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Affection Love and Duty, These Three

Posted by Dr No on 25 January 2013

corinthians_13_12_13.jpgDr No’s mother is a heartsink patient, and she happens to be dying. Unpalatable as they may be, Dr No says these two things as matters of fact. On one level, as a doctor, he cannot not see his mother as he would see a patient – and the hallmarks of heartsinkery are undeniably present. Although Dr No has had a hunch about prognosis for some time, it was his mother’s consultant who gave it form, in a measure of months. She is a heartsink patient, with only months left to live. Those who care to opine that heartsink is a term of derogatory abuse might also care to reflect that the term is not so much a patient label, notwithstanding the inescapable fact it is one, as a useful term from the lexicon of countertransference, under the general heading of those feelings and emotions engendered in a doctor by his or her patient. Countertransference matters: those who choose to ignore it do so at great peril, not just for the patient, but also for themselves.

The NHS, although it has not definitely failed Dr No’s mother, has so far achieved a half-term report of ‘could do better’. An Easter admission to a world famous teaching hospital provided a carnival of care delivered by singing housepersons, backed up by an assembly of registrars who would be stuck to know which way the wind blew out of their own backsides. Her GP, a two trick heads are antibiotics tails are steroids apothecary, has managed his own countertransference by the questionable tactic of telling his patient to bugger off, unless and until she deteriorates. Meanwhile, the cogs of community care have groaned into action, at a pace which makes watching the grass grow dangerously exciting. A privatised home oxygen service has so far shown itself to be about as much use as a match in a munitions store.

Doctors are more often than not awkward patients, for the personal and professional realms get blurred. A similar process happens when the patient has a medical relative. The real doctor cannot escape the medical elephant in the room. Is the elephant a doctor, a relative, or an elephantine hybrid? Roles are uncertain, and again boundaries blur. And so, inevitably, partly because of the role confusion, and partly because the NHS hasn’t yet got all its slates on the roof, Dr No has, ipso facto, been defaulted - the passive voice is intentional - into an informal partial doctor to a heartsink patient who just happens to be his mother. The situation is far from ideal, but short of talking an extended trip overseas, there is little Dr No can do about it.

So now Dr No the doctor has a heartsink patient, and, because he is also the son, he too has a heartsink parent. As those who have struggled with a heartsink parent will attest, such relationships are as awkward as they are inescapable. The clinical measures one might use to manage a heartsink patient fall short when the patient is a relative. Or do they? The dynamics of a doctor-heartsink patient relationship are after all very similar to those of an adult child-heartsink parent relationship.

And so Dr No was reminded of recent discussion here and elsewhere on the management of heartsink patients. The RCGP elite favour caring, preferably so much that it hurts. JT reckons all you need is love. Dr No, for his part, went Zen, and declared for non-attachment.

Watching the terminal illness of a heartsink patient/parent has given the clinical Dr No a rude reminder of how difficult these things are. Dr No the son has felt the inevitable rendering down of his emotions as he grappled over time with at first a difficult and then a heartsink parent. The shared joy of a spring walk after a bout of winter pneumonia gets strained in time as the parent regresses and – a typical development – becomes an ‘entitled demander’; and the warm tide of affection runs out. But the sea of love remains even after the tide of affection has gone out. But over time, even seas can run dry. With the tide of affection has gone out, and the sea of love drained, what else can the doctor/son fall back on? The answer, at least for this doctor/son, is duty.

In his First Letter to the Corinthians, the apostle Paul describes three virtues: faith, hope and – in the King James version – charity. Other Bibles replace the word charity with love, and strictly speaking this is perhaps the more accurate translation of the Greek αγαπη, but mundane love, which is the sort of love Paul is describing, is too fallible to make sense. Love is too easily puffed up; too prone to seek her own ends; too prone to fail. It cannot be the greatest of the three, which is why Dr No prefers the King James use of charity. And so, in an echo of form which puts love in its place, for doctors/sons at the end of their tethers as they face heartsink patients/parents: there abideth affection, love, duty, these three; but the greatest of these is duty.


