Tears and touching are some of the most profound forms of connection among people. They soften hearts and open doors to each other’s hearts that were otherwise closed. Spiritual care in a hospital environment brings people together in the best way possible under the worst of conditions. I regularly meet strangers and confront situations that require patience and acceptance so I can do the best for others.

What does a multi-faith hospital chaplain do? First and foremost, a chaplain is always there to be a listening ear in a compassionate and caring manner. A hospital chaplain cares about spiritual and emotional well-being of patients, their families or loved ones, as well as the staff at the hospital. As chaplains, we are in the service of everyone, religious or non-religious, faithful, agnostic, or atheist, during both good times and bad times to share joy and sorrow. We visit the patients that need comfort and support, and listens to their worries, concerns or happiness. We are with the patient in their last moments to offer blessings and stay with the families when their loved ones are going through this transition. We are together the broken-hearted who need to be heard, patients who request prayers before their surgeries, and babies who are newly born or die young. We touch hearts, wipe tears, listen to life stories, open spiritual gates, and help people reflect on their own lives to find out where they are on their journey. Lastly, we encourage and empower the ones who are in their recoveries. Sometimes patients are the teachers who allow chaplains journey with them.

I had an interesting encounter with a 67-year-old Catholic lady who came to the hospital for spinal surgery. She did not ask for a chaplain visit but her name was on my unit list. I met her post-procedure during my regular rounds. She was frustrated and upset because the doctors told her that she had cancer; however, what type of cancer she had was still unknown ten days into her stay. She was emotionally overwhelmed with worry about her physical condition because the doctors were still testing the results, and she felt they were not giving her clear answers. She was not alone, because her daughters lived close to her however she could not help but cry when she started to speak about being away from her home and family for a long time, along with the uncertainty she faced which was obviously hindering her ability to cope. I was very concerned with her psychological and emotional state. She was not ready for a longer conversation with me. She dismissed me after a few more minutes and said, “I rather want to be alone at this moment”. I replied, “I understand, it is okay with me.” Upon leaving, I reflected on not being able to help her at all. I felt badly of the situation, and felt that I had missed an opportunity to provide care that I was not able to reach through to her.

The next day, the patient’s nurse telephoned the Spiritual Care Office and requested that I return. The phone call meant a lot for me because I anticipated that there was something significant happening. I immediately went to the patient’s floor and saw her nurse. She told me that the patient wanted to see me before she was transferred to another unit. Upon entering the room, the lady told me that she did not want me to know her as a rude person. She apologized for her attitude the other day and said, “We are both believers and we should not be like that towards each other.” I confirmed this sentiment, and she continued, “I don’t know as much about your faith as I should know, and I felt that I need to know more of it.” She asked me if I could talk about the main principles of Islam, and I accepted her request. I stayed with her explaining, shortly, the basics of Islam, how God sent prophets to all human beings throughout history, and how the Qur’an was revealed and compiled. We had a good discussion which relaxed her and as our conversation ended our relationship between each other was more important than her illness. Her embarrassment replaced with peace at the end. “I am so glad that I was able to call you back,” she said with contentment. “I am so glad that you took the opportunity to invite me again to your room” I responded with a smile. This time, I left her room with a great sense of relief and satisfaction.

“Can you hold my hand?”

Another thought-provoking visit was with a 69-year-old lady who came to the Emergency Department (ED) on a night when I was on overnight duty. It was 4:40 am when I was paged by the ED nurse as the patient asked for a Catholic priest, who was not available. She indicated that the multi-faith chaplain was okay to visit with her. She looked youthful and pretty in her bed but, as I asked her about her concern, she responded, “I am scared of dying.” Doctors had told her that she had an obstruction which was resulting in a removal of one of her kidneys. She was also experiencing blood pressure and diabetic issues.

She was alone at the hospital and her emotions were in a whirl with many thoughts on her mind as the surgery was imminent. We continued the conversation in a manner to address the frustration and fear she was feeling. She responded positively to my empathy and reassurance. She told me about her financial difficulties and that she would lose her home soon. Then she asked me, “Can you do me a favor?” I said, “Sure, what is it?” She asked, “Can you hold my hand?” I took her hand gently and prayed to God, asking Him to provide her with comfort, peace, relief from her worries and for a successful surgery. It was a moment that we both appreciated. After prayer, she asked me about myself and we spoke of our families. I reminded her that the Spiritual Care would be happy to be with her and that I would like to follow up with her during her stay. She seemed relieved and less anxious by the time I departed. I can only imagine how stressful it was for a lonely lady who was dealing with many issues in a strange place in the middle of the night.

From a personal point of view, conversations on faith or religion always remain behind the feelings or emotions of the patients during my visits. I focus on their current spiritual or emotional crisis within the hospital. My goal in my interactions with patients is to provide a safe and non-judgmental space built upon trust and a genuine human connection. After assessing their needs, sometimes I explore if they have a religious background or community, any spiritual practices such as reading holy texts, prayers, rituals, or meditations which might be helpful support for them. I also try to understand if any of their practices help them cope with their difficulties in any way. On the other hand, each patient is unique and each visit is different than the last. One common point is that when words cease to be enough, a warm touch on the hand or the shoulder, or a silent tear shed, become powerful enough to build the connection between the chaplain and the patient. The goal is to always share a genuine moment between two strangers, one of which may literally be on their death bed. It helps to remind us that our faith and appreciation of the Divine can unite us, and that we will all return to God someday.

As I wheeled Chris off the elevator, he was quieter than the day before, definitely not in the mood for pranks. He didn’t complain—my husband never complained—yet he clearly wasn’t feeling as well.

Two steps forward, one step back: that still qualified as progress.

Rolling through the hospital hallways, following signs for Radiology, we passed several women wearing nasal cannulas and pulling oxygen-cylinder carts. The sight wasn’t remarkable in that the National Institutes of Health runs clinical trials on virtually every ailment—from the common to the rare, the treatable to the terminal. What was surprising was seeing a cohort of patients similarly afflicted, all female and relatively young.

At least they were ambulatory. When Chris’s doctor ordered a scan this morning, his nurse ordered a wheelchair.

During his first few days after readmission, Chris’s condition fell somewhere between depleted and God-awful depending on the degree of his sawtoothing fever. As his treatments—withdrawal of anti-rejection meds included—began to take effect, however, I’d sometimes arrive to find him sitting up in bed, looking comfortable and alert, like a patient soon to be released.

Towards the end of the week, his humor kicked in. After opening a colleague’s get-well card to find a droll reference to their firm’s new management—a buyout of the Rouse Company was but two weeks away—Chris reached for the bedside phone. When a recording advised him to leave a message, he deepened his voice and pretended to be the CEO. “This is John B—,” he said gruffly. “It’s come to my attention that you have a poor attitude about the merger.”

To me, the spoof was proof of recovery. To his friend, who didn’t recognize Chris in disguise, it was cause to call the head of security: Someone was impersonating the chief executive.

Come Friday, Chris remained frail despite signs of improvement. His nurse took me up on my offer to drive him to his appointment.

In the Radiology waiting room, we found two more women on oxygen therapy. After positioning Chris at the end of a row of seats, I took the one beside him. If silence had been a preference en route, now it was a prescription. No one spoke or made eye contact. No one leafed through magazines, for there were none. No one asked the time or glanced at their watch. It was as if chronic illness had instilled a monkish composure. Or torpor.

I was the only non-patient in the room, the Lucky One. As the others sat alone with their thoughts, I wondered what those might be. That three back-to-back tests followed? That with sick leave exhausted, the boss had to be told? That scrambled eggs might stay down? That last time the shadow had shrunk, so this time, well, don’t get too hopeful?

Or were they trying to avoid thinking, instead imagining doing something—anything—more agreeable? Strolling through the hill town of Assisi. Watching a Coen brothers film. Defending an IRS audit.

One of the women on oxygen finally had enough. Silence wasn’t a chance to grab a shot of mindfulness; silence was a looming endgame. By talking, she could ward off quietus. But she needed a partner.

“What brings you here?” she asked me, in a tone so warm and genuine that she might have been a greeter in a small-town visitors bureau.

She looked about forty, or a little older, but it was hard to tell; illness can age a person faster than a Broadway makeup artist. Although her appearance was middling in every respect—from her height and build to her facial features and shade of brown hair—her spirit was striking. Whether the vivacity was innate or cultivated for survival, she offered me what she desperately needed: a deep breath of fresh air.

“My husband needs an X-ray.” I glanced at Chris. He showed no sign of wanting to engage. Under the circumstances, it felt unfriendly, even hurtful, to not offer more. “He had a kidney transplant a few months ago,” I added. “Now he has mono.”

Immediately, another patient stood and left. Perhaps she went to the restroom, or realized she’d left her purse in the car. More likely, mononucleosis spooked her—even though it’s not an airborne infection.

I paused, realizing that my interlocutor might want to leave, too. She didn’t budge. “How about you?” I asked. In deference to patient privacy, I avoided the politeness of trading names.

“I need a double-lung transplant. There’s a group of us here who have the same disease. We get together every year.” She chuckled. “It’s like a reunion!”

Lymphangioleiomyomatosis, or LAM, is a rare condition that primarily affects women ages twenty to forty. Abnormal cells invade the lungs, as well as lymph nodes and kidneys, leading to reduced pulmonary function and respiratory failure. Treatments, including transplantation, can enhance the quality and duration of life but the disease is incurable. After diagnosis, life expectancy is usually ten to twenty years.[1]

Her disclosure was stunning. Not long ago, I wouldn’t have grasped the challenges she faced, merely to delay the inevitable. No longer.

