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Second Opinion

Let Go of Guilt

Leap, Edwin MD

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doi: 10.1097/01.EEM.0000296437.94005.20
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    Guilt is the most holy sacrament of modern life. It inhabits our social policies as a nation, our environmental movements as a culture, and even our international interactions over terrorism, trade, and prosperity. I'm amazed sometimes at just how much guilt the media and intelligentsia of America can harvest from the people, year after year. I find it especially hilarious when people say that religion is ridiculous because it makes people feel guilty. We don't need religion for that!

    I know from guilt. You can keep your Jewish mothers and ruler-wielding nuns. I grew up in evangelical Protestant Appalachia. I'll give you an example. My mother won't mind. (I hope.) My freshman year in college, I dated a girl named Elysabeth. I was 18, and she was 23. She was an art major, a young woman with long, blonde hair and a lithe shape. She was my “older woman.” I thought I was quite the man.

    I took her to a homecoming dance where someone thought a carousel would be romantic, in a grade-school, drunk-college-student sort of fusion. Elysabeth and I rode the carousel, and toasted our evening out in a photo, in which we were holding glasses of what passed for champagne.

    I later showed the pictures to my mother, as if to say, “Hey, college is fun! Look at my date!” Apparently, what she heard was, “Hey, look! I'm with a blonde bimbo, and we're both getting as drunk as humanly possible because I want to be a drunk!”

    Mom didn't speak to me for a few hours. Fortunately, she forgot about it. I never became a drunk, and I never showed mom any other pictures of that sort. In fact, I never let anyone take any other pictures of the sort. But I did feel some guilt. It wasn't mom's fault. She learned guilt from her mother, my grandmother, who remains the high priestess of inappropriate guilt at 89 guilt-laden, blue-haired years.

    So I understand it all. In fact, I've felt guilty about almost anything you can imagine over the years so it was really an easy transition into the power of guilt as a professional. In fact, when I put on my guilty doctor suit, it fit like a powdered latex glove.

    Physicians collectively feel a lot of guilt. We feel guilty that we don't know more. We feel guilty that we don't do more. We feel guilt about our need to be on committees and to be educators. We often feel guilty about the money we make, even as we feel frustration when insurers deny payment. We feel guilty when we speak angrily to another doctor, a nurse, or staff member, and extra guilty when we talk down to our patients. We feel guilty when we don't stand up to someone who berates us. We feel guilty about our delinquent charts. We sometimes feel guilty about the economics of medicine, and a fair number of physicians feel guilty enough to advocate a national health care system.

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    We feel guilty that we eat junk food, drink too much coffee, and exercise too little. We feel guilty that we haven't spent enough time with our spouses and children, and then feel guilty that the retirement and college tuition accounts aren't bulging with money.

    And worst of all, we feel guilty about suffering and death because, especially in emergency departments around America, we see a lot of both. As medical students, we learned that death was the thing we were supposed to stop. And our constant inability to stem the tide of the death (now in its gazillionth year) fills us with untold milligrams of pure, autoclaved, concentrated guilt.

    I realized this recently. I had some remarkable deaths in my department, and they left me feeling sad. They left me feeling guilty. And as always, they left me going back over the entire situation in my head.

    Even as I write this, I'm considering the patient I saw last night (who may have died by now) after her toxic carbon monoxide inhalation. What could I have done differently? How could I have saved the other woman who died last week? Or the man the week before that? If only they could just open their eyes and talk to me again, and say, “Thanks! I feel better! I think I'll go home to my loved ones now.” Often I wonder if I failed. Guilt quite literally rises from the dead.

    Our culture doesn't help the guilt problem. Every tragedy, every inconvenience must be blamed on someone. We have review boards and commissions, congressional inquiries and consulting bodies, plaintiff's attorneys and medical boards. It seems at times that all they do is sit around trying to assign guilt (never guilty themselves, of course, for the problems and even tragedies caused by layers of administrative refuse). And we in the culture at large and in medicine in particular respond with new policies, new procedures, new classes, new algorithms, and newer, deeper levels of guilt than ever before.

    But here I want us to stop and ask this question: What does our guilt do for us? And I'll give the answer because I don't want you to feel guilty while trying to find it. Guilt serves a function as a moral guide. Without guilt, we become sociopaths, incapable of feeling remorse and incapable of making proper judgments in our interpersonal interactions. Guilt helps to hone our relationships with God and man.

    Beyond that, it does little else. When we feel guilt over things that have nothing to do with choices between right and wrong, then we misuse guilt. Like performing an appendectomy with a baseball bat, it's simply the wrong tool for helping us make day-to-day decisions. And it is a horrible implement to use for our own self-assessment; we are always our own worst critics who can never see how brightly we shine.

    Guilt is an especially terrible thing to use on ourselves when we work in a place where pain and death are regular visitors. It wears us down. And usually it is false. Even if we make a mistake, it isn't a moral failure. It isn't that we intended to give a wrong dose or miss a diagnosis. If we harm intentionally, we should feel guilty. But if we only make a mistake (and that's what they are, mistakes), we should try to make amends, to undo the damage, and to learn so that we don't repeat our error. But we don't need guilt.

    The thing is, we practice an imperfect science on human beings, who are uniformly doomed from day one. They will all have illnesses and accidents. And 100 percent of them will die. It's our job to stave that off for as long as possible. It's our place to make humans healthy and comfortable so they can lead productive, happy lives. But it isn't our place to make them immortal. And it isn't realistic to think that we won't do the wrong thing from time to time.

    I know there are consequences to errors, and there are emotional weights to bear when we see death and tragedy. But guilt is one weight we have to learn to set down. It keeps us from moving forward. It drowns us in emotion and memories of what might have been. And it doesn't help anyone, whether laid upon us by patients, families, administrators, or attorneys. But more to the point, when we lay it upon ourselves, we are trying to make a sacrifice to atone for our humanity. And we can never scar ourselves enough to change who we are: mortal, fallible, imperfect, wicked, self-hating, amazing, near-angelic, loving, wonderful, awe-filled, and God-created. We will be those things no matter how much guilt we think we need to heap upon the altar of our hearts.

    So lay it down. And try for once to live a day without guilt. It's an amazing experience when you can do it.

    (For more on guilt, see www.edwinleap.com.)

    © 2007 Lippincott Williams & Wilkins, Inc.