Generosity

Generosity may be the one parameter significant to health that providers never think to assess. I surely didn't, until I met "Carl" and "Catherine," and thought off and on for years about what their dilemma taught me.

Carl had been a highly successful and prominent attorney, representing as his personal counsel, among others, a well known politician whose name if I disclosed it would be recognized around the world. Widowed and retired, Carl had moved into an upscale retirement community where he enjoyed an expansive apartment on a high floor with magnificent views of the city and park. His neighbor and lady friend Catherine was similarly situated, in a beautiful apartment of her own in the same building. Both were wealthy and wise, and delightful. Carl was my patient, and enough years have gone by now that I don't remember the details of his medical case, but I vaguely remember cardiovascular disease and dressing ulcers on his legs, an endeavor that can take some time and thereby allow ample opportunity to chat beyond the necessities of healthcare. From time to time Catherine would appear during our visits, impeccably dressed with hair coifed just so and understated jewelry carefully in place. Carl grumbled some because the bulky dressings on his legs hampered his otherwise equally debonair appearance, and the two indeed were a handsome couple who clearly adored one another.

At one point Carl and Catherine considered marrying, and while the love and compatibility they shared were beyond question this was a difficult decision because they needed to consider the potential impact on their respective financial positions as well as the concerns of their adult offspring, who struck me not as self-serving or worried about their own inheritance but rather as realizing that legally joining the lives of two well-to-do elders was a more complex process than planning a wedding and life together for two young adults just starting out in life. Ultimately Carl told me that he and Catherine had reached an understanding and agreed to continue just as they were, loving and devoted to one another, but avoiding the tax burdens and legal complications of a new marriage at that stage in their lives.

Now and then something would remind Carl of his late wife, "Lois," prompting him to tell stories of their many years together making a home and rearing a family. This perhaps was my first lesson learned about the possibility of having more than one great love in a lifetime, as Carl could become a bit tearful speaking of Lois and remark about how he missed her, even as he clearly was deeply happy with his beloved Catherine. He was a special gentleman, emblematic of a bygone era. Never was that clearer than when his 95th birthday approached.

With Carl's approval, Catherine planned a party at the private club where they often enjoyed dinner. Close to 95 years old herself, she planned the menu, the guest list, the setting, and every last detail. I had been to that club just once, as the guest of another member who I was dating at the time, and can attest to its elegance and to the air of "upper crust" festivity that surely characterized Carl's birthday party. But then came trouble in paradise.

Carl would not, could not, under no circumstances and in no way, accept Catherine's paying for that party. And she was devastated, cornering me in a hallway one day to explain that at almost 95 herself she could not go shopping any more, she wanted to do something special for Carl's birthday, this was her gift to him, and he wasn't willing to accept it. One doesn't turn 95 every day, and at that age I suppose one can't help but realize that there might not be future birthdays, so there was no compromising "this year" with intent to do something differently "next time." The party was on, and fabulous it would be, but who would pay the bill was a point of bitter contention.

Carl was as distressed as Catherine. He understood and so appreciated what she was doing, he told me, but there was no way he was going to sit at a dinner table and allow a woman to pick up the check! No way, not happening, not in his lifetime; that simply wasn't who he was. Now, all of this unfolded in about 1995, and with Carl turning 95 years old then a little quick arithmetic shows that he was born in approximately 1900. I can cut a gentleman of that era some slack with respect to the understanding of gender roles, particularly since his respect for Catherine was so very obvious in every way. It was a "money thing"; she could have all the money in the world and do with it what she wished, but when they were together he would pay, because that's what gentlemen do, he said, what he always had done, indeed, this deep-seated value was core to who he was.

So Catherine saw Carl as rejecting her gift, the only one she possibly could offer him, while Carl saw the party Catherine had planned so carefully as his gift, and that he would be the one to pull out a credit card at the end of the evening or ask that the bill be posted to his personal account was immaterial to anything except his ego. Why couldn't she just give him the party and let him pay?, he wondered. Why couldn't he understand that if he bought his own present then she wasn't giving him anything at all?, she wanted to know.

I believe he ultimately prevailed and her disappointment eased somewhat, while she swallowed the rest and with perhaps the greatest generosity of all allowed him to enjoy his party on his terms. I vaguely remember her telling me that it had been a lovely evening, and adding a bit wistfully that she wished he had allowed her to give it to him.