One day she would lie in an OR, as we recently had. But unlike Chris, whose kidneys were allowed to fail in place, with one of mine nested beneath them, she would have both lungs removed to accommodate her grafts. No matter how damaged and inadequate, those lungs were infusing her blood with oxygen, ridding it of carbon dioxide, maintaining life. Temporarily, she might require a heart-lung machine and a ventilator; ultimately, she’d either breathe though the new air sacs or wouldn’t . . . breathe. If her grafts failed, there was no recourse like dialysis to sustain her.

In short, she would perform a death-defying, net-free launch from a trapeze with no turning back once she let go of the fly bar. Her odds of surviving even five years after transplantation were not much better than one in two.[2]

And that was if she got lucky. With the chronic shortage of deceased-donor organs, lungs might not become available in time. Although living donation was possible, she’d need two Good Samaritans, each providing the lower lobe of a lung.^⁠ They’d face a riskier surgery and longer recovery than kidney donors, which meant friends and relatives were less likely to volunteer.

A radiology assistant called Chris’s name. Together, they disappeared through a door leading to the imaging machines. Moments later, the woman was called, as well.

She’d shared no details about her personal life. She’d only spoken of her illness, which, understandably, had come to define her—from what lung-healthy products she could buy to how she should dress, walk, or perform daily chores, such as unpacking groceries, to minimize exertion. If she seemed compelled to tell me she had LAM, it was not because she sought sympathy; she struck me as someone devoid of self-pity. What she wanted was to be heard. To be heard is to be remembered.

In no time, Chris was back and we were retracing our route through the cold fluorescence of the corridors. As we entered an empty elevator, he said, “You shouldn’t have mentioned I have mono.”

“Why?”

“You saw the woman leave.”

“But she had a right to know. I’d want to know.”

I hadn’t meant to embarrass him. For that I was sorry. But I was as disappointed in him as he was in me. Chris was still “chesting” his health cards, as if this were a hand of bridge, with nothing but his pride at stake.

No doubt a gender difference was at work, a primal XY-chromosome trait, which he’d exhibited many times before: Never show weakness lest a contender seize the advantage—be that your mate, your kill, or your year-end bonus. According to such logic, illness fell between failing and fatal flaw.

A strategy suitable for the savanna or a boardroom, however, is counterproductive in a medical setting where any debility you don’t reveal is one that isn’t treated. The woman I’d just met understood the importance of communication, on every front, regarding her health. I was sorry that my husband didn’t.

And hadn’t.

At the same time, I was grateful. As we made our way back to his room, my mind unspooled a skein of “at leasts.” At least he isn’t suffocating to death. At least he can fall back on dialysis. At least he isn’t alone while undergoing treatment. At least his graft shows no sign of rejection. At least I haven’t had to kiss him goodbye outside an OR and wonder if he would return. At least both of us were able to presume we would return.

Counting blessings was my luxury, not Chris’s. Sick as hell, he was entitled to feel however he felt, unthankful included, with no obligation to parse his advantages relative to others.

Later that night, Chris’s doctor called me at home. He’d had Chris moved to intensive care. He spoke so calmly and matter-of-factly that I didn’t panic. In fact, the thought never occurred to me that every “at least” would soon count for nothing.

[1] National Heart, Lung, and Blood Institute, “Health Topics: LAM,” http://www.nhlbi.nih.gov/health/health-topics/topics/lam (accessed February 1, 2019).

[2] Organ Procurement and Transplantation Network, “National Data: Lung Kaplan-Meier Patient Survival Rates For Transplants Performed, 2008 – 2015; Survival by Single vs. Double Lung (Lung Only),” https://optn.transplant.hrsa.gov/data/view-data-reports/national-data/# (accessed February 2, 2019).

Amyotrophic Lateral Sclerosis (ALS) is a terminal illness of the nervous system, resulting in the degeneration of neurons. When the motor neurons in the lateral spinal cord degenerate, the muscle cannot be stimulated and gradually atrophies. As the disease progresses, the brain cannot initiate and control muscle movement, so voluntary muscle actions, such as reaching for your phone or typing on a keyboard, are lost. Currently there are no treatments or cures to reverse the effects of ALS and the disease process is still widely unknown. Some noteworthy individuals diagnosed with this disease have included Lou Gehrig, Stephen Hawking, Jon Stone, George Yardley, Henry A. Wallace, and Steve Gleason. These are the facts, but I could have never realized what living with ALS was like until I listened to a retired senior, a teacher, and a musician tell me their stories.

The older couple told us of their past year as the husband wrote on an electronic note pad to fill in the gaps of his spouse’s version of their story. They had first noticed his symptoms when he began choking on his food, and they had to adapt as the disease progression got more and more severe. His wife comically said that she doesn’t know where to look when he’s trying to talk to her – “Should I look at his eyes, his mouth, this pad?” Every day, they had to face a new challenge and overcome it together, as a family.

Another patient was a mother, a teacher, now wheelchair bound and with a respirator to help her breathe. Because of her age, none of her physicians expected ALS and thought she was struggling from carpal tunnel syndrome or an ulnar nerve injury. She told us her husband was her biggest caregiver and supporter; her husband joked, “She makes the list and I carry it out.” He talked about his struggles, working full time as well as being a full-time caregiver for his wife and their 3-year-old daughter, as well as still finding time for self-care. Even with all this juggling, he felt guilty. This guilt was expressed by many of the caregivers: some because they didn’t even notice the symptoms and others because they felt like they couldn’t help their spouses. Guilt was felt by the patients too. The mother was upset because her daughter would only remember her in a wheelchair. Despite the difficulties, family was a major support system for each patient.

When asked about how she felt after getting her diagnosis, the musician said, “I felt like a deer in headlights… I never pictured I was going to go out that way… with a terminal illness… Last year I had no trouble walking, singing, cooking, gardening, and this year…” Despite all of this, she said she felt relieved. Her struggle to find a neurologist who respected her was heartbreaking. She had gone to a physician because she felt helpless; she was having trouble playing guitar, she was losing her identity as a musician. However, the physician assumed from her past medical history of anxiety that she was having mental issues with memory, anxiety, and depression. As she continued to receive hostile treatment, she found a second doctor who listened to her. Unfortunately, even though he took her seriously, he didn’t have the courage to diagnose her with ALS, telling her instead that she had a motor neuron disease and referring her to a specialist. When she finally received the diagnosis of ALS, she was relieved. She no longer felt crazy. She was able to be heard. She was able to communicate with someone who wanted to help her. ALS is already a hard disease to diagnose; not having someone on her side only made her situation more difficult. She says now, as each symptom appears, she isn’t afraid anymore, because she knows it’s ALS. This relief of having a concrete diagnosis, of having a diagnosable disease, even one that is untreatable, was reiterated by several of the other panelists.

Although a diagnosis was a relief for many of the patients, they all saw the importance of taking part in clinical trials. They recognized that ALS affects everyone at different times in different ways and hoped that one day they could explain why this illness is so hard to detect and track. Participating in various studies and trials made them feel like they were helping future patients and physicians to be able to better understand why this terminal disease can strike at any time, with no discernable warning signs, affecting each individual uniquely in initial symptoms and progression.

Getting a concrete diagnosis gave these patients the freedom to seize the day and live in the moment. For the musician, as her ability to play guitar diminished chord by chord, and she started slurring her words, preserving her voice and her identity became very important to her. She is using a message banking app to preserve her voice. The software requires her to read thousands of words and sentences. Although she had to accept the things she could no longer do, she realized that she did not have to give up her identity or love of music because of ALS. Overflowing with her love of music, she told us about how when choirs sings together, their hearts become synchronized; and how music lowers blood pressure and stimulates all areas of the brain. As she interwove details about her symptoms with her favorite song, Fire on the Mountain by the Grateful Dead, the two had become part of the same spiritual transformation. Smiling peacefully, she explained, “Maybe nobody else hears it the way I do. I see death as the final healing, finally being released from your body.” She viewed her diagnosis as graduating early and the symptoms that came attached with it as her disappearing slowly, rather than all at once. The unavoidable indignities were just something she had to accept. What mattered most to her was keeping her individual personality in the face of intense daily struggles.

By the end of our discussion, I felt the weight of my white coat as I never had before and recognized that this would be the first of many times that I would have to carry this symbol of patient advocacy. As these patients spilled all their vulnerabilities to a group of 50 students, I realized the most important thing I will learn in medical school is opening my heart without getting crushed under negativity. I learned that, as doctors, we have the tendency to think the ultimate solution is life, when in truth, mortality is the reality. What matters is being present when there is a fire, realizing that “a pail of water” may not be enough to put it out, but continuing to carry that water for your patient.

Long distance runner, what you standin there for?
Get up, get out, get out of the door

There’s a dragon with matches that’s loose on the town
Takes a whole pail of water just to cool him down
-The Grateful Dead

Heart Failure

The heart is basically a pump that provides the force needed to circulate blood and its contents to the body. It consists of four chambers: left ventricle, left atrium, right ventricle, and right atrium. The right ventricle and atrium collect the blood from the whole body and pump it to the lungs for removal of carbon dioxide and replenishment of oxygen. On the other hand, the left ventricle and atrium are responsible for collecting the blood from the lungs and pumping it to the body through the aorta (main artery). Non-stop blood circulation requires life-long and unfailing heart muscle power. Common symptoms of heart failure include waking up at the middle of night with shortness of breath and decreased ability to walk a few steps upstairs. Heart failure could arise due to any condition that decreases efficiency of the myocardium (heart muscle – Figure 1) through myocardial infarctions (death of muscles due to lack of oxygen, also known as heart attack) or overloading, such as hypertension, that requires increased contraction force. Loss of function in the ventricles (lower chamber of the heart) may require the use of ventricular assist devices (VAD).

