most glorious, comforting, and reassuring of all events of human history had taken place—the victory over death. The pain and agony of Gethsemane and Calvary had been wiped away. The salvation of mankind had been secured. The Fall of Adam had been reclaimed. 

The empty tomb that first Easter morning was the answer to Job’s question, “If a man die, shall he live again?” To all within the sound of my voice, I declare, If a man die, he shall live again. We know, for we have the light of revealed truth. “For since by man came death, by man came also the resurrection of the dead. For as in Adam all die, even so in Christ shall all be made alive.” [8] 

I was 20 years old when I heard these words, serving in Korea as a missionary for The Church of Jesus Christ of Latter-day Saints. I had long loved hearing Thomas Monson’s stories and testimony, but when he said, “I declare, if a man die, he shall live again. We know,” something resounded inside me, and a thought filled my mind with striking clarity, “This is true. Resurrection is real.” It was clear and certain, distinct from ordinary thoughts and emotions originating from within myself, and as powerful as any inspiration I had ever experienced. From that moment, I could count the resurrection of Jesus Christ, and of all God’s children, as one of the foundational gospel truths of which I have a sure, personal witness.[9]  

As I passed through medical school and residency training, this certainty about Life after death made a profound difference in each encounter with human morbidity and mortality. It came to my mind again as I pronounced Ms. G dead, knowing even as I signed the note that my words would be overridden by the One who has true authority over life and death, the Life and Light of the world. I have often wondered how anyone can tolerate working in the medical field without some hope beyond what medical science has to offer. Enjoying life’s simple pleasures now and living on in fond memories later isn’t good enough, it just doesn’t hold a candle to eternal progression here and hereafter. So many times I have wanted to share my own source of hope with patients and colleagues. To those who find resurrection unlikely or even absurd, I would share the words of Lawrence Corbridge: 

“While it is understandable that we may be challenged by the extraordinary, we shouldn’t be, because ordinary things are actually far more phenomenal. 

“The most phenomenal occurrences of all time and eternity—the most amazing wonders, the most astounding, awesome developments—are the most common and widely recognized. They include: I am; you are; we are; and all that we perceive exists as well, from subatomic particles to the farthest reaches of the cosmos and everything in between, including all of the wonders of life. Is there anything greater than those ordinary realities? No. Nothing else even comes close. You can’t begin to imagine, much less describe, anything greater than what already is. 

“In light of what is, nothing else should surprise us. It should be easy to believe that with God all things are possible. 

 “The healing of the withered hand is not nearly as amazing as the existence of the hand in the first place. If it exists, it follows that it can certainly be fixed when it is broken. The greater event is not in its healing but in its creation. 

 “More phenomenal than resurrection is birth. The greater wonder is not that life, having once existed, could come again but that it ever exists at all. 

“More amazing than raising the dead is that we live at all. A silent heart that beats again is not nearly as amazing as the heart that beats within your breast right now.” [10] 

I know this is true. [11] It is so real and comforting and exhilarating that I want to shout it from the rooftops and help everyone I meet to learn for themselves that it is true. I don’t know how to do that, but writing a blog post seemed like one useful approach. For anyone who is curious to know more, there is nothing I would be more happy to discuss and share together. 

Marcus Callister

Last updated 03/29/2023

References :

[1] Terminal extubation is a morally charged topic. I have much respect for those whose religious or moral framework leads them to decline to participate in it. I personally believe it is an ethical option in specific situations, including the one described, and that a key factor is what the patient would choose if they could. In this case, the attending physician Dr. S had told the family them that in these situations there was no right or wrong answer for everyone. He had encountered patients who had written wishes that, “as long as I can watch my favorite TV channel, I’m fine with being kept alive hooked up to a ventilator or any other machines indefinitely.” He had met other patients who declined to even go on intermittent hemodialysis because, “Then I’d be tied to the hospital every other day and I couldn’t go out hiking for weeks in the wilderness anymore, and if I can’t do that then I’d prefer to pass away in peace.” The difficulty, of course, was that most people fell somewhere between these two extremes, often along the lines of, “I’m OK with being on mechanical support for a short time to save my life, but I don’t want to be stuck half-dead on artificial life support forever.” The family decided Ms. G was in this group. I may write further about end-of-life decision-making in a future post. 