Tough time for you. I hope community care kicks in. I found the district nurses by far the best

It would perhaps be too crass to say I wore this teashirt; the one emblazoned with 'duty', but I did. I wore it for years in service to my difficult and eventually 'heartsink' mother. And yes it eroded pretty much all of the love and left me often drained of all vestiges of campassion, especially once the dementia kicked in.
Her worst excesses had been checked by my stoic father but when he left us via the coronary ward, I and my siblings were left with the duty of caring for her; one who didn't.
I abandoned them to it, once she was in the nursing home and she eventually died. Until I saw that coffin descend, I was nonplussed by their vitriol about my ommission of duty, but then such a welter of devastation overwhelmed that I was inconsolable, that I had done this evil thing.
My twenty years of duty, for that is what it was, robbed me of so much that it seems to have taken years for me to adjust to have 'normal' emotional responses to difficult situations. So beware of duty; it can suck the life from you, my eloquent friend.

By definition duty obliges us to go on irrespective of personal consequences - duty is hard, but most people expect to face a dose of it at some point in their life?

Perhaps the other elephant in the room (when death comes calling) is how it might be for us when it's our turn, and who the mantle of duty will fall to when it does?

The duty, the moral obligation of a son to his parent is, in particular circumstances – as you so eloquently describe – a heavy burden to carry and oft engenders emotions difficult to bear.

We do what we do as it is the right thing to do and wearily accept the destructive forces at play as love and affection dissolve and re-emerge as new emotions of hate and contempt – and we hate ourselves for it, resent/despise the person who made us this way as we reach the end of our tether.

But we do what we do as it is the right thing to do – for the unlovable parent who was once much loved. And although at this time the burden of duty is wounding to you – you will eventually emerge from despair with a clear conscience.

You are a good honest man Dr No and my thoughts are with you.

Duty: from the Latin debere via the anglo-french duete meaning a debt; something owed.
Maybe looking at the "real" meaning of the word would take some of the emotional charge from the act.
We are all well-versed in the act of paying taxes for example. We don't particularly like doing so but we don't have strong emotional reactions of guilt for not ENJOYING it neither do we have feelings of guilt for begruding the taxman his "due".
At the risk of upsetting anyone I would suggest that doing our duty (in this sense of the word used here) does not make us "good" (on the plus side of this it means that we also cannot be characterized as "bad" if we do not do it!).
It is simply something that we do because we have decided that to NOT do it we would not be the person we wish ourselves to be.
It is, without doubt, a horrible situation to be in for anyone but I believe that unjustified feelings of guilt is the element that makes this situation more exhausting.
Take care

I am so sorry to hear Dr No's news.

Dr No has already done his duty as a doctor in my battle to save some children and my grandpa, Dr JTS Hoey who I last saw at the Dragon School in May 1976, would be proud of his effort on my behalf:

In the summer of 2009, I visited Lincoln Cathedral where I read Luke 12, Matthew 18 and "To My Son" by Mary Hoey in front of the altar rail in Lincoln Cathedral dedicated to Captain John Brunt VC MC and Major Charles Ferguson Hoey VC MC.

Charlie Hoey is my first cousin once removed and is now being given credit for turning the war against the Japanese in Burma with a surprise Bren gun attack.

The JTS Hoey site about the storming of Horseshoe Hill on August 18th 1916 by the Oxford and Bucks was put up in the interests of fairness and justice and when I got back from Lincoln I sent the regiment a link and a picture of the occasion.

On 11/11/2009 I had a message to say there were new additions to the website:

I think all those who gave up their lives for our freedom from Nazism and other forms of facism have been very badly let down and I continue to make mental war rather than corporeal war for my friends as instructed by William Blake in the introduction to Jersualem.

England expects and all that ...