Ventricular assist devices

A VAD is a mechanical pump that is implanted into the chest of patients to support the heart function through bridging the blood flow from the lower chamber to the aorta (Figure 2).^2,3 A VAD is usually useful during or after cardiac surgeries until recovery of the heart or while waiting for a heart transplant. VADs could also be used long term if the patient is not eligible for a heart transplant due to other complications. A VAD has several components, including a tube carrying blood out of the heart into a pump, a pump with another tube carrying blood to the aorta, and a power supply connecting to a control unit that monitors the VAD`s functionality.

There are different designs of VADs such as HeartMate, HeartWare, DuraHeart, and so on. Some VADs pump like the heart does, using a pumping action, and others use continuous blood flow. Intriguingly, VADs with continuous flow lead to a loss of normal pulse, but this has been found to decrease complications and increase survival. Two types of VADs include left ventricular assist device (LVAD) or right VAD (RVAD). LVADs are the most commonly used ones due to higher incidence of left ventricular function loss. If both LVAD and RVADs are used together, they are called a biventricular assist device (BVAC). VADs nowadays could be used not only for people with end stage heart failure, but also earlier stages of heart failure, including children. A VAD takes ninety percent of the pumping function of the heart. When using a VAD, your heart will still beat and have a rhythm. If none of these works for a patient, this requires the use of a mechanical or artificial heart, also known as total artificial heart (TAH).

Total artificial hearts

An artificial heart is a mechanical device that substitutes for the failing heart.^4,5,6 They are commonly used during heart transplantations to bridge the blood flow temporarily or to replace the heart permanently during a shortage of transplantable hearts. Early studies with artificial heart trials go back to the 1940s. Since then, various groups worldwide have invested in development of artificial heart prototypes and performed animal and human trials. Total artificial heart prototypes include, but are not limited to, SynCardia, ABIOMed (AbioCor), and Carpentier (CARMAT).6

SynCardia is developed from the Jarvik-7. It was first implanted in 1982. Dr. Robert Jarvik originally designed the Jarvik-7 (Figure 3). Barney Clark underwent the first artificial heart implantation at the University of Utah and survived for 112 days. This was followed by other implants. The longest survival with the Jarvik-7 is 620 days. However, the device is more commonly used on patients as a bridge during heart transplants. It has two pumps that resemble the two ventricles of the heart and is pneumatically (air) powered. The pump of SynCardia is covered with polyurethane. A pneumatic driver used in the US is a non-portable console, and requires patients to stay in the hospital. However, a portable version has been developed in Europe that could be carried a backpack while a patient waits for a donor heart.

The ABIOMed (AbioCor) is a completely self-contained, total artificial heart, which avoids the need for an external console or having wires or tubes piercing the skin to power the device. It uses a wireless energy transfer system, also known as a transcutaneous energy transmission system. This decreases the risk of developing infections due to implants.

CARMAT, on the other hand, is designed by Alain F. Carpentier.⁷ It is a fully implantable artificial heart with embedded biomaterials that make the device more biocompatible. In addition, the CARMAT includes valves made from cow heart tissue and has internal pressure sensors. This allows a person to adjust the flow rate in response to increased demand, such as during exercise. This feature distinguishes the CARMAT from other artificial hearts that provides a constant flow rate.

Biological artificial hearts

Synthetic replacement of organs is one of the long-sought dreams of modern medicine. To this end, there are efforts to develop biological artificial hearts in the laboratory. One recent study took the approach of producing a decellurized (empty from cells) scaffold of a mouse heart and recellurized it with human cardiac cells, and showed that lab-grown human heart tissue can beat on its own (about 40-50 beats per minute) in as short as a few weeks (Figure 4).⁸ They took the advantage of induced pluripotent cell (iPS cells) technology to produce multi-potential cardiovascular progenitor (MCP) cells, which could give rise to all three types of cardiac cells found in the heart. This area of research is still in its infancy but in the future, at least, it may provide tools to generate patches of heart tissue to replace damaged parts of the hearts. Given the success of a mouse heart cellurized with human cardiac cells, it’s possible that scientists will also try to decellurize the heart of a monkey or another animal and then cellurize it with human cardiac cells to produce a beating human heart in the laboratory as an alternative source to a full heart transplant.

Another approach to a biological artificial heart is to genetically modify animals in a way that their hearts will be compatible with a human body. Genetic engineering is a rapidly evolving field that one day could provide such tools for scientist to grow necessary organs in monkeys, dogs, or maybe even horses. Genetic modification may overcome tissue rejection issues when they are transplanted into a human body. For instance, one study tested the possibility of a heart transplant from genetically modified pigs into monkeys and showed the applicability of heart transplants between different species.^9,10

Until the development of biological artificial hearts, ventricular assist devices and mechanical artificial hearts seem to the best options. However, artificial heart implants have had various complications, including infections, pneumonia, high fevers, and multiple organ failures with variable survival rates based on the type of device and materials used. Another issue is the necessity of artificial heart to meet requirements of the body in terms of heart flow rate. For instance, the required flow rate of someone walking or exercising is different than someone at rest. In addition, the possibility of mechanical or computerized systems to fail may be a source of distress in patients implanted with artificial hearts or assist devices. This reminds us of that as long as we take care of our heart’s health, we won’t have worry whether its battery could fail – and what a mercy that is.

It is stunning that even with so much need and effort we are still not able to develop something that completely replaces all the functions of a heart. This clearly points that the heart is a marvelous gift granted to us. We are counting on every beat of the heart for our survival, and we should give thanks, with every beat, for what an incredible gift we’ve been given.

References

1. Bui, A. L., Horwich, T. B. & Fonarow, G. C. Epidemiology and risk profile of heart failure. Nat Rev Cardiol 8, 30-41 (2010).

2. What Is a Ventricular Assist Device? NHLBI, NIH. Retrieved from www.nhlbi.nih.gov/health/health-topics/topics/vad/ on 1/2/14.

3. Ventricular assist devices (VADs) Definition – Tests and Procedures – Mayo Clinic. Retrieved from www.mayoclinic.org/tests-procedures/ventricular-assist-devices/basics/definition/PRC-20020578 on 1/2/14.

4. Artificial Hearts. Retrived from www.umasswiki.com/wiki/Artificial_Hearts on 1/2/14.

5. Artificial heart. Retrieved from en.wikipedia.org/wiki/Artificial_heart on 1/2/14.

6. Heart Assist Devices. Texas Heart Institute. Retrieved from http://texasheart.org/Research/Devices/index.cfm on 1/12/14

7. Carmat artificial heart patient in good condition: hospital. Retrieved from www.reuters.com/article/2013/12/30/us-carmat-patient-idUSBRE9BS07O20131230 on 1/2/14.

8. Lu, Tung-Ying, Bo Lin, Jong Kim, Mara Sullivan, Kimimasa Tobita, Guy Salama, and Lei Yang. “Repopulation of decellularized mouse heart with human induced pluripotent stem cell-derived cardiovascular progenitor cells.” Nature communications 4 (2013).

9. Heart of genetically modified pig ‘successfully transplanted into monkey’, South Korea scientists claim. Retrieved from http://www.dailymail.co.uk/news/article-2164964/South-Korea-scientists-successfully-transplant-heart-genetically-modified-pig-monkey.html on 12/1/14

10. Pig to human transplants. Retrieved from http://www.theguardian.com/world/2002/jan/03/qanda.simonjeffery on 12/1/14

Before anasthesia, even routine surgeries were painful and dangerous. Its advent has allowed for amazing advances in public health and patient safety.

Humanity has faced various kinds of health problems throughout history, and will be facing them until the end of time. Even someone who has not yet suffered from an illness, will almost certainly suffer from one in the future. Let’s take a moment to reflect on all the people who are currently undergoing treatment at hospitals in the hopes of curing an illness.

From time to time we visit close friends and relatives who have undergone such operations. We wish them health and talk with them a little. We ask them how the operation felt, how many stitches they have. They usually say, “They injected me with something and I don’t remember the rest.” Then they may show us their gall bladder, wrapped in gauze, or their kidney stone, which was removed. Have you ever pondered how it is possible not to feel any pain during these kinds of operations, or how it is possible not to remember anything?

Surgical practices have advanced so much in present times. Heart, liver, and kidney transplants are now commonplace, as are finger and arm reattachments. Anesthesia, which makes all of these operations possible and painless, is a great blessing. Even the small and simple surgeries performed just 150 years ago were very difficult for surgeons – not to mention very painful for patients.

In his famous book on physiology and treatment, The Canon of Medicine the renowned 10th and 11th century scholar, Avicenna (Ibn-i Sina) (980-1037), defines anesthesia as, “a numbing and a cooling remedy.” He gives pathophysiological commentary on the influences of anesthetics and analgesics, and summarized painkilling methods as following:

1. A mixture prepared from linseed and dill should be applied to the area of pain.
2. Decreasing the sensitivity of the area of pain by increasing the moisture of the area, or providing narcotics for sleep.
3. Providing cooling and analgesic and anesthetic medicine.

Biruni, another Islamic scholar from the 11th century, documented his work with analgesic and anesthetic medicine. One of his writings recommends boiling the root tubers of henbane, Mandragora, horned poppy (Glaucium flavum), and Iris, together with the attar of roses and vinegar.

In his pharmacological works of the 12th and 13th centuries, Samarqandi recorded the analgesic, sedative (calming), anesthetic, and hypnotic effects of opium, mandragora, henbane, lettuce, beaver testicles, aloe vera, and coriander.