[2] https://n.neurology.org/content/98/13/532  

[3] See Daniel Kahneman, Thinking Fast and Slow 

[4] The Quotable Osler, American College of Physicians, Philadelphia, PA, 2003. 

[5] Charles Dickens, A Christmas Carol, Stave 1 

[6] With one notable class of exceptions: there are members of the healthcare team who are trained and enabled to help patients work through issues of life, death, suffering, and purpose, and these are the chaplains. I love and respect the work they do, engaging in deep reflective listening and sharing spiritual encouragement suited to the patient’s own belief system without proselytizing. Unfortunately, in most healthcare settings they are involved in only a minority of patients’ care, mostly those who already have some religious faith or spiritual inclinations, and patients without spiritual resources or interest are the least likely to see a chaplain, even though I believe they are the ones who could benefit the most. I also reject the notion that only chaplains should engage with patients on spiritual matters: while aggressive preaching to patients in difficult and vulnerable situations raises ethical concerns, what I see far more often are patients expressing some spiritual desire and hope, and their medical team becoming awkwardly silent and then changing the subject, instead of embracing and encouraging the patient’s spirituality as a vital part of their care and wellbeing. A chaplain referral is nice, but I also want to appropriately connect with my patients’ spiritual health, just as I connect with their physical and social determinants of health. In Dallas, I met clinicians who regularly offered to pray with and for their patients, I admire them greatly and would like to work up the courage and finesse to do similar.

[7] https://www.tate.org.uk/art/artworks/bramley-a-hopeless-dawn-n01627  

[8] https://www.churchofjesuschrist.org/study/general-conference/2010/04/he-is-risen?lang=eng 

[9] See separate blog post “My Postulates” for the full list  

[10] https://speeches.byu.edu/talks/lawrence-e-corbridge/stand-for-ever/  

[11] A thoughtful modern reader may ask, “Isn’t faith like yours just wishful thinking that has been reinforced by emotional placebos to the point that it is self-perpetuating?” I would answer that as a neurologist I am deeply aware of and fascinated by the inner workings of the human brain, including confirmation bias and construction of emotions. The key difference I find between self-deception and spiritual truth is in the fruit they bear: the former can be preserved only by self-defensive insulation, while the latter grows stronger as it connects with other related truths and brings ever greater insight and understanding. I have many thoughts on this subject and will prioritize it for a future post.

The Cost of Healing

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There’s an account in the New Testament of Jesus Christ healing a wild and unstable man possessed by evil spirits. This unnamed man of Gergesa spent his life outside the village, crying and injuring himself with rocks. His neighbors had tried to help and subdue him, going to the point of placing chains to physically restrain him, but he broke the bands and lived as an outcast.

When Christ met this man, He had compassion on him and cast out the legion of demons tormenting him, and they entered into a nearby herd of pigs. These animals then ran into the Sea of Galilee and drowned. The pig keepers, understandably shocked and alarmed, ran into town for help, and a crowd gathered and found Jesus and the man, now in his right mind. The townspeople were soon informed of the miracle and the disaster, and after hearing and seeing for themselves they asked Jesus to depart from their country. Christ assented, leaving only the healed man to share his experience and testimony with his neighbors.

Whether you read this account as a literal miracle, as I do (see note 1), or a literary story, there are lessons to be drawn for our day. What stood out to me this time in reading Luke 8 was not the experience of the healed man or the unfortunate pigs but the local people who witnessed the miracle. A member of their community who they had been unable to reach or assist was suddenly restored to stability and health by divine intervention. This should have been a cause for wonder and rejoicing, but this miracle had come at a high price: the loss of a whole herd of valuable livestock. The villagers weighed the costs and benefits brought to them by this remarkable visitor, and concluded in fear that they wanted Him to leave.

