Living and Dying Well
A Conversation with Matthew Loftus
In the final episode of season 4 (listen here!), we sat down with Matthew Loftus to discuss the teleology of medicine, race relations, and applied medical ethics. Matthew and his wife Maggie recently returned with their three children from Yei, South Sudan, where they were medical practitioners at a local hospital (Matthew is a doctor and Maggie is a nurse). They left the country after the significant violence in Juba over the summer, but hope to return when the political environment stabilizes. The following transcript has been edited for brevity and clarity. If you like this interview, be sure to tune in next season for our book club discussion of Atul Gawande’s Being Mortal.
Zac: Why did you decide to go to South Sudan instead of practicing in the U.S.? What were some unexpected challenges you faced while living there?
Matthew: Thanks for having me! We moved there because we felt called there. When I was 17, I felt called to some sort of cross-cultural ministry, and over the years that was confirmed slowly in more clarified stages to wanting to do medical missions, then wanting to do medical education as well. So when we started looking around at places that were doing medical education in places of great need, we looked at a couple of different hospitals and visited two of them, with the one in Yei making the most sense for our family. But at the end of the day, I felt called by God to go to a place where no one else was going, to train medical professionals to do health work and disciple and plant churches.
Zac: I know you and your wife Maggie have written about these experiences on your site and that you’ve written quite a bit elsewhere for places like Christianity Today, Christ and Culture, and many others. Talk us through what it was like to live in South Sudan? What was it like to practice medicine in a place that was radically different from where you were trained?
Sally: And bringing your family with you!
Matthew: Yea, it was different. Although it’s funny, because there are some things that are completely universal when it comes to practicing medicine. People are always complaining about food, different parts of the staff are complaining about certain things…the clinical staff are complaining that the nurses don’t follow their orders, the nurses are complaining about the clinical staff — the exact same things that I saw in residency. But other things were vastly different.
There were definitely challenges in terms of resources — the need was huge but there was only so much time and physical and emotional energy to address it. So we were always thinking about ways to be sustainable in what we did, which was one of the reasons why were focused so heavily on education. But then even within education, it was challenging to move from the medical education system that I learned in, which tended to have a lot of Socratic dialogue, to another educational culture that operated very differently. And there were different sets of clinical realities in terms of the resources you depend on. Over there, our social work department was the hospital chaplain. And we also counted on them to figure out what was going on with families, and to do background investigations in suspicious cases, because wedidn’t have the same resources and civil justice institutions backing usup. It was really wild and different.
Z: Did you find that by virtue of scarcity you were faced with ethical dilemmas that you wouldn’t face in an environment with resources? Even just with a lack of laboratory equipment I imagine you would have to make decisions on prioritizing some patients over others, for example.
M: Oh, definitely. And the positive spin we tried to put on it was that it was a way to teach people on how to apply the principles that should guide clinicians on serving their patients. But there were definitely hard times when we would say, “Well, we have seven doses of this one medication left, so which patients are going to get them?” The really, really, sick patients you have to assess and determine how likely the patient is to die even with the medication, and then determine if the medication should be used for someone who may also be really sick but whose prognosis is much more likely to be improved by the medication. Another really common one that we faced was whether or not we would refer someone, because that would mean going to Juba or into Uganda. If we referred them and we were right in our diagnosis, then they could possibly get their issue fixed. But if we were wrong, then the patient might have ended up making an expensive thousand mile journey for something that can’t be fixed.
S: And tell us about your wife Maggie. Did she have a career that she could pick up and move to South Sudan?
M: She’s a nurse, and one day a week I would watch the kids and she would go to work. There were also times when I would make rounds at the hospital in the morning, and since she has a lot more experience in lactation and postpartum care (that was what she did in the States), she would go assess those patients in the hospital and put together detailed plans for their healthcare. And her primary role both in the States and in South Sudan was raising our kids and keeping the home and cooking and hanging out with people around us. So that transition was a little more seamless than mine in terms of day to day work for her.
Z: We’ve had a lot of conversations on this podcast about medical ethics and bioethics. A lot of times those conversations have come back to, “What is the purpose of medicine?” I think that’s the question you have to answer to get to the heart of any bioethics issue. So in your opinion, as a practitioner, what is the purpose or end of medicine?
M: I’d say that the end of medicine is to do whatever is within your power and the power of the person you’re working with to be healthy. But we also have to think about what health is. I think most people would agree on that definition of medicine, but they would either define health as “everything in your body working ok,” or they focus on the numbers on a blood test that are wrong. And that approach is horrifically reductionist, and does things that are terrible not just for the body but also for the soul and the mind. I think we have to think about health as “wholeness,” and think about that wholeness in the body but also in the mind and in emotions and in the spirit. I think that helping people to achieve that wholeness is what medicine is about. There’s almost nothing that doesn’t affect one’s physical and mental health. Medicine is always trying to find ways to help people do what they need to do for themselves, and adding whatever drugs or treatments are in the gap that help people improve themselves and get to the place that they want to be. I think we also have to think about what our bodies are for. And I do think very strongly that bodies are for worshiping God and for loving other people. So in that sense, a lot of medicine is about getting people to a point where they will be worshiping and loving for a longer time on earth, or they are more capable of doing those things than they would be without medical intervention.