During the end of the 17th century, in Italy, anasthesia was performed by preventing the patients from breathing until they lost consciousness, and then immediately performing surgery on the patient who had fainted. This was called the asphyxia technique. The surgeries performed were relatively easy, such as the cutting of an arm or leg. The surgeon who was fast was considered the best, because patients could wake up during the surgery – that is, if they survived the procedure.

Another interesting anesthetic technique was making the patient lose consciousness by hitting them on the head. The hitting had to be done, “Hard enough to break the shell of an almond but gentle enough not to destroy its seed.” However, a bitter truth is that many patients were killed during this process.

Many have suffered the consequences of the absence of anesthesia in the past. Dr. Warren, a professor at Boston’s Massachusetts General Hospital in 1846, had placed his operating room on the very top floor of the hospital in order to avoid disturbing others with the screams of the suffering patients. One day, while examining one of patient’s tongues with pliers and a scalpel, he pulled the tongue of the patient without warning, and cut off his tongue with the scalpel. Afterwards, without hesitation, he cauterized his patient’s tongue with a hot iron. Dr. Warren observed the screaming, moaning, and suffering of the patients with no sign of emotion. He did not seem disturbed, and this was the exact attitude he needed in order to perform his duty. However, years later when enough advancement was done in the area of anesthesia, he couldn’t hold back his tears during the first operation that was performed with anesthesia.

Surgeries performed without anesthesia were hard on surgeon and patient alike. During his studies, the English gynecologist, Doctor James Young Simpson, fainted while cutting off a breast and considered quitting being a surgeon. Prof. Dr. Robert Liston was a famous surgeon at London University College. Dr. Liston had a reputation for being rude, arrogant, and strong. But he had no choice: he was forced to cut off a leg in 28 seconds, as anesthesia was not yet developed.

As can be seen from these examples, the absence of anesthesia, and the incredible suffering of the patients, pushed surgeons to be incredibly fast and emotionally insensitive. This period of time defined surgeons as strict, insensitive, and despotic. This went on until 1846, when William Thomas Morton performed the first surgery with anesthesia.

Since then, anesthesia has made surgeries much easier for all involved. Today, the definition of general anesthesia is total or partial loss of sensation in a human or animal body before surgical intervention.

Usually, anesthesia is performed by injecting medicine into the blood, or by making a patient breath an anesthetic gas. First, the patient loses consciousness, and then, with the help of muscle relaxants, the patient is put in a state of paralysis. Artificial respiration is performed until the end of the operation with the help of breathing machines called ventilators. For this purpose, an endotracheal tube is inserted in the windpipe of the patient and they are hooked to an anesthesia machine. This feeds oxygen, air, and the anesthetic gas to the patient. The anesthesia doctor controls the patient’s breathing, blood pressure, and heart rhythm, as well as other various, vital parameters, and the fluids that will be fed to the patient throughout the surgery. By doing this, the continuity of the anesthesia is made possible. When the surgery is over, the anesthetic drugs are no longer fed to the patient. When the muscle relaxants lose their effect and breathing returns to normal, the endotracheal tube is taken out and the patient is taken to another room to wake up. This is where the patient opens their eyes; it’s almost like a re-birth.

The chemicals in cannabis, opium, and coca were the essence of the first drugs used for general anesthesia; they are still being used, partially, in modern times. These chemicals, and some synthetic chemicals like them, are used for anesthesia and can be used after surgery in order to soothe pain. Most of our contemporary drugs are mostly synthetic, and they require many years of difficult education to be properly handled. It takes four years of additional education, after medical school, for a surgeon to become proficient with anesthetics.

Medical research done in the last two centuries about the dosage and quantity of these chemicals has advanced the practice of anesthesia incredibly. All this research provides a very good answer to why drugs have been created. While surgeons use the chemicals extracted from cannabis, opium, and coca, and from the synthetic chemicals like them, as a service to humanity, it is really hard to understand why some ill intentioned people use them for the detriment of human health.

Life, illness, and death are basic human conditions. But at the same time, it is a very individual decision which specific meaning you ascribe to these elements. These meanings also affect the behavior patterns of our life and its consequences. Ascriptions of meaning can – considered without any judgment – be of religious, nationalist, pluralist, and atheistic nature, or be supported from the symbiosis of several ways of thinking.

In the training of health care professionals and in public lectures, the author of this article noticed that illness has a very negative image: the color which stands for physical and mental discomfort is a deep black, while shiny white is the color of health. Consequently, modern medicine therapies have been developed that do not necessarily try to diagnose the causes of diseases, but most of all combat the declared enemy. For this purpose, high-dose drugs, radiation and other weapons are out in the field, according to the motto: attack is the best defense.

The doctors make every effort to win the battle, but there is a risk that the emotional state of the ill person falls into despair – because it is taught to him that his new physical condition is an unnatural, undesirable condition. Thus, a melancholy forms, which reduces the quality of life dramatically. The patient regards the illness as invincible.

In the following, I will present some perspectives that renowned scholar Said Nursi (d. 1960) demonstrated decades ago. They are still powerful today. In my opinion, they harbor the potential to raise the quality of life not only of the ill, but also of healthy people.

In his treatise “The Twenty-fifth Gleam: 25 Remedies for the Sick”¹ Said Nursi throws 25 views (Turkish: Deva² ) on the phenomenon of illness. His outlook could assist in transforming the negative picture of illness into a positive one.

What makes a shift in perspective so important?

Anyone who prepares himself while he or she is a healthy person, if they later catch a more serious illness, will benefit from this text. Nursi’s thoughts on the meaning of illness and potential remedies can play an important role in preparation. Those who internalize his message can help prevent the emotional fall into depression and may instead hope for a cure.

Said Nursi’s first view presents its readers with the understanding that illness should not be seen as a problem that brings bitterness into life, but that you can also draw strength out of it. There may, as said before, be different ascriptions of meaning to human life, but ultimately all people agree that life is something precious and offers a variety of opportunities. The direction of our lives depends on which use we make of these opportunities.

Those who consider illness as something negative will experience every illness as a curse. Such an attitude has a negative impact on the patient and their environment and turns them very pessimistic. They might castigate themselves, and ask questions like: “Why is it me of all people who has ​​this disease?” In extreme cases, this can lead the patient to become delusional and withdraw from society. A shift in perspective, however, can release positive energy and let sorrow and pain melt away.

Those who recognize the opportunities offered by life and appreciate the efforts and labors of everyday life as something positive will concede that even diseases have a meaningful function – for themselves and humanity as a whole.

Nursi says that ill people perceive time differently, which enables them to observe their environment from a more passive perspective. This passivity is supposed to tear modern, urbanized people from the hustle and bustle of everyday life and move them to a pause. It decelerates the lives of those affected and leads them to horizons healthy people find difficulty to access.

Nursi’s second view goes to the role of prayer which he defines in two forms: positive and negative prayers. He refers to prayers like ritual worship, fasting, supplication, and other forms of remembrance as “positive” (müspet) prayers. “Negative” (menfi) prayer on the other hand is attaining awareness and knowledge of one’s own vulnerability and mortality – which is more likely to arise in moments of illness rather than any other time – as a result of which one turns to God in praise of His ultimate power and infinity. Nursi signifies these positive and negative prayers as the second remedy.

The insight into our own transience, which is the third remedy, allows the ill person to recall their past mistakes, many of which might have been forgotten, and allows them to reconcile with themselves and their fellow humans. According to Nursi, this allows a person to realize they are not as perfect and as infallible as they thought. Illness makes people honest: honest with themselves and with others. The confession of the own fallibility is tantamount to an admission of human weakness and mortality.

Viewed from this perspective, the question arises as to whether illness itself is a cure for mankind. It conveys us new views and leads us to reconsider our previous positions. The ill person becomes an observer, and he finally has time to start thinking. As said by Nursi, he realizes that mankind may be considered the crown of creation. But man’s frailty, his aging, and also the health problems of other people make him realize that life on earth is not all there is – a realization that opens his eyes and takes him out of the darkness into the light. Becoming aware of one’s mortality takes away any thoughtlessness. It causes a person to shed laziness and reflect on their obligations.

If the patient manages to do so, they will feel gratitude and be patient, not least in dealing with physical ailments. This gratitude and patience is what Nursi refers to as the fourth remedy. For Nursi, the body is not the property of man, but rather a loan, which he may not dispose of freely. Suffering is to be endured, since it can do some good, too. Nursi characterizes it as a kind of bonus, which God the ultimate owner of our body grants to us, and we should not protest against it.

Chronic diseases or disabilities, which are seen very negatively in today’s society, can be reinterpreted positively in this way because, as Nursi asserts, they bring a gain in knowledge compared that we cannot achieve when healthy. As a result of their illness, they understand new things that healthy people cannot, just as blind, deaf, or dumb people perceive their environment differently, and sometimes more sharply, than people without physical limitations.

Each person strives for well-being, mercy, and forgiveness, and every sorrow and misfortune also harbors rays of mercy in it. From behind the veil of the illness many quite pleasant insights can emerge. A new consciousness arises, and thus many people gain the courage to take risks and reposition oneself in life.

This maturity Nursi describes as the fifth remedy and it can be observed especially in young ill people. Because of their illness, and in contrast to their peers, they have to cope with issues that seem to contradict their youth. They do not fall into the typical noise of youth and are relieved of thoughtlessness and of the pressures of everyday life.

From this point of view, health, for some people, can be even a calamity that can make their heads spin and blind, and lets them lose sight of the fact that their life does not last forever.

Conclusion

Even these first 5 of 25 views on the subject of illness show that not everything, which is interpreted as negative, is actually negative. A shift in perspective can often work wonders.

