Flight: The Eloquence of Silence

When tragedy leaves open wounds, silence can be the most soothing dressing. To blindly uncover the "truth" in the midst of a tragedy sacrifices people's need for hope when they are most vulnerable. It is a sacrifice that contemporary ethical and legal advocates seem to brush aside, under the banners of informed consent, due process and public disclosure. Just as physicians have come to recognize the harm of the mechanistic pursuit of truth via science, we now need to see clearly the harm of uncovering the truth in the midst of illness, even in the name of ethical duty or legal obligation.

In the past I have offered the concepts of ethicogenesis and critogenesis to remind the ethicist and the Athenian judge within each of us of this harm. Yet, when it comes to the story I wish to tell, these abstract terms are inadequate: the language we need lies closer to image and metaphor than it does to concept. Perhaps this is so because it is a story of the aged. "The aged, sharply aware of their limited imprint, are in a good position to communicate without words ' wrote Avery Weismann in The Coping Capacity: On the Nature of Being Mortal (1884).

So we must turn to traditions even older than medicine, the poetic and the religious, to illuminate the conflict between compassion and the pursuit of truth in the midst of tragedy. "The Sacrifice of Isaac" in Genesis reminds us of how ancient the conflict between truth and compassion is:

"Isaac spoke to his father Abraham. 'Father he said. 'Yes my son he replied. 'Look,' he said, 'here are the fire and the wood, but where is the lamb for the burnt offering?' Abraham answered, 'My son, God himself will provide the lamb for the burnt offering'. Then the two of them went on together.

"When they arrived at the place God pointed out to him, Abraham built an altar there, and arranged the wood. Then he bound his son Isaac and put him on the altar on top of the wood. Abraham stretched out his hand and seized the knife to kill his son." (Genesis 22: 7-11)

After a life filled with adventure and professional accomplishment, Ms. D., a tall, elegant, worldly wise woman, had moved to the country in Maine where the woods and bays meet. When I first met her, introduced by a friend, she had already had for several months the diagnosis of a kind of breast cancer with which no one had survived more than two years. She believed the diagnosis, but refused to believe she would be dead so soon. No, she was going to beat the odds by using every possible means, including various holistic health measures.

"Such beautiful woods these are," she said to me one day as we walked through the woods. "They are still and yet alive."

She continued in her composed manner, "Look, with your background in psychoanalysis, you know that there exists an influence between the mind and body. That's why, along with the radiation and chemotherapy they are giving me, good nutrition, a macrobiotic diet, visualization, relaxation, and cleaning myself of negative feelings and thoughts are going to help. If I do all that, I know I can beat the odds, don't you think so?"

I did not think so, but what could I say? I could say neither no nor yes. I chose to remain silent as a friend. Silent, but supportive. At some point I mumbled something like, "Oh my, how I admire the way you take charge." That was it. We kept walking silently through the woods. As we did, I remembered being told how she devotedly had nursed her own dying mother.

Soon after she left the Boston hospital where she had traveled for her mastectomy, we met in her kitchen filled with herbs. She and her husband hat joined forces. Each had changed. He, a fighter, a talented sculptor of birds, seemed more peaceful and yet more in the picture than ever. She seemed even stronger, no longer spoke of banishing negative thoughts, but appeared to be in the midst of a fierce struggle. He and I spoke of the Battle of Gettysburg. She spoke of her brothers, and how once to tease her they had left her up on a roof. How beautiful she looked that day even as the battle raged.

Toward the very end, there was one last glimmer of hope. She was told at a famous medical center that there may have been a misdiagnosis and that she might have a benign condition. Oh my, how I seized on that hope myself. How I broadcasted and broadcasted it to her closest friends. "You see, you see!" I would say. Somehow in her hope, I experienced a hope for reprieve from those things -- my own patients' deaths, my family's deaths, my own losses and eventual death -- toward which I had previously felt so weak and rebellious. But there was no mistaken diagnosis.

The last time I saw her the initial diagnosis was being confirmed as metastases ravaged her as she lay on her bed. She was at peace with herself and yet very strong. She pointed to the photograph hanging on her bedroom wall of her father in a Danish army uniform. What a handsome man he was. The Danes were always a peaceable people, yet there was a need for an army. She, the most peaceable of souls, was proud of him in that uniform.

She was the first in a circle of friends who had known me for two years to ask about my family's experiences during the Holocaust. We spoke. She ended by telling me of a beautiful piece of land next to hers that was up for sale. "Go look at it" she said.

She was dead a few months later. It was spring. She had lived on for a total of two years and eleven months from the time of diagnosis. She did beat the odds.

During those years she gave many gifts of friendship and encouragement to those who knew her. She included a gift for me, a profound gift -- a love of nature. Before, I had been so preoccupied with my own family's history of sorrow, that I could not appreciate the nature around me in the present.

She left another gift for me -- a gift of feeling comfortable amidst the varieties of silence. From the silence we shared, I learned that all silence is not a lie, that there can be a truth in silence as profound as there can be in the spoken word. I now feel the depth of the truism that there are times when one has to choose when to speak or when to be silent and then live with it. Such silence need not be consent. If it is given with a spirit of compassion, it can take hold and comfort in a particular kind of way.

This is a lesson that is hard to learn, especially in this age of showing, of informed consent, of telling everything and of true confessions. We must be careful that our wish to show and be shown, our curiosity, our wish to educate, to be informed, to know, to control, and to unmask does not run astray.

We must put neither ourselves nor others in the position of mortal danger, as the mythical Greek hero Odysseus was, when shipwrecked on a foreign coast and he had to lie to survive. In his final journey home, Odysseus learned how to be silent, to preserve the truth and at the same time preserve his own survival and the survival of hope. Not that he forgot how to disguise when necessary, but it became a matter of judgment rather than habit.