My father has dementia. As a father bringing me up, he recoiled from hugs, expressed no affection, just approval of straight As and disapproval of anything else. Nothing was ever good enough for him. When his mother got dementia, he largely ignored her in favour of his career until she was so far gone he had to put her in an asylum where he continued to ignore her for many years. When I was ill (I have bipolar disorder), he mostly ignored me and avoided visiting me.

I now look after him. I visit him every day, do his laundry, sort out his medication, do most of his shopping, sort out his paperwork, watch old films with him, cook him meals etc. Why? Because I am not him and I am treating him as I wish he had treated me not as he did treat me. It is as much about who I am as about who he is.

And I do love him. Not the spontaneous love that some friends express. Not the love I feel for the friends I have chosen. The love I feel for my neighbours, my colleagues, my fellow-sufferers and all the other people who cross my path and need my help.

I imagine Dr No has given it great thought before publishing this post as he goes through what is probably one of the most difficult times of his life.

Nevertheless, now that he has posted it, many issues are raised.

One very practical issue is the question: Where are the GPs when they are most needed?

It happens that WD has a close friend who is trying to care for a relative at home in an intolerable situation for both of them. The friend has made WD aware of what is happening every step of the way. The GP is conspicuous by his absence and why this is eludes me. Communication is poor, continuity of care is poor, some things are said inappropriately, information given by some members of the team are at odds with what is being said by other members, and the GP never visits. I could go on and on. My friend is the main coordinator of care at every level and she now tells me she will have to bypass her GP and do something that would formerly be considered inappropriate. Much of what she has to do, with great difficulty, a good GP in the past would have organised with a team that knew each other, met with each other and worked closely together. The GP would have kept his eye on things and made frequent home visits to support the patient and family.

My understanding is that in any practice, a single GP will have about 20 deaths a year. Some of these will be sudden, and some in hospital. So any GP will be responsible for less than 20 per year. Is it too much to ask that they support these few patients and their families during the last year, months, weeks or days life?

Dear Dr No,

Charity is not duty. I think if you look at where you're at you'll find that you have gone well beyond duty by now. Nor is it affection that comes and goes. Charity is love, but the deepest kind. It's what is left when everything else is stripped away and doesn't depend on what you feel - only on what you do.

I'll be thinking of you as you care for your mum. Please be gentle with yourself, and don't fret too much about what you do/don't feel. It's what you do that matters.

Dr No thanks you all for your thoughtful and kind comments.

Never have four letters been under such strain as they are when assembled in the form l-o-v-e. We all know instinctively that there is more than one type of love. We also know instinctively that some types are purer, or somehow more noble, than others. For those with a Christian faith, there is, so far as Dr No understands these things, what we might call ultimate, transcendent or Divine love. This, again so far as he understands these things, is the deeper magic, the magic that goes back before the dawn of time, that CS Lewis describes in The Lion, The Witch and the Wardrobe.

Love, charitie (Dr No uses the pure KJB spelling to distinguish it from the more common modern usage) and duty, these three: Dr No agrees these not are one and the same thing. Indeed the distinction is critical to what Dr No is grasping at in this post. There are the many varieties of mundane human love alluded to above. These are the prone-to-be-fickle ones: the ones the apostle Paul says charitie is not: there are seven nots, one no and one never (maybe P was a bit of a DN himself) in these five short verses:

4 Charity suffereth long, and is kind; charity envieth not; charity vaunteth not itself,
is not puffed up,

5 Doth not behave itself unseemly, seeketh not her own, is not easily provoked,
thinketh no evil;

6 Rejoiceth not in iniquity, but rejoiceth in the truth;

7 Beareth all things, believeth all things, hopeth all things, endureth all things.

8 Charity never faileth...

The trouble with ordinary mundane human love is that, with notable but rare, perhaps extraordinarily rare, exceptions, it never achieves unconditionality. Indeed, we might even say that human unconditional love is an oxymoron. The more human it is, the more frail it is...for frailty is part of our condition. Ordinary love is almost invariably conditional, and that makes it finite. In practical terms, it has it's limits - the ones we have all come up against from time to time.