Nevertheless, such a shift in perspective appears quite disconcerting initially in our modern society in which health equals to a gift and illness to a disaster. If we have considered diseases as the enemy for so long, why should we suddenly welcome disease? A notion that a disease may also enrich the patient and their friends and family is a useful approach. Surely, the thought that positive thinking can influence the illness (coping), and even contribute to the healing process, is quite common. However, the angle shift described by Said Nursi goes much further. And in my eyes, there is no doubt that it is able to significantly improve the quality of a patient’s life and environment.

Illness allows ill persons to pull out from everyday life, at least for some time. Thereby, it gives them new insights and opens doors that probably would have remained closed if they had stayed healthy. Illness allows a refocusing of which we can benefit from as individuals and communities.

Erdogan Karakaya is pursuing a master’s degree in history in Heidelberg, Germany.

Footnotes

1. Nursi, Said. 2009. 25 Remedies for the Sick, the Twenty-fifth Gleam, NJ: Tughra Books.
2. Deva in Turkish actually means cure, resort, and solution. In this article it is also understood as view or view angle.

Though we cannot see humor, like faith, we perceive it all around us.

Once upon a time there was a planet in an unknown corner of the vast universe. For a long time, this planet was distinguished by having inhabitants with no sense of humor at all! This sounds like a joke, doesn’t it? But I am here to tell history, not jokes. This planet’s history was studied in three eras, each having a different state of humor: the Ancient Period, the Middle Period, and the Modern Period.

I. Modern period

The inhabitants of this planet were extremely serious, conscientious, sincere, hard-working, and moral. Besides all these good qualities, they considered humor as a pathological phenomenon. They never laughed or jested, kidded or joked. There was no room for any kind of humor.

A small minority, who had some feeling for humor, occasionally laughed and joked. However, their behavior was extremely alarming to everyone else. These few people were called “laughers,” and they were promptly hospitalized. What was so obnoxious about their behavior, aside from the strange noises they made and the peculiar facial expressions they bore while “laughing,” were the utterly pathological things they said! They seemed to lose all sense of reality. They said things which were totally irrational, indeed sometimes logically self-contradictory. In short, they behaved exactly like anyone else who was deluded or hallucinating, hence why they were put into hospitals.

More importantly, it was definitely verified that this “laughter” was somewhat contagious and that certain individuals became laughers for the first time in their life only after repeated contact with other laughers. Indeed, this was another thing which made the laughers so dangerous. They were not only hallucinating themselves, but tended to pass these hallucinations to others! Hence they had to be hospitalized, not only for their own sakes, but also for the sake of the society.

In the hospitals, doctors tried quite a number of different treatment regimens to cure their pathologic behavior. Besides many unsuccessful treatment attempts, one drug, called “laughazone,” was finally found to kill the symptoms of humor. Almost immediately upon administration, the patient would stop laughing as well as quit the verbal activity called “joking,” and would instead start screaming. The patient would just lie there screaming, hour after hour, day after day, week after week, and month after month. And the most amazing thing of all is that not once during this screaming period did the patient ever laugh or make a joke or even smile. They thought this drug was really phenomenal!

The problem with “laughazone,” though, was that its effects were temporary. After the months long treatment, the patient would, for some unknown reason, fall into a deep state of depression for several weeks, and sometimes longer. After this, he would gradually convalesce, and his original symptoms of laughing and joking would return. So, the doctors had to put the patient through the treatment again and again.

II. Ancient and middle period

The Modern Period contained no literature at all on laughter, except in textbooks and periodicals on abnormal psychology. The Middle Period, on the contrary, was chock-full of laugh-literature. This literature contained absolutely no material which contemporary laughers called “funny.” Indeed the writings were written in a wholly sane, serious, scholarly, and philosophic mood. The writings consisted mainly of analysis and commentary on the ancient texts. The ancient writings, unlike those of the middle period, were totally non-philosophical. They never spoke about laughter or anything like that. They were simply what the Middle Period called “funny.” These archaic manuscripts contained all sorts of incomprehensible and contradictory material called “jokes” or “funny stories.” Therefore, philosophers of the Middle Period extolled the Ancient Period, and referred to it as “the golden age of humor, when men could freely laugh and joke and really enjoy life.” Appreciating the ancient writings required a certain, almost mystical, faculty called “humor.” What was so puzzling was that humor could not flourish in the wholly serious and rational atmosphere of the Middle Period.

So, the Middle period witnessed many discussions on humor. One such discussion which had taken place between the mystic-humorists and the skeptical anti-humorists went as follows:

The Mystic-Humorists claimed that the only reliable way humor could be known was by direct perception: “We can see humor in many situations. Life is permeated with humor, if you can only see it.”

The skeptical Anti-Humorists said, “So, you claim you can see humor! Tell me, what color is it?”

The Mystic-Humorists laughed and said, “Humor doesn’t have any color!”

The skeptics continued: “Oh, so you can see it only in black and white! Well, then, what shape is it?”

“It doesn’t have any form or shape.”

“Then I am confused! Is humor visible or invisible?”

“Of course it is invisible!”

“But I thought you just said that you can see it. Didn’t you say that you could see the humor of certain situations?”

“Well, yes, I said that, but I didn’t mean ‘see’ in the literal sense of ‘see with your eyes.’ Ocular vision really has nothing to do with it. I used ‘see’ in the sense of directly perceive, not see with the eyes. Perception, although as direct as vision, is really through a different sense altogether.”

“A different sense? Which sense is it – hearing? If so, what does humor sound like? Or is it smell or taste or touch or what? With which of the five senses do you perceive humor, or is it a combination of more than one of them?”

“No, it is not any one of these five senses, nor is it a combination of them. It is a totally different sense. In a way, it is a nonphysical sense. We call this sense the ‘sense of humor.'”

“Good God, you literally mean a nonphysical sense? In other words, you mean it is something occult, like telepathy or clairvoyance? But scientific integrity requires us not to believe in anything occult; hence we cannot but believe that this humor is something totally unreal, a mere figment of the imagination.”

In vain the Humor-Mystics protested that there was nothing the least bit occult about humor and said: “If only once you could see what humor was, you would realize that it is the most natural thing in the world, and also that it is delightfully pleasant.”

Another thing, the “Mystic-Humorists” claimed was that the label “Mystic-Humorist” was most misleading. They claimed that there was nothing at all mystical about humor, even though it might seem mystical to those who lacked the immediate sense of humor. They said, “Why not rather call us laughers, which is, in fact, what we are.” And so, the term “Mystic-Humorist” was gradually replaced by “laugher.” Later, this term would be used in the Modern Period as explained above.

Another discussion during the Middle Period was between the “laughers” and the Faith-Humorists, who believed that reason could be somewhat helpful in understanding humor but that an act of faith was crucial. Essentially, Faith-Humorists did not take a hostile, skeptical attitude toward the laughers, but instead believed in them wholeheartedly. They knew that the laughers were in direct contact with that which the Faith-Humorists could only reason about and accept on faith. However, they were heavily criticized by the “laughers” because of their approach to the issue:

You seem to think that knowledge about laughter is somehow more important than the ability to laugh.

You take an approach which is far too objective and scientific. You read all the literature you can find on the philosophy of humor. You perform elaborate linguistic analyses of what the word “humor” could possibly mean. The only way you will ever find out what it really means is by acquiring a sense of humor.

The most insidious error of all is to try to learn humor by merely imitating the outward forms of the laughers. You must remember that the activity of laughter is only a manifestation of humor. Humor itself is something entirely within the spirit.

Another thing that you do out of mere imitation is this ridiculous practice of memorizing jokes. You commit thousands upon thousands of jokes to memory and you think you are thereby acquiring a sense of humor! But memorizing these jokes is absolutely pointless for you until, and unless, you have acquired a sense of humor.

You combine the two techniques of joke memorization and forced laughter, and then you are sure you have matured. But God Almighty, how wrong you are! You go forth into the world claiming yourselves to be authentic laughers. Nothing sabotages our cause more than this! The skeptics who meet you are almost rightfully reinforced in their belief that humor is something which is a mere sham and delusion. Yes, the pseudo-laughers like you are the major cause of the disappearance of humor from this planet.

As laughter disappeared more and more from this planet, the people of the Middle Period realized that this was a tragic loss rather than a gain, and they did everything possible to stem the tide. Only at the very end of the Middle Period did it first occur to mankind that laughter, far from being something good, could actually be something totally undesirable. People started saying: “Maybe we should stop trying to stem the tide. Maybe the tide is our greatest blessing, although we don’t know it. Maybe it is high time that this silly archaic thing called ‘humor’ should disappear. Maybe laughter was all right for savages, and we are now becoming civilized!” Then the idea fully occurred to mankind that humor was but another form of psychosis; laughter was a type of psychopathology. Thus was ushered the Modern Period.

III. Back to the modern period

As we discussed earlier, people of the Modern Period had to accept the painful fact that the laughers were not permanently curable, at least for the foreseeable future. This fact split the medical opinion into two divergent camps; hospitals, similarly, split into two widely divergent types. Hospitals of Type I were called “laugh-scream hospitals”; those of Type II were “pure-laugh hospitals.” In the laugh-scream hospitals, the doctors realized that no patient was permanently curable. Hence, once a patient was admitted, they were admitted for life. All that could be done was to administer the laughazone treatment over and over for the rest of the patient’s life. The discipline at these hospitals was ironclad: no patient was ever released, and there was to be no letup in treatment. It was better for the patient to face reality and scream than to withdraw into his fantasy world of humor and laugh.

The philosophy of the pure-laugh hospitals was, however, entirely different. They agreed with the laugh-scream hospitals that no laugher was permanently curable. But they thought: so why not let the patient enjoy his life? Was it really all that bad that he had these fantasies? Similar to the laugh-scream hospitals, patients were incarcerated for life. But they were given no treatments whatsoever! The patients in the pure-laugh hospitals were very happy. Everything possible was done for them to ensure their happiness. The pure-laugh hospitals, in the true sense of the word, were merely isolation centers. Their only function was to prevent the inmates from infecting the outside world with their laughter-psychosis.