This decision was driven by more than just fear, a reflex rejection of a startling event which they did not understand. It was a manifestation of what they valued most: economic stability and prosperity, rather than human life and flourishing. As He so often did, Jesus had confronted these people with a dividing line where they had to choose one side or the other: their neighbor or their pigs, learning new ways of helping the needy or carrying on with business as usual, progression or complacency.

Modern medicine is confronted with this very choice today, as a field and as individual professionals. Will we go out of our way and even change our ways to serve the needs of our patients, even if it may involve personal economic cost? When we know what our most vulnerable patients need, will we devote the time and resources to deliver it to them, or are they brushed aside to carry on with another busy and productive workday?

I’ll acknowledge upfront that as a young doctor in training, this is unfairly easy for me to talk, ponder, and preach about. While I am already learning much about the conflict-laden challenges of medical documentation, trainees are shielded to a large degree from coding, billing, RVUs, prior authorizations, and direct grappling with insurance companies and healthcare administrators. I’ve never had to balance the budget for a private practice. I’ve never had to worry that I might have to lay off staff if I couldn’t adjust to the latest Medicare hurdle. I’ve never had an administrator announce that my clinic visits with patients would be cut down by another 5 minutes to catch up on the backlog of people waiting to be seen. I’ve never even had to look a patient in the eye and say that while we have teatments for their condition, we can’t do anything for them because they’re underinsured (my first training institution was a county hospital where uninsured was the norm and civic and charitable funding systems were well established, and my second is a world-renowned medical center where the underinsured usually can’t get in).

Nevertheless, money and medicine is a subject that weighs on my mind, and I feel it is vital for me to think about it now, rather than a year after signing my first contract. I don’t pretend to be an economist: I did work as an undergraduate research assistant to economist Dr. Arden Pope at Brigham Young University studying health effects of air pollution, but this mainly gave me great respect for the complexity of health economics rather than facility in working through the details myself. Dr. Pope did manage to impress upon me Ricardo’s theory of comparative advantage: to focus on doing what I do best and enlist other people to do what they do better, rather than trying to do everything myself. In writing about medicine and money, I will therfore try to focus on principles and patterns, along with frontline observations, and ask for the help of others in working through details and reconciling theory and practice. Here’s a starting list of topics on my mind:

  • Caring for the sick, injured, and afflicted is not intrinsically profitable, it never has been, and I doubt it ever will be.
  • Pure capitalism is an unsuitable foundation for a healthcare system, or at least insufficient. The profit incentive is a powerful servant in developing and implementing medical innovations on a large scale, but it is a dangerous and perverse master which quickly deviates from good patient care and real improvement in health.
  • Transparency is one key to avoiding and minimizing perversions and externalities which distort the healthcare system.
  • Those who work in healthcare should not expect to be rich. The current situation of high salaries in medicine is a very recent change which brings both benefits and dangers, the greatest of which is the danger of compromising patient care to maintain high income, individually and as a profession.
  • Modern medicine requires real teamwork, collaboration between various skilled healthcare professionals built on a foundation of mutual respect and clear communication. This must replace the current situation of compartmentalism and turf wars.
  • Physicians and healthcare workers should be paid in a manner that attempts to incentivize good patient care and outcomes. But incentives will never be sufficient without moral foundations, for by its nature as a complex profession, medicine will always have opportunity to take advantage of patients. Denying this reality leads to regulations that obstruct rather than assist patient care.
  • Some of the most useful and important things that healthcare professionals do for patients are difficult to measure and track, such as assisting with behavioral change, and are therefore vulnerable to be smothered by lesser things which can be measured, from number of falls to patient satisfaction surveys.
  • Everyone needs to pay in to healthcare system, for their own sake and the sake of the system. When people personally invest in a system, they are more likely to productively engage with the system, carefully evaluate options, and work to improve the system. And medicine cannot care for the sick without the support of the healthy, who should understand that they are paying to support their neighbor’s health and not just their own.
  • Physicians have a moral duty to engage in the great debates of health economics as representatives of their patients and as leaders in healthcare. The age of “I take care of my patients, someone else can worry about the money,” is over. Lack of physician input is a major factor in the development of our healthcare system’s worst problems, and they will not improve without physician input and sacrifice.