Z: So this is interesting, because implicit in your description of “health” is the idea that someone can be dying but still be healthy from a holistic standpoint. They might have the lab results that show that they have a terminal illness, yet they are still healthy. Is that accurate?
M: Yea, there’s always a tension in all of us. We’re all going to die — we’re all terminal. But I think that for each individual, especially the older that we get, health and wholeness looks different. So for a mother in South Sudan, wholeness and health in her life is going to look very different than it is for a kid in the suburbs of Baltimore. Being aware of the context is essential — so in the context of a terminal illness that you can’t change, or in the context of a war-torn nation, you have to do what you can. So there are ways in which you can have a terminal illness and be very unwhole in your mind and spirit, and there are ways in which you can have a terminal illness and be whole in mind and spirit.
Z: I want to unpack this a little bit, because some of the things that you were saying about spiritual and mental wellness bring to mind alternative medicine. Much of modern, western medicine has a sort of snooty approach to alternative medicine — these things are not peer-reviewed, not rigorously repeatable — so as a doctor, how do you embrace approaches that emphasize these “non-scientific” ideas?
M: You have to ask the patient, and you have to leave space for the patient to talk. As a practitioner, you have to ask questions that help you understand what the patient values and what works for them. I’m obviously a great believer in using evidence-based medicine and rigorous scientific studies, but I think we also have to accept that the number of things that evidence-based medicine can tell us is very small relative to the number of problems that human beings have. And this is true even in the realm of physical complaints in the human body, much less anything else that touches on a person’s health! If we can say, “this is what the evidence says about these things,” but let the focus of our scientific inquiry be focused on what the evidence-based stuff can say, and be open about the rest. Obviously you have to be careful because you may not be able to convince the insurance company to pay for a magic juice cleanse, and if you’re always chasing after the juice cleanse, that may be indicative of something else that’s going on in your life. But I think as doctors we have to listen to the patient, to let science do what science can do, and be connected with the patients and their communities, asking them about all the things that impact their health: relationships, institutions, workplaces, living spaces, etc. These all need to be in the conversation about health.
Z: South Sudan has an infant mortality rate of around 65/1000 births; in the U.S. that number is about 6/1000. So it seems like people are exposed to death much more in South Sudan than they are here. Were people in South Sudan more comfortable with death than people are in the US? How did that affect your care there?
M: Yea, absolutely I would say. The struggle that we have in the U.S. is in playing God, thinking that we should do everything within our power to resist death without thinking about how to die well. This mindset leads to prolonged ICU stays and people who are getting very expensive and difficult and painful treatments that don’t improve their quality of life or help them to feel or be more whole — instead, they just keep them breathing. Instead of thinking about how we die well, we just think, “gotta keep them alive.”
It’s almost the opposite problem in South Sudan that even we as practitioners would struggle with, where there is a certain degree of fatalism about death because it was so common there. Since I graduated from medical school and did residency, I had never seen a child die. But sometimes we would have multiple children die in a single day in South Sudan, just because of how late they presented, especially if there was malnutrition or some other medical condition going on. But when this happened several days in a row, you started to get really numb and your heart could become calloused to a child dying. Which is a terrible thing to say, but people would struggle with it.
Families would have really pronounced rituals of mourning together, and our house was on the other side of the hospital, so we could hear mothers wailing throughout the night when their child had died. But when you were treating a patient who was really sick but not getting better, you could sometimes see people tuning out and becoming fatalistic about it. And that’s a difficult thing, especially when the fatalism is cloaked in religious langauge of, “Well, God’s in charge.” It was definitely a struggle and I wrestled with it: how much do you continue yourself to be moved by the need and the sorrow but not completely fall apart so that you can keep doing your job every day?
S: Could you spell out a little bit more about what it means to “die well”? To some people, I think that’s an oxymoron.
M: Yea, I think it means accepting that death is inevitable. I think the best way to die well involves being a Christian and trusting that death is not the end and does not have the final word in our lives. Death is following in the footsteps of Jesus, who died and was resurrected, and we die trusting that we will also be resurrected. Even thinking about this body that I have is somehow going to be transformed, and whatever it will become is different from this body, as a fully grown plant is to a seed. But there is still something sacred and precious about this body that I have, and maybe I shouldn’t be flogging this body with fluids and a ventilator and dialysis an all of these other things that emphasize keeping it breathing rather than preparing my mind and soul for that next step. It’s very complicated, but again I think it goes back to wholeness: trying to achieve wholeness in this life will always be imperfect because of sin and because of the brokenness of our bodies, so medicine is always trying to approximate the closest thing to wholeness that we have. Again, it’s about anticipating resurrection and savoring the good that you have in life now to the best of your ability.
S: What are your plans for the future? What’s next for your family?
M: We’re going to have a baby in February! So we’ll reevaluate our plans after that. We’re still hoping and praying that we can return to South Sudan and return to the hospital. But if not, we’re very open to and praying about a lot of the people of Yei, who fled across the border into Uganda and are in refugee camps. So we’re thinking about how we might be able to serve them there.
This conversation has been edited for clarity and brevity. You can listen to the original on our podcast (iTunes) (Google Play) and you can follow Matthew’s work here.