Thus the conditions inside the pure-laugh hospitals were close to idyllic, except for one thing! Good God, the patients cried “How unfair that our brothers are screaming themselves to death in the laugh-scream hospitals while we are free to enjoy our laughter. Those doctors at the laugh-scream hospitals! They believe that they are helping their patients! They are the maddest of all! We must find a way to free our brothers so that they can enjoy laughter as we do.”

Occasionally, patients would escape from the laugh-scream hospitals, and they would immediately rush to the pure-laugh hospitals, where they were cheerfully admitted. As the patients in the pure-laugh hospitals increased in number day by day, at last, they managed to find the loopholes in the system. It didn’t take them long to organize raids on the laugh-scream hospitals, through which they freed all the laugh-wards, and brought all the patients back to the pure-laugh hospitals. The laugh-scream hospitals eventually went out of existence.

However, laughers were not satisfied with this success. They were bothered by the thought of those outside the laugh-communities who never knew the joy of laughter. What could be done for them? Just about nothing, they decided, since the old loopholes they had used to escape were taken care of. But here, providence intervened in a very remarkable way. What happened was this:

The standard of living inside the laugh-hospital communities was far higher than outside. One by one the outsiders pretended to be laughers in order that they might be incarcerated in the laugh-communities. The pretended-laughers knew perfectly that they had no sense of humor, and they couldn’t have cared less; they deliberately lied just for the purpose of joining the laugh-communities with their high standards of living. What happened was that the lying-laughers, being surrounded by an enormous majority of genuine laughers, very soon caught the laughing sickness themselves, and in but a few weeks turned completely into genuine laughers. And so one non-laugher after another lied his way into the laugh-communities, and shortly, became a genuine laugher. Then finally, even the psychiatrists succumbed, and no non-laughers were left behind. The entire planet was now one huge laugh-hospital, and the Modern Period that was devoid of humor became the funniest era ever.

This story was adapted from Richard Smullyan’s This Book Needs No Title: A Budget of Living Paradoxes by (Englewood Cliffs, New Jersey: Prentice-Hall, 1980). Copyright (c) 1980 by Raymond M. Smullyan (Acquired necessary permissions from the author).

Nural is a graduate research assistant in computer science at the University of Georgia, Athens, Georgia.

One of the signs of anarchy in a region could be the marching of an army to get a particular situation under control and, if it is indispensible, destroy or suppress anarchists. Similarly, the first response of the body to such uncontrolled growth is the destruction of tumor cells by activating inner mechanisms that lead to cellular suicide (apoptosis). Anarchy is by definition not to accept any border and authority, causing disorder or upheaval. According to twentieth century thinker Nursi, anarchy cuts and throws away norms and laws that organize social life, one by one, thus destroying the order and leading to mischief and rebellion. In addition, anarchism does not consider the rights of any. Analogously, one by one, cancer breaks genetic rules that organizes cell proliferation and eliminates pathways that suppress tumor formation. Thus, it eradicates the order and triggers chaos and malignancy. Again, cancer works against the life of the body without considering the rights of other cells.

Another characteristic of anarchism could be the elimination of its leaders. Thus, once you get rid of the key players, anarchy may not resurface. Likewise, you can use a strategy in certain cancer types where you can specifically target cancer stem cells. As a result, cancer growth could be suspended and it may bring an opportunity to shrink tumor through chemotherapeutical approaches. One such example is the targeting of CD24, a putative cancer stem cell antigen expressed by a minority of adenocarcinoma cells. This cell-based cancer immunotherapy method uses genetically engineered cancer killing T cells, which are directed towards cancerous tissues using chimeric antigen receptors. This is similar to the taking over of trained Special Forces when anarchy becomes malicious and unceasing. Both natural and genetically engineered cancer killer T cells in our body resemble trained Special Forces that patients need to fight against cancer.

Cancer treatments

Cancer is nowadays mainly treated with chemotherapy, radiotherapy and surgery, and to some extent with immunotherapy. The many purposes of chemotherapy include relieving or preventing the suffering of the patient, prolonging the life span, and if possible, completely curing the cancer along with surgery or radiotherapy regimens. Chemotherapy mainly uses cytotoxic drugs that kill cells by attacking one of the main properties of cancer cells—rapid division. Unfortunately, since cancer cells are not the only rapidly dividing cells in the body, chemotherapeutic agents also harm healthy cells. Another fall back of chemotherapy drugs is the lack of specificity that does not provide a therapy against a specific cancer type and their efficacy vary from patient to patient. In these cases, the indispensable path is synergistic use of radiotherapy with chemotherapy.

As its name implies, radiotherapy involves the use of ionizing radiation to kill cancer. It relies on the destruction of dividing cells by introducing DNA damage, which leads to induction of cellular death through apoptosis. Radiotherapy is therapeutically useful in cancers that are localized to one part of the body. It is also useful to prevent tumor relapse after surgical removal such as in breast cancer. However, radiation, which radiotherapy depends on, is itself the potential cause of cancer and leads to various side effects.

Citizens of the body need justice

Chemotherapy or radiotherapy, which harms both healthy and cancerous cells, recalls the practice of absolute justice versus relative justice. Absolute justice requires protection of every individual while punishing the criminals. On the other hand, relative justice is the justice where the rights of one person are ignored for the betterment of the whole. Absolute justice is always the best practice if it can be properly established. However, relative justice may be sought if absolute justice is absolutely out of reach. Current chemotherapy and radiotherapy treatments are like the practice of relative justice, which harms both cancerous and healthy cells. Of course, these treatments are considered as the last resort for many cancer patients but this analogy regarding absolute justice toward cells in the body urges us to seek for cancer therapies that follow absolute justice. In other worlds, we need to practice an approach that is more specific toward cancer cells. This could be, as we mentioned above, the use of cancer immunotherapy where cytotoxic T cells are directed towards cancer cells through genetic engineering by introducing chimeric antigen receptors (CARs). CARs should be able to recognize unique or relatively specific antigens located on the surface of cancer cells to execute them.

Cancer killing T-cells: Equipped with chimeric antigen receptors

There are three main approaches in cancer immunotherapy including immunization, use of antibodies and cellular immunotherapy. Immunization by administering a cancer vaccine prepares the patient’s own immune cells to recognize tumor cells as targets to be destroyed. The use of therapeutic antibodies specific to cancer cells recruits immune cells in the patient to abolish tumors. Cellular immunotherapy, on the other hand, uses patients’ own immune cells like the natural killer cells, cytotoxic T cells and so on. Basically, those cells could be stimulated in patients with the administration of interleukins or they could be isolated from the patients’ blood and cultured in the laboratory and following expansion and in vitro training, then transfused back to the patient to fight against cancer.

Cytotoxic T cells are unique immune cells that recognize target cells via T cell receptors. Over the past decade, scientist engineered T cell receptors and developed chimeric antigen receptors that specifically recognize target antigens. This recognition lead to signaling pathways that resulted in apoptosis of tumor cell through the production of granzymes, perforins and cytokines such as IFN-γ, and TNF-α (Figure 1). There are a number of success stories using CAR+ T cells for cancer immunotherapy used in patients. Encouraging results were obtained with CARs targeting lymphoma (by targeting CD19 antigen), coleractal Cancer (by targeting CEA antigen), and melanoma (by targeting melanocyte-specific markers MART1, MELOE-1 and gp100).

Universal chimeric antigen receptors

Two recent studies published by two different groups increased the hopes in the battle with cancer. They developed novel and universal CAR technologies that combines cell based immunotherapy and use of therapeutic monoclonal antibodies. This new approach relies on the recognition of specific molecules such as FITC and Biotin by corresponding Anti-FITC and Anti-Biotin (Avidin) CARs. The decent thing about these specific molecules is that you can attach them to any antibody, ligand, or aptamer known to target specific tumor antigens (Figure 2). One of the universal chimeric antigen receptor, for instance, uses FITC, a fluorescent molecule widely used in flow cytometric assays. Since it is easy to label antibodies, this provides wide range of antibodies to target cancer cells. In addition, scientists using this approach could target more than one tumor antigen or could use another antibody that targets different antigen even if cancer relapses. Moreover, since antibodies used to activate CAR+ T cells will degrade and their bioavailability will decrease in the body by time, there will be no need to kill injected T cells with suicide mechanisms. Once FITC labeled antibodies are stopped from being given to patients, CAR+ T cells will stop attacking cells and cease-fire since their guns (CARs) cannot recognize tumors or anything nonspecific. This approach is highly encouraging and has brought with it great hopes in the treatment of cancer.

Anarchy, spirituality, and prayer therapy

Hunger, poverty, social inequality and economical issues could be asserted as the basis of anarchy within a society. However, according to Nursi, the real basis of anarchy is spiritual weakness and poverty. Similarly, the basis for cancer could possibly be the lack of appropriate spiritual diet that may eventually make a person fall spiritually and physically weak. For example, fasting is a physical and spiritual fast prescribed in monotheistic religions which increases spirituality and has been shown to be synergistically effective in chemotherapy with cancer treatments. It has been observed and scientifically recorded that patients with strong beliefs and continuous prayers and spiritual support overcome diseases much faster than those without. This raises certain questions regarding our spiritual makeup and many other dynamics involved in being sick and getting well. So, are we getting ill because some evil spirits are manipulating our biological condition by settling in the tumors and propagating cellular anarchy? Is radiation, which leads to cellular mutations, a result of spirits that are created of “scorching fire” (The Qur’an 15:27)? Is cancer a result of such manipulations and should we seek cure for it not only through biological medicine but also through spiritual healing?