When to speak and when to be silent, when to look and when to unmask. and when to leave be and to wait patiently in silence, that is the essence of any decision involving potentially tragic consequences. Decisions involving other people are fraught with the dangers of acting solely in self interest rather than the interests of those toward whom one has a duty.

Yet, when we seek certainty by pointing to duty, we still find ourselves in conflict. The need to choose remains Had a member of Ms. D's family or a close mutual friend asked the question she posed, would the balance between truth and the need to preserve hope have remained the same? Would my interests and duties as Ms. D's friend? Were it not for oblivion so dogging our tracks, could our exploration have reached the place where truth and compassion meet in words? And finally, why did this discreet, caring soul, so careful not to burden her friends with her suffering, pose so direct a question to me? Did she seek more that day than someone to walk beside, play with, and be remembered by?

We cannot say everything that comes to mind. There is always a choice to be made. A first hope is that I am making a choice for others as much as I am for myself. Yet another hope is that in choosing, I am free to choose either to speak or to be silent irrespective of how I experience activity or passivity in the face of tragedy. Here only "know thyself" can be of help. At the end of Odysseus' journey, he is recognized by Penelope, and perhaps himself recognizes those sides of himself (one wonders, the feminine?) previously portrayed as the goddess Athena.

When I returned to Maine, the Canada geese were migrating south. Soon thereafter, I would approach Ms. D's husband and ask him what of this I could now reveal and what need be kept silent.

"None of you shall come near anyone of his own flesh to uncover nakedness: I am the Lord." (Leviticus 18:6)

There is a silence of fear, rage, frustration, disappointment or despair. There is also a silence of exploitation, domination, control and manipulation by the withholding of information. There is still another silence of withdrawal and abandonment. Our age has seen all these forms of silence at work, notably in the Nazi Holocaust in World War II, where victim, perpetrator and bystander each wore silence to clothe the most differing emotions and purposes imaginable.

Walter Laquer has detailed such varied uses of silence in The Terrible Secret: The Suppression of the Truth About Hitler's Final Solution (1980). How Nazi physicians were engaged in particular abuses, including those of silence, has been recently unveiled by Robert Jay Lifton in Medical Killing and the Psychology of Genocide (1986).

Yet, even during the Holocaust, the unspoken could be communicated in a silence that allowed for life. Sometime in 1940, after having been tortured by the Nazis, my father lay suspended between despair and no doubt suicidal action. In a prison infirmary in newly occupied Poland, a prison physician, himself a prisoner, stopped by. He looked at my father, was silent, and then put his silence in the midst of the ongoing murder in a context: "If you are fated to survive this war, you will." My father took heart, and survived to save the lives of others, including his future wife, my mother in 1944.

As physicians or patients, we must always question our purposes, our own moments of silence. In the course of the physician/patient relationship, we need to be continually alert to abuses of silence, so well portrayed in Jay Katz's The Silent World of Doctor and Patient (1984).

On the other hand, examples of the need for silence abound. In Oliver Sacks's book The Man Who Mistook his Wife for a Hat (1985), for instance, a music professor, having lost recognition of people and things, lives in a world of music. Sacks chooses not to tell him what his condition is. In another case, a man has lost his memory and has aged a great deal, but still believes himself to be young. Here, Sacks attempts to force the man to recognize the truth by holding up a mirror to the man's face. The man recoils, and so does Sacks, from the cruelty of his act.

Finally, there is silence for the good. The hands of a woman who has been blind since birth have atrophied through disuse because everyone has waited on her hand and foot. Sacks asks that the nurses, rather than feed her, place the food so that the woman can reach for it herself. She is not told that this is being done, there is no informed consent. It is done. Finally, impatient, she reaches for the food herself. A year and a half later, she has become a locally well known sculptress.

The philosophical issues involved in these choices are brilliantly clarified in Sissela Bok's twin masterpieces, Moral Choice in Public and Private Life (1978) and Secrets: On the Ethics of Concealment and Revelation (1983). Verbal silence has its parallels in a visual world, which we can discover in John Berger's remarkable Ways of Seeing (1972). In an age of mechanical reproduction of the visual image, the choice of what is to be reproduced raises all the same questions: what to reveal or hide, communicate or leave alone. As with the spoken word, the choices have full potential for good and evil.

In my own practice of psychiatry, the choice between words and silence is crystallized in psychoanalysis. Psychoanalysis began with the impossible injunction, "Say everything that comes to mind." Of course, we cannot; neither patient nor analyst can or must. The choices that each makes, about what to say and what to be silent about, achieve a degree of freedom only in the course of a long, uncertain relationship in which two human beings strive to know each other and themselves.

When understood in this way, as in Arnold Modell's Psychoanalysis in a New Context (1984), psychoanalysis joins other traditions and disciplines concerned with the choice of when to speak and when to be silent. These choices cannot be made in a vacuum without recourse to the wisdom and the symbols of art, philosophy, poetry and religion. Alienated from these traditions, from the ancient dance of truth clothed in symbol and silence, psycho analysis cannot achieve wisdom or grace.

Harold Bursztajn, '76, is co-director of the Harvard Medical School Program in Psychiatry and Law at the Massachusetts Mental Health Center; consults to the department of psychiatry at Mt. Auburn Hospital, and is in private practice in Cambridge, MA. A version of this manuscript was presented at the 150th anniversary of Mt. Auburn Hospital at the invitation of Don R. Lipsitt, MD. The author is grateful for helpful readings of this article by Drs. Howard A. Corwin and A. Stone Freedberg, and Merloyd Luddington and Tori Alexander.