Charity, however, 'never faileth'. Dr No's understanding is that Paul's 'charitie' is the human expression of the deepest love, whether we call that Christian love, Divine love or unconditional love; and because it is unconditional, feeling is indeed stripped away, leaving only doings, or acts. It is a wonderful concept (Dr No is not being facetious here), but, to Dr No, it does seem a rather 'big ask' (what kind of phrase is that???) of your average human, who is routinely wrapped up in the more mundane conditional love? This is where love falls apart: the ideal form is rarely present in or expressed by us frail all-too-human humans: and that is why Dr No demoted l-o-v-e from being the greatest of these three.

Dr No is happy to see charitie as the greatest of these three in the Bible; and it can remain there as a lofty and noble ambition (again Dr No is not being facetious), to be promoted from the pulpit. Back down on the shop floor, however, where we get our l-o-v-e-s hopelessly muddled and confused, we need something simpler, and more practical, to guide us. Dr No's stab at what that might be is duty.

Nor does duty have to self-destructive. It sure did for Nelson (one of Dr No's heroes) but Nelson had an intense, profound, even sacred sense of duty, and might even have tangled it up in another D word, destiny. For those of us not engaged in annihilating combined fleets, and instead routinely engaged in looking after frail all-too-human humans, a more practical, survivable form of duty is sufficient; a form which includes within it the duty, as Dr No has it, to 'look after the machine'. Put more prosaically, what practical use is a doctor/carer who self destructs?

There is a sort of full circle to all this. As we let feelings drop away, and are left with just doings - themes common to both Julie and Suzanna's comments - we find, in the removal of emotion, a form of non-attachment where we just 'do': chop that wood, carry water; which is where Dr No started on this. He need only add that the form of l-o-v-e mentioned in that graf is: well?

And, once again, thank you all for your kind and thoughtful words.

Love is indeed one of the most difficult words, perhaps because the English language has not created enough of them to express the various types of love. It may be that the running out of what is considered to be love and affection that was once there is a great help in heralding in proper “caring” of a relative by a relative. Perhaps it is nature’s way, if nature indeed has a way. Strong human love for a suffering relative is so powerful that can render the ”carer” almost paralytic as they deal with their own grief and mourning long before the loved one is even near death.

The word “duty” though is difficult also. Susanna points out the term “owed.” Duty/owed/debt to whom? Is it duty to yourself, the relative, the patient, the state, all of them? What if the various duties clash? Does one always have a duty to care for a close relative? Or for a neighbour, or friend, or patient? Or is it at times OK to walk away?

I struggle with the word “duty” as much as with the word “love” and prefer two words used side by side to replace it. These words are “empathy” and “help.” Empathy does not need human love and drives a relative, friend, neighbour or doctor to help an individual rather than to be a slave to the state, the community, or even to his/her thoughts (“what will the neighbours think if I walk away”). Is “duty” a kind of slavery whereas the hybrid “empathy/help” keeps you free up to a point.

But what if there is no empathy?

I absolutely agree with WD's post and I love the vocabulary used "empathy" and "help". Certainly 2 words that releive the "doer" of his/her emotional burden.
Whatever words we choose to use I feel it paramount to relieve the carer of feelings of guilt. Guilt is the most useless and destructive of emotions. Guilt for feeling or not feeling something is taught to us from a very young age. The toddler's feelings of hate towards his mother when deprived of something wanted can be a huge threat to the mother. Very few can take a step back and see that the toddler hates her in THAT MOMENT. Emotions do not last. The fear the mother feels compels her to teach the child that hate is not allowed. "How dare he?" "After all I have done/given up for him!" From this, and many other social situations, we learn that we should not feel what we feel. Thus we learn "GUILT". We are not taught that feeling and thinking "bad" things is natural. We are taught that if we have these feelings and thoughts that we are intrinsically "bad". Great! Now I have to unfeel feelings!