Various scientifically proven causes are known to increase the likelihood of cancer, which includes, but is not limited to, smoking, viral infections, radiation, and pollutants that lead to internal genetic faults within cells. Considering the fact that there are many cases in which patients have been reported to have recovered from their illnesses by reciting prayers, then such cases are worth examining to find out whether and to what degree non-material factors are involved as causes for our illnesses. Studying these cases may offer science new opportunities to be able to remove the present obstructions and make greater advances in the medical field by perhaps developing cancer therapies that combine prayer therapy and cancer immunotherapy using genetically engineered T cells during the treatment of patients.

Ali Fethi Toprak is a PhD candidate at University of Texas Southwestern Medical Center.

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Gülen. M. Fethullah. “Cinler, Hastalıklara Sebep Olabilir mi?” Retrieved from http://tr.fgulen.com/content/view/708/3/ on 12/24/12.

Bukhari, i’tikâf 8, 11, 12; Muslim, Salam, 24; Ibn Maja, Siyam 65; Abu Dawud, Sawm 79; Adab 81; Muslim and related hadith narrated by Abu Hurayrah, Bukhari 7.582.

¹ See Yücel, Salih. 2010. Prayer and Healing in Islam, NJ: Tughra Books.

She has conducted research on the psychology of meditation for over 25 years, including investigations on the effects of meditation on heart rate control, general well-being, spirituality, psoriasis and anxiety disorders. Her other (but related) line of research is investigating the role of spirituality in adjustment to serious medical illness. A recently published randomized intervention study documented benefits of a very brief physician-delivered spirituality intervention offered to cancer patients on quality of life, emotional well-being, and satisfaction with care. Current work is investigating how religious and spiritual resources, from the patient’s perspective, may help in adjusting to cancer. Matter&Beyond spoke with her on her research.

Matter&Beyond: Dr. Kristeller, you are doing research on the spirituality of cancer patients. You also developed an intervention technique called OASIS that could benefit the patients who are going through spiritual struggles. What was your starting point for this project?

The OASIS Project stands for Oncology Assisted Spirituality and Intervention Study. In this project, we were exploring how individuals draw on their spiritual and religious resources to deal with having a cancer diagnosis. The other question was how physicians perceived that aspect of their patients’ resources and whether they felt it was appropriate to bring it up in the medical environment. First we went out and actually asked physicians what they thought about the role of patients’ spirituality in dealing with cancer. We actually got back a very positive response. Substantial proportion of the physicians actually felt that it was helpful to their patients; it was something that was valuable to engage within the medical environment.

M&B: Were they able to address the spiritual dimensions of the patients?

What we found out was that they didn’t know how to do that. They were afraid if they brought it up, their patients might get upset with them and they’d be triggering off a reaction perhaps that would require so much time and effort on their part to explore with their patients that it just wasn’t practical. So when we found that out from the physicians we decided that we would systematically look at that from that patient’s side.

What we heard from patients was that they also wished to bring it up in the medical environment but they felt that the physicians wouldn’t want to and that they would bring it up if the physicians asked about it first, and the physicians were saying they’d talk about it if the patients brought it up first. So nobody was bringing it up.

So we moved this onto the next step. What if we taught the physicians a particular approach to bringing up this issue with their patients because we couldn’t sit down and teach the patients how to do it. We decided to take a risk and teach physicians how to bring this up to their patients in a very simple way. And we found a few very brave oncologists who were willing to work with us around this and we designed literally a 5-minute patient centered way of introducing this concept.

M&B: How did you design this approach and what were its characteristics?

In a way, we’re guided by previous research on how physicians can talk to their patients about difficult topics. This is actually research that I had done previously in relation to other difficult topics like smoking and alcohol use. And what we did in those cases was we taught the physician a very neutral, gentle supportive way to introduce those issues with their patients and then we took a look at how we could use that with introducing the questions about spiritual resources. So a physician may say something like “Many patients draw on their spiritual or religious resources to deal with something like finding out they have cancer. As your physician I would like to hear more about whether that is true for you, it may or may not be, how do you feel about that?” And that very gentle open way of introducing it feels very comfortable to the physicians and it feels very comfortable to patients. And what we find again is most of the patients respond very positively to that.

M&B: What if the answer is no and they are not interested in talking about spirituality?

We also taught physicians that if the response they get back from a patient is something like “oh no, I’m not religious or I don’t want to talk about that,” how they should respond to that. They should say something like “really what I’m concerned about is how you’re dealing with this and I’d like to hear more about that. Is that ok?” And that shifts it just a little bit. But for about 90% of the patients, they really open up and they are responsive and they start to talk about it and if they are a little hesitant we then teach the physicians how to draw them out a little bit more. Very simply saying, “Tell me more about that. I’d like to hear more about that. Are there any problems you’re having around that? Who else can you talk to about this?” It’s very important. So being encouraging and thanking them for having the courage to share their feelings with the physician. Asking them a little bit more about how they draw on a sense of inner meaning and peace, because we’ve identified that in research as one of the key elements for moving to a different level of coping with cancer.

To our surprise this actually worked very, very well. What we found was that patients have appreciated it. Over 50% of them actually told us after the fact that they had found that conversation helpful to them in dealing better. And about a month after this very brief exploration, they actually said that they were feeling less depressed and they were coping better in comparison to patients from the very same physicians who didn’t get this, who just go their usual appointment. So we’ve been continuing to work on this line of research to deepen it and to expand it at this point.

M&B: You also discuss that a small number of patients are coping in a negative way with spirituality. How does it happen?

Our research and research from some other groups, for example Harold Koenig’s work at Duke, is systematically coming up with a pattern that shows that individuals who feel angry at God, who feel that they’re being punished by having cancer are not doing very well.

Most people feel that at some point. But what I’m talking about is a sort of enduring ongoing struggle around this. And what we find is individuals who are really caught in that struggle in fact are doing very poorly. They are more depressed, and their relationships are not going as well. We don’t have any evidence at this point to show that it actually affects the course of their disease. That would be a challenging kind of study to take on and we haven’t been able to do that. But certainly it’s affecting their inner struggle and their inner well-being. What we encourage physicians to do if they realize that one of their patients is struggling at that level is to encourage the individual to find somebody else to talk to, maybe a Chaplain for example from the medical environment. We really encourage them to look to that and to try to provide those resources and not take that on themselves.

M&B: Maybe it is difficult to estimate how the constant spiritual struggles affect recovery time, but maybe it is easier to estimate how it affects the quality of life.

The individuals caught up in that struggle have a poorer quality of life in general and the research again is pretty consistent in that. And of course it would be naïve to say that you just turn that off. If somebody is struggling in these deep personal issues, they deserve to be recognized and I think we have to assist the individual to find some way to talk to people in their own personal circle of friends, family, religious community about how to deal with them.

M&B: Regarding spiritual intervention, what is the general opinion of the medical community? Is there a growing interest?

I think we are just shedding some light on this. Given how positively the patients respond to even just 5 minutes, I think that there is a growing awareness that there can be a role for this. Within the care of the whole patient, when you shift into the perspective that the spiritual and religious resources people bring to a medical crisis are actually tremendously valuable, and the more they can bring those to the crisis the better they’re going to be doing then. I feel that that defines within the medical environment in a different way.

One of the issues that often physicians would bring up with us is “I don’t know if I have the same beliefs as my patient does” and “if I don’t have the same beliefs maybe it’s not appropriate to bring this up.” And one of the things we do in our training is to work with them around that. Saying you know it isn’t about the beliefs that you have and whether they match your patients. It’s about listening to your patient; it’s about hearing the underlying feelings and meaning that the patient has.

M&B: In terms of spiritual response to cancer, do you see people going through a spiritual transformation?

Let me give you a little bit of frame on that. We’re funded on the Spiritual Transformation Project. When you think of spiritual transformation you’re actually thinking about a real shift in people’s beliefs and people’s sense of themselves as a religious or spiritual person, their relationship to God, or their sense of relationship to God. We’ve compared our data to data that’s been collected on AIDS patients in Miami. Something like half of the AIDS patients communicated that spiritual transformation happened to them. We had 2 out of 100 cancer patients relate that level of change occurred.

M&B: Fifty percent compared to two percent. That is a huge difference. What is your explanation for that?

A couple of reasons I think, one is that even though cancer is a very frightening disease, it’s nowhere near as frightening as AIDS. The prognosis is much better in truth. The other is that the AIDS patients were really people who were struggling with their lives in general. Most of our cancer patients have really quite well-functioning lives. They’re already members of religious community. They don’t need a transformation. They just need to deepen or engage that religious support more fully or the spiritual side of themselves. So, one of the issues is that transformation isn’t necessary, it isn’t needed for this. Engagement though is what we’re talking about.

M&B: What are the fundamental difficulties in doing research on spirituality?

One of the things that is so challenging about this area is trying to measure, trying to capture very elusive concepts and do it in a way where we can systematically identify them, where we can frankly put some numbers to them. So we can compare individuals, so we can look at the effect, for example, of a stressful life event on something like spirituality. So, one of the other lines of work we’ve been doing here is to develop the framework for measuring what we call religious and spiritual engagement, and it’s very challenging to do that. Within Psychology, there’s a long tradition of trying to capture these psychological processes, something like depression or fear. And we have lots of different measuring tools.

M&B: Is there a widely accepted measure of spirituality and religious participation among the healthcare and medical research community?