The bottom line is that in healthcare economics, healthcare comes before economics. The focus must be squarely fixed on individual health outcomes, that is, on healing. This is not done “regardless” of cost, because a system that disregards cost will collapse and be unable to care for anyone. or be bought out by the more profitable. But considerations of cost must always be made with patients first in mind, with sustaining and improving our service to them. It’s not surprising that the system is currently messy: we’ve had less than a century of practice with genuinely effective medicine, and as Atul Gawande pointed out, deploying modern medical science to serve humanity is the most ambitious thing that human beings have ever attempted. I just know that healthcare won’t evolve into the system we want and need without solid principles and earnest effort by morally grounded doctors.

Marcus N. Callister

Last updated 3/26/2019

 

 

Note 1: It is not my purpose here to explore in detail the complex and speculative subject of psychiatric and neurologic illness and demonic possession as presented in the Bible. My general understanding is that the culture of the day treated them as one and the same, and the scriptural writers follow suit in their accounts of Christ’s miracles. In my reading some of these instances seem to involve strictly medical mental illness, some involve genuine affliction by unembodied spirits, and sometimes the distinction is unclear or there may even be overlap of both. I do not know how such relates and applies to our day, though I am inclined to agree with C. S. Lewis’ observation that in modern times Satan seems to have decided to play it subtle and mostly refrain from showing himself in open and dramatic fashion in order to focus on sinking us in secular unbelief (see The Screwtape Letters). But this matter is not relevant to the lesson I wanted to draw from the scriptural account for this post.

My Postulates

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I’ll start with the beginnings. 

In September 2012, I sat down for my first day of Organic Chemistry 351. The professor, Paul Savage, didn’t waste a lot of time going over policies for attendance and late work. Instead, he jumped straight into the core of the course by introducing the list of “postulates” for the class. Starting with “Atoms are most stable with filled electron shells,” this was a list of scientific statements that were to serve as the foundation pillars for the next 2 semesters.

“There are simply too many different chemical reactions to have any chance of memorizing them all.” Dr. Savage told us. “But if you can trace everything you learn back to these basic, fundamental principles, you will build real understanding that will allow you to reason through any o-chem reaction, without any need to blindly memorize. For each reaction we study, ask ‘why does it work that way?’ and then ask ‘why?’ again until you arrive at one of these postulates.” Going deeper than that, he said, would have to wait until later classes. For now, we were to accept these postulates as the final “answers to why” and try to tie everything we studied back to them.

I managed a B+ in Dr. Savage’s class, and I was grateful for it. I’ve since forgotten most of the o-chem reactions he taught, but his method of reasoning has stuck with me: don’t just memorize scattered factoids, dig deeper until you get to foundation principles, then you’ll have a solid basis for thinking through future questions. I have found this applies far beyond strictly scientific fields: it is a powerful lens to analyze human behavior, economics, politics, and even, or rather especially, religion. In fact, I was taught the same method of thinking in another course that same semester: The Scriptures as Literature 303R, by Steven Walker.

“In the scriptures, answers are a dime a dozen,” Dr. Walker taught us. “They’re all over the place. It’s questions that really matter. Good, thoughtful questions, asking ‘why?’ and then asking it over and over again, allows you to stretch beyond your present comfortable, superficial understanding of the scriptures, dig deeper, and find real pearls.” He taught us to shake ourselves from the stagnant “I already know this story” mode of reading and look with fresh eyes at what was really going on for Abraham, Jonah, Nephi, Peter, and Joseph Smith. In the process, I found myself examining my own beliefs, and trying to sift through and separate the assumptions and theories from the fundamental core. 

