MR. ARABLE’S AX | Jennifer DeCoste
After my last NICU rotation of Pediatrics residency, I was seething.
I had cared for a newborn with a rare genetic condition that would make her profoundly dependent on medical technology throughout life, but also hold the potential for excellent outcomes in many ways. Her specialists shared that they had another patient with the same mutation who attended school, played sports and even took up scuba diving in his teen years. Our team was deeply relieved to confirm a genetic diagnosis, especially given how hopeful her prognosis appeared to be.
The baby’s family remained terrified to raise a child who was precariously dependent on medical technology. They asked repeatedly if life-sustaining technologies should be withdrawn to allow their daughter to die naturally. These requests clearly came from a place of love. Her specialists and our primary NICU team validated the parents’ fears, the difficulty of the road ahead, and the uncertainty in prognosis for such a rare condition. However, the specialists also insisted her long-term prognosis was so hopeful they could not recommend withdrawing treatment.
Soon, a new attending rotated onto our service. She immediately concluded that our team’s unwillingness to withdraw care was cruel and misguided. We pleaded with her to learn more about the condition before making this irreversible decision, but the attending dismissed our passionate reactions as inappropriate and immature. She said life and death decisions are routine for her as a seasoned neonatologist. She saw no place for our inexperienced opinions, nor the outside ethics consultation we had initiated. The first day this attending ever met the patient and family, before the ethics team could weigh in, she offered the family to withdraw care. The baby was extubated that same evening, and a few short hours later, she was dead.
The following week, still reeling, I sat down with my daughter to read Charlotte’s Web. The story begins when eight-year-old Fern Arable learns her father is going to the hog house with his ax to cull the runt from a new litter of piglets. Horrified, Fern chases after him. On page 2 of this classic children’s book, written by E. B. White and illustrated by Garth Williams, there is an illustration depicting a dramatic struggle for Mr. Arable’s ax. Mr. Arable, tall and stable, in a straw hat and overalls, looks wide-eyed and puzzled as Fern attempts to wrench the ax from his grip. Fern, by contrast, is sketched in furious motion. Her dress and pigtails are flying, one foot is in the air, and her mouth is wide open in a wail.
“Please don’t kill it!” she sobbed. “It’s unfair.”
“Fern,” he said gently, “you will have to learn to control yourself.”
“Control myself? yelled Fern. “This is a matter of life and death, and you talk about controlling myself.”
Tears ran down her cheeks and she took hold of the ax and tried to pull it out of her father’s hand.
“Fern,” said Mr. Arable, “I know more about raising a litter of pigs than you do. A weakling makes trouble. Now run along!”
Tears ran down my own cheeks as I paused, too emotional to keep reading aloud. In its first two pages, this children’s book perfectly captured my experience as a physician in training. Repeatedly throughout medical school and residency, my fresh and uninitiated eyes perceived unthinkable atrocities where experienced physicians saw only business as usual. In response to my outrage, I was met with the same brand of benign confusion that was sketched into Mr. Arable’s face.
I prayed I would never lose those fresh eyes or capacity for outrage.
***
Years later, now an attending pediatrician myself, I was finishing notes from a hectic morning when a medical student arrived for afternoon clinic. Just behind us in the busy work room, another pediatrician was making a call to Child Protective Services. As my colleague described the details of the alleged sexual abuse over the phone, I tried to tune her out so I could focus on my queue of in-basket messages. As I turned toward the student to huddle about our upcoming patients, I was surprised to see tears welling in her eyes.
“I need to step away for a few minutes to process those horrible things I just heard,” the student said as her tears spilled over. “When I come back, maybe we could talk about…well…how you are able to just keep working like everything is normal, while something so awful is going on.”
In that moment, the best I could offer was an expression of gentle bemusement. After all, cases of suspected child abuse are not especially rare in the day-to-day business of primary care pediatrics. “Yes, of course, take all the time you need,” I muttered, a bit disoriented.
Once she was gone, my thoughts settled upon those opening pages of Charlotte’s Web. I remembered how Mr. Arable ultimately chose to respond when his daughter reacted with raw emotion to what he saw as a routine farm chore.
[Still grasping the ax, Fern replied], “This is the most terrible case of injustice I have ever heard of.”
A queer look came over John Arable’s face. He seemed almost ready to cry himself.
“All right,” he said. “You go back to the house and I will bring the runt when I come in. I’ll let you start it on a bottle, like a baby. Then you’ll see what trouble a pig can be.”
Due to Fern’s passionate appeals for justice and mercy, Mr. Arable allows the pig to live, and Wilbur the pig thrives under Fern’s love. Eventually, they meet a very special spider whose own love for Wilbur leads her to achieve miraculous and lifesaving feats of web-spinning. These miracles were set in motion because Mr. Arable did not dismiss the instincts of his young and inexperienced daughter. He listened with curiosity and allowed her moral vision to guide and reshape his own.
I thought back to my initial reaction when I read this passage years earlier. Back then, I prayed I could always retain the fresh eyes and moral clarity I had possessed as an uninitiated outsider to medicine. But it turns out that with enough time and experience, we all lose those fresh eyes.
However, as a physician educator, I am blessed with ever-new sets of fresh eyes accompanying me in my work and renewing my own fading moral vision. For my long-ago prayer to be granted, I need only learn how to listen to my students and trainees.
When the student returned, I thanked her for speaking up. Her response had reminded me that just because something is routine for my line of work doesn’t make it any less abhorrent. We discussed strategies we could both incorporate to create space for genuine lament in response to the suffering we witness as physicians, while maintaining the composure to stay present for other patients, colleagues, and loved ones.
Since that day, I have pinned above my desk a copy of that simple black and white illustration of Fern furiously trying to wrench the ax from her loving but bewildered father. It is a reminder to listen with openness and curiosity when a learner has a strong reaction to something I see as routine. I ask myself what miracles might ensue if I follow Mr. Arable’s example and relinquish my ax, trusting them to raise their own pig.
Jennifer DeCoste is a primary care pediatrician and medical educator at Duke University.