When we started working in this area, what we discovered were a couple of hundred different scales to measure what people called religious and spiritual involvement. But most of them had been developed in very small groups of individuals, they hadn’t been put into a larger theoretical model and we knew there were probably not hundreds of different dimensions but we didn’t know whether there were 2 or 4 or 5 or 10 and one of the projects we’ve done here is to identify using a group of these measures that seem to capture different aspects of spiritual and religious involvement like belief, compassion, like sense of growing within oneself. As in mystical experiences, we’ve had several of these projects where we’ve given this set of measures actually over almost a couple of thousand people at this point.

Another dimension is interestingly their willingness to tolerate questions about their beliefs and their spiritual well being. Tolerating those questions seems to be a separate and important element that is linked into doing better, to growing more. Mystical experience is a separate dimension so someone who has a mystical experience may or may not be strong in their belief system. Having that may shift that strength but it’s somewhat separate.

We focused on several dimensions. One of the 5 or 6 dimensions is what we call spiritual struggle and that is a separate dimension and again people might be high or low on their strength of their beliefs. If that dimension is strong or high, you do see a lot of distress not only in that part of the person’s life but often in other areas of their life.

M&B: People often think that hope, love, and compassion are the indicators of spirituality. But you are giving other dimensions as toleration to questions or having a mystical experience etc. Do you choose them because they are easier to analyze?

That’s a very good question. It’s very important to include as a part of someone’s total spiritual well being their ability to feel compassion towards others; their ability to feel hope. One of the challenges now in this area is to understand those dimensions in and of themselves and I see them more as overlapping with spirituality rather than defining it. And I say that partly because there are many people who feel that they are not religious or spiritual perhaps, but they certainly have the ability to feel hope and they have the ability to be compassionate toward other people in their lives. From the perspective of Psychology, we don’t have the answers to this yet but we’re applying tools out of Psychology that we’ve used in other areas of understanding human emotions, personality, and patterns to try to apply them within this arena of understanding something as complex as religion and spirituality.

M&B: You are using tools from both religion and psychology. Are psychologists generally interested in spiritual experiences?

Well. William James who is considered one of the founders of Contemporary Psychology in the 1800s wrote the Varieties of Religious Experience. And he wrote that from a very sophisticated perspective where he said we really do need to look at some of the universal aspects of religious or spiritual experience. At the time he didn’t really have the tools to do that but he introduced the discourse around the value of doing that, the value of understanding those very human experiences from a psychological perspective. And it began with a respect for those experiences rather than discounting them. And I think that that is a very important distinction.

In contrast, when some of the thinking that came out of the Psychoanalytic Schools and particularly Freudian theory tended to pathologize those experiences considering them as an anomaly or like a sickness. In fact one of the differences between Freudian thinking and Jungian thinking was the discounting of those experiences as regressive and pathological. It is an aspect of human experience that could tremendously contribute to the best in human nature. And if understood and cultivated in appropriate ways, this could tremendously increase people’s ability to engage with their fellow human beings to act ethically.

The Qur’an orders patience in many verses, such as: Seek help in patience and prayer (2:45) and: Endure, vie with each other in endurance (3:199), and prohibits haste in verses like: Show not haste concerning them (the unbelievers) (46:35) and: When you meet in battle those who do not believe, turn not your backs to them (8:15). In many Qur’anic verses, God praises the patient, declares that He loves them, or mentions the ranks He has bestowed on them: The patient and steadfast, and the truthful and loyal (3:16); God loves the patient (3:145); and Surely God is with the patient (2:153).

The Qur’an mentions many other aspects of patience. For example: If you endure patiently, this is indeed better for those who are patient (16:126) advises patience as a preferable way in dealing with unbelievers while communicating God’s Message to them. We will certainly bestow on those who are patient their reward according to the best of what they used to do (16:96) consoles the patient with the best of rewards to be given in the Hereafter. If you have patience and guard yourselves against evil and disobedience, God will send to your aid five thousand angels having distinguishing marks, if they [your enemies] suddenly attack you (3:124) promises the believers Divine aid in return for patience.

How meaningful is the following saying of the Prophet Muhammad, master of humanity, peace be upon him, concerning patience and thankfulness:

How remarkable a believer’s affair is, for it is always to his advantage, and such a condition is only for a believer. If something good happens to him he thanks God, which is to his advantage; if something bad happens to him he endures it, which is also to his advantage.

The characteristics of patience can be grouped into five categories: enduring difficulties associated with being a true servant of God or steadfastness in performing regular acts of worship; resisting temptations of the carnal self and Satan to commit sins; enduring heavenly or earthly calamities, which includes resignation to Divine decrees; being steadfast in following the right path and not allowing worldly attractions to cause deviation; and showing no haste in realizing hopes or plans that require a certain length of time to achieve.

With respect to its degrees, patience can be divided into six categories: showing patience for the sake of God; showing patience and attributing it to God (being convinced that God enables one to show patience); enduring patiently whatever comes from God, knowing that He acts from His Wisdom; being resigned to whatever happens in the way of God; showing patience by not disclosing the mysteries of one’s achieved spiritual station and to preserve one’s nearness to God; and resolving to fulfill one’s mission of communicating God’s Message to people despite one’s deepest desire to die and meet with God.

There are other definitions of patience as well. For example, preserving one’s manners in the face of misfortune; being steadfast when confronted with events, and showing no sign of being deterred; never giving in to one’s carnal desires and the impulses of one’s temperament; accepting the commandments of the Qur’an and the Sunna as a sort of invitation to Paradise; and sacrificing all possessions, including one’s soul and beloved ones, for the sake of the True, Beloved One.

Those Qur’anic interpreters who were interested in the text’s secret or esoteric meanings have made the following commentaries on the verse: Endure, vie with each other in endurance, and continue your relation with God (3:199):

Be steadfast in performing your religious duties, endure whatever displeasing thing happens to you, and maintain your love of God and desire to meet with Him. Or, be steadfast in fulfilling all your responsibilities for the sake of God and to please Him, and endure the difficulty of always being aware of His constant supervision of you and feeling His omnipresence. Or, be steadfast in following the Straight Path without any deviation, even when Divine bounties pour out onto you. Resolve to endure all difficulties and hardships, and maintain your connection or adherence to God whatever happens to you.

Another approach to patience is to attribute to God Almighty whatever is in the universe and happens therein and, while giving thanks for what appears pleasing, being resigned to what appears displeasing. When a believer unburdens himself or herself to God while trying to overcome a misfortune or hardship, a responsibility that is very hard to fulfill, or sins that might be committed, this must not be considered a complaint against God. Rather, it is a believer’s way of asking Him for help and seeking refuge in Him. In no way can such an action be considered a complaint or a protest against God or Divine Destiny. In reality, and according to one’s intention, such an act may even be regarded as a supplication and an entreaty, as putting one’s trust in Him or as submitting to Him.

The cry of Prophet Job, upon him be peace, to God: Truly distress (disease, tribulation) has seized me. But You are the Most Compassionate of the Compassionate (21:83) and the groaning of Prophet Jacob, upon him be peace: I only complain of my anguish and my sorrow unto God (12:86) are supplications or entreaties for God’s pity and compassion. God Almighty praised Job, upon him be peace, for being an excellent servant distinguished with patience and supplications: We found him patient; how excellent a servant! Truly he was ever turning (to God) with supplications (38:44).

One of the most distinguishing characteristics of Prophets and saints is their embodiment of patience in all of its manifold forms and degrees, and that without deviating from their utmost devotion to God, they do their best to communicate God’s Message to people and bear all misfortune and difficulty arising there from. The Prophet Muhammad, glory of humanity, upon him be peace and blessings, who is a mercy for the whole of creation, declared: Among mankind, those who are stricken with the most terrible of misfortunes are the Prophets, and then follow others according to their degree of faith.

Patience is an essential characteristic of those believers who are the most advanced in belief, spirituality, nearness to God, and who guide others to the truth. It is, moreover, the source of power for those advancing toward this final point. Since the most advanced people experience the most misfortune, they are perfect embodiments of patience, which is the price they pay for the rank bestowed on them. Others who have been destined to advance to that final point cross the distances traveled by others through different and frequent acts of worship, by enduring whatever happens to them. Of these, God’s Messenger, upon him be peace and blessings, says:

If God Almighty has destined a servant of His to a rank or position which he cannot reach through his religious actions, He causes him to suffer from his own self and family, and equips him with patience to endure all his sufferings. He elevates him through patience to the rank to which he has destined him.

Thus the suffering to be endured, the difficulty in fulfilling one’s responsibilities, and the pressure of sin contain potential mercy, mercy that is attracted by one’s patience. One subjected to such affliction should not unburden himself or herself to anybody else. How beautifully Fuduli says:

You say you are a lover, then do not complain of the affliction of love;
By complaining, do not make others informed of your affliction.

Travelers on the path to God should know how to burn and boil with love or be consumed with affliction, but never complain to others of such love and affliction. Even if crushed by difficulty or responsibility as heavy as mountains, they should not complain to others.

Rumi summarizes such a degree of patience as follows:

In order to be sustenance for man, a source of strength for his knees, a “light” for his eyes, and a substance for the maintenance of his life, a grain of wheat must be buried in the bosom of the earth, germinate under it, and grow to emerge into the air. It must come into the air after a fierce struggle with the earth, and then be sown and threshed, and ground in a mill. After that, it must be kneaded, baked in an oven, and, finally, chewed by teeth, sent into the stomach, and digested.

To attain true humanity, each individual must be “sieved” or “distilled” many times to discover his or her true essence. Otherwise, the ability to develop one’s potential to its fullest, to be truly human, is not possible:

It is expected of God’s servant to suffer,
And of an aloe wood to burn.

Patience is an essential and most important dimension of servanthood to God, and is crowned with resignation, the highest spiritual rank in the sight of God, to whatever God has destined.