Years later I am still thinking, digging, sifting, and searching, and I intend to carry on doing so for the rest of my life and beyond. What is emerging is a slowly growing set of postulates, foundational ideas which I hold as my core of truth and strive to connect everything else to. They are grounded in a combination of personal experience, logic and reason, observation of the world, consistent feelings and insights which I recognize as promptings from God, and hopes for a universe that makes sense and has meaning and purpose. Here they are, as best I can express them at present:

  1. There exists absolute truth. Truth consists of concepts, principles, and eternal laws which describe and govern reality, or things as they really are. Truth is truth whether or not we know it, believe it, or like it. 
  2. Recognizing, understanding, and applying truth brings power, progression, and joy.
  3. Exercising moral agency, that is, making choices with respect to truth in an environment of opposition and consequences, is absolutely necessary for learning and growing in truth. 
  4. There is a God, a divine living being who has a full and perfect understanding of truth borne of experience, and thereby a fullness of power, perfection, and joy.
  5. All human beings are children of God, literal daughters and sons of loving Heavenly Parents, with divine potential to grow and become like them. 
  6. Every action of God toward His children individually and collectively is founded in mercy and love.
  7. God formed this Earth as a place for His children to receive physical bodies, make choices, learn by experience, and take critical steps to become like Him and live in eternal families.
  8. Jesus Christ came to earth to set an example of perfection, teach truth, gain understanding of each of God’s children, and be empowered to cleanse us from sin and guide us into all truth.
  9. Repentance, that is, changing our mind, desires, and actions to align with truth and God’s will, is real, cleansing, empowering, and joyful. Jesus Christ makes repentance possible, guides us through the process, and brings about the change in our very nature.
  10. Resurrection, the reuniting of body and spirit after death into an immortal, eternal soul, is real, and through Jesus Christ will come to every person who has ever lived on this Earth.
  11. God communicates with His children individually by means of the Holy Spirit; a being of spirit who speaks to us through thoughts and feelings which carry true insight, peace, and strength.
  12. God communicates with His children collectively by means of prophets; designated individuals inspired through the Holy Spirit to share specific messages of truth with a group or the world. Select prophetic messages are compiled in the scriptures. Every individual can obtain personal confirmation by reason and revelation that a prophet’s message from God is true. 
  13. The Book of Mormon is true, a genuine ancient record of prophetic messages focused on Jesus Christ brought forth by God for our day.
  14. Prophets and leaders in The Church of Jesus Christ of Latter-day Saints are mortal men and women with special authority and responsibility from God to receive and teach specific messages of truth.
  15. Covenants, that is, authoritative commitments between God and an individual, bind us to God in a special relationship of love, mercy, faithfulness, kindness, and grace. God will never forsake His end of a covenant, and will continually reach out to His covenant children to help them draw closer to Him.
  16. Humility before God, recognizing our limitations and weaknesses and acknowledging Him as the source of all our blessings, talents, and achievements, is the beginning of true wisdom and strength.
  17. Focusing primarily on oneself causes stagnation and shrinkage, while focusing on serving others leads to growth and joy.
  18. Gratitude is a divine key to happiness and seeing God’s power, kindness, and mercy in our lives and the world.

These postulates are by no means complete or final, I will continue to refine and add to them as my understanding grows. As they are, they stand as the surest points of truth I know and hold dear. I do not hold them as self-evident per se, and I am willing to discuss sincere questions regarding the validity of any or all of them. However, they undergird much of my reasoning and worldview. Many times when I find myself in a serious clash of opinions with someone, I can trace the conflict back to a disagreement or differing interpretation on some of these fundamental points. I therefore wanted to give you, the reader, a clear and honest explanation of “where I’m coming from” as a thinker and writer, as a matter of intellectual transparency, and in hopes that it will enable productive discussion of important matters, especially when we disagree. I also wanted to begin this blog by sharing the things I consider to be most important, in hopes that someone might find them intriguing and enlightening and desire to learn more. I’ll conclude with a beloved quote from my would-be namesake:

“If someone is able to show me that what I think or do is not right, I will happily change, for I seek the truth, by which no one was ever truly harmed. It is the person who continues in his self-deception and ignorance who is harmed.” Marcus Aurelius, Meditations

Written February 14, 2019. Last revised January 26, 2023