You could look at it from the old testament perspective instead of the new testament. כבד את אביך ואת אמך

This is usually translated as honour thy father and they mother.

The septuagint Greek translation has tima, which is more often translated into English as fear.

Other translations include respect.

But loving mum and dad didn't make it into the ten commandments.

Jesus told us to love God and our neighbours. That appears to include our parents. But he doesn't seem to have made a thing specifically about loving our parents.

Honouring your parents sounds to me rather like doing your duty towards them. It doesn't sound all lovey cuddly. That doesn't mean you can't be that way towards them, just that where looking after mum is concerned, if you're looking at the bible, I think it helps to take the honouring bit into account.

There's a poem by U A Fanthorpe called 'Altas', which goes like this;

There is a kind of love called maintenance
Which stores the WD40 and knows when to use it

Which checks the insurance, and doesn’t forget
The milkman; which remembers to plant bulbs;

Which answers letters; which knows the way
The money goes; which deals with dentists

And Road Fund Tax and meeting trains,
And postcards to the lonely; which upholds

The permanently rickety elaborate
Structures of living, which is Atlas.

And maintenance is the sensible side of love,
Which knows what time and weather are doing
To my brickwork; insulates my faulty wiring;
Laughs at my dryrotten jokes; remembers
My need for gloss and grouting; which keeps
My suspect edifice upright in air,
As Atlas did the sky.

This question may sound extremely impertinent so perhaps I should apologise in advance for raising it, but did Dr No expect something different?
The NHS creaks - dying is a grim business, aging parents regress, adult children become guilty, or confused about their feelings - the pressure of such experiences distorts relationships (although some degree of revisionism takes place afterwards).

Anyway, this is how I found it when it was my turn - dipping into happier family memories helped a bit, but not much.

I have thought long and hard of what (I think) love is, what it means to me, how fragile it is and how it can be sorely tested. Love is indeed an attachment, an affection attachment given freely with the hope, the desire of reciprocal engagement, engendering a sense of belonging, a selfish (and necessary for survival of self) need to be needed, to matter.

Love is a physical and emotional thing; physical in the sense of how we feel it in our bodies, how it fills up our chest and emotionally how it can leave us anywhere from elated to extremely vulnerable.

The level of love is not a constant and is as varied as our moods. Do I actively love my family all of the time or some of the time? Honest answer, I think my love for them constantly changes from that of affection to deep affection to that thing I think love is, that is, when I am overwhelmed by the strength of my emotions and that powerful wonderful feeling in my chest.

Love can be deep or shallow – dependent on who is giving or receiving. Love can be the most wonderful thing or the most dangerous weapon. Love carries with it the potential to destroy those caught up in the need of it – and the need of it exists within us all.

Can love be killed within the heart of us – yes it can. As my mothers dementia progressed (and she became a stranger) – I gradually ceased to love her and eventually felt cold towards her – and ?oddly that is the emotion that has remained with me long after her death. All those years I loved here (and indeed I did) are gone and only the coldness remains, is all I have left.

In those final years I visited her out of a sense of duty, or did I? I think I visited her as I did not want those who cared for her to think ill of me, and the people I love to think less of me – for I did not want to go – and because of this I had become someone I did not like.

It is true that those with dementia receive very few family visits and I can understand why, for it is very difficult to hold on to love as someone you love disintegrates before your eyes. You lose the person you loved so cease to love the person, the stranger that remains, and the stranger that lingers for years as a constant reminder of what you have lost.

I think what I am trying to say Dr No is that I understand how torn you are, how emotionally wrecked you are and how difficult your situation as a doctor/son must be. If the sense of duty is all that remains – do not be embarrassed or ashamed of it for it allows you to cope.

Care in the community is a joke, a cruel joke at end of life and you are giving your best, your very best – however painful it may be.

My thoughts are with you.

Been in some remote places so late in offering my thoughts. Here they are,they are with you.

Where I come from, it has always been the children's duty and often that of the eldest son. With our ancient believes, one needs to trust the superior power of whoever was the god.

Unfortunately some of us are caught up in the Biggest sale of the century: The NHS. To achieve, it was necessary to turn a once superior Health Care system bad; starting with Mid Staff. Then it was necessary to fail many hospitals.

It was not really to sell these "BAD" places but the idea that punters should go "PRIVATE" or accept AQPs as they have to be better.

So old age care went out of the window together with Mental Health ones.

Mid Staff happened because of central policies. In public health, chronic patients are costly and they need to be got rid of one way or another.

In AQP system, the best patient are chronic ones as the State will have to pay but not in true private health and that is why they are dumped back to the NHS. Death is of no good to AQPs.

In Cambodia, Khmer Rouge recognise this and so they later did not kill the dissidents but maim them(blindness etc) to increase the burden on the families so that they cannot have the energy to fight the regime. There are now many blind musicians begging in Cambodia.

Why am I writing about this when I recognised the pain DN is going through and as a Doctor, I too felt much frustration thinking about it: it need not be so. As we all have non doctor relatives, one is expected to have the answers and if not, the influence on the doctor colleagues or at least favours.That is how the world of those in power operates and aren't doctors powerful!

Little did they know: not any more, not for a long long time anyway.

We need to bring back real and efficient medicine, free from incentives for Privateers which would include the doctors. We need to bring back community spirit so that we share the rare commodity : the medical profession; instead of allowing those with money to buy the best care.

Am Ang Zhang,

These and other Khmer Rouge atrocities in Cambodia and those currently elsewhere in the world not only make The Witch Doctor feel physically sick, but are also a tough reminder that the medical profession should never become servants of the state. Employees yes, but servants never.

Such evil could never happen here.

Of Course not.

Re the NHS: It is interesting that following the Olympic opening ceremony they say the NHS is now being seen as a gold standard for healthcare outwith the UK and several countries now want to purchase our know-how. The NHS brand is now being marketed worldwide by Healthcare UK, a new organisation that is a joint initiative between Dept of Health, NHS Commissioning Board and UK Trade and Investment. Healthcare UK is being launched in Dubai this very day. Perhaps a previous CMO had this in mind when he said the country needs more doctors. Indeed maybe Liam Donaldson is some kind of visionary who saw the NHS going global long before anyone else.......

This silly old bag of a witch identified herself as anonymous in the above comment. She was so excited about the NHS going global!

Of course! And Baby P would bot be the part of the Gold Standard. Or perhaps the visionary would also remove his registration with the GMC for good measure. Nor would it be a Dubai Mid Staff. that was a tactical move.

Trying to be so excited too.

Charity is an interesting word that is used in the King James Bible in the place of love. However, there is a need to observe how the word is used in scripture. In Webster's Seventh New Collegiate Dictionary, the first meaning of the word Charity listed is LOVE and the second meaning is kindness or help for the poor. The word Charity in the King James Bible is used to express the Christian love for other Christians. It is never used to express the love relationship between a husband and his wife, between parents and their kids, or between the skeptic and the no skeptic. Even the word Love can have several meanings. If we say, "I love apple" and "I love that person," these both sentences imply different meanings.

Charity, how often we misused such word but the previous comm-enters are right. Charity is not a duty. Will be praying for you.

I got tears in my eyes after reading your post. How tough are things i can understand. Hope all goes well.

Informative posting! I think this posting would be effective for all. Thank you for sharing with us. invites you to read Dictionary of love

Love and duty are most important aspects in our life. If we get these things right, then the rest of the things will get along without any intervention.
Windows 8 installation
A good person will be loyal to both his love and duty.

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