This wasn't an easy dilemma by any means, but it was a wonderful one to watch and from which to learn: Here were two people urgently trying to give their best to one another, while the two versions of "best" clashed irreconcilably.

Today from time to time I hear discussions and debates about how the expenses of dating should be managed, and Carl and Catherine come to mind each time. To my mind there is nothing romantic, nothing caring, nothing generous about "splitting the check," taking turns, or carefully sharing expenses. I do realize that with student debt and living expenses being what they are now for young people there is a practical need to be counterbalanced with romance, and I hope that if it is financially necessary to split the check or else limit dates to the taco cart on a street corner, couples are finding 21st century ways to be generous with one another. It's said that any time someone says, "It's not about the money," in fact "it" is about the money. But not in this case, I don't think. Carl and Catherine each had, as it's said, "more money than God," and none of their friction points were about economic hardship or fairness. Carl's commitment to providing for his lady had little to do with Catherine; rather it was who he was, he was the provider. And Catherine's planning that elegant party, down to the last detail, in no way suggested that Carl couldn't have called the club and arranged his own bash, or that any number of his friends or family members wouldn't have done so. No, the gift of that party was who Catherine was. Carl could have had twenty other celebrations, but this one was from her, and that's what made it special.

With such phenomena as speed dating, "hooking up," and virtual relationships as well as women emerging as financially independent professionals and having reliable birth control, the world has changed radically since Carl's and Catherine's formative years, and since mine. Clearly the old dependency was not a good thing, and equally clearly, sharing has value. But I hope the "I'll take care of my part and you take care of yours" mentality, the dinner parties that always are potlucks and never are hosted by someone who cares enough to plan and serve a meal, the constant inner weighing and measuring to assure that one isn't somehow being exploited; I hope in 2016 these aren't taking the place of generosity, of giving because one so desires and because it's who one is rather than because of a sense that the other somehow is needy, or of receiving, that is, allowing another to be generous and accepting it gratefully and gracefully, because the world is so much warmer when hearts are open and calculations set aside.

My best friend as a child was "Barbara," and one of our favorite pastimes was pretending we were chipmunks (why chipmunks I never will know, nor do I know if I ever had so much as seen a chipmunk at that age, but chipmunks we were) and preparing "meals" for one another from the various leaves and berries growing in my parents' backyard. We crafted our masterpieces side by side on the sill of a bedroom window, and proudly presented our creations to one another. Now, we both had the same quite limited array of plant life from which to choose in that suburban space and probably designed virtually identical offerings as we labored at that window sill. But that wasn't the point. Some fifty-five years later I still remember the excitement of making "dinner" for Barbara and looking forward to her reaction, and to receiving and delighting in what she made for me. I hope children today, whether they're seven or eight, as Barbara and I probably were, or fifty or sixty, or ninety-five, like Catherine and Carl, I hope they haven't lost that.

In fact, as I work with people I'm struck over and over that those who are healthiest also have the most finely honed habits of generosity, and those with the most troubles tend to have impairments in this respect.

There are pathological givers and takers, there are those for whom the "What's in it for me?" question always looms, there are manipulators who give to get and others who cultivate neediness in order to draw attention. There are some who serve only themselves, a subset of which includes angry, angry people convinced that life has given them a raw deal from the time they were born and they're not about to waste a thing on anyone else. There are relationships that crack under the strain of one person's illness or disability, and others that shift and thrive. There are open hearts, closed ones, and broken ones. Indeed, the variations on the theme of generosity seem endless, and endless in their impact and significance.

So when we're assessing heart, lung, and gut sounds; when we ask about intake, elimination, and pain; when we poke, prod, and scan; I wonder if we also should be mindful of the ways in a person's life that she or he simply is, or is not, generous with others and receptive to others' generosity in turn. And when patients are before us assessing us fully as much as we do them, determining if we know what we're doing and if we're a good fit for them, I wonder if it might be most telling for them to consider whether we're giving our time and talent generously or with one eye on the clock and the other on our bank accounts, pressured and pressed down by a system that should offer the most humane of services but instead often is cold and cruel. Indeed, as I type on this computer there's another screen behind it on which I can access a myriad of details about thousands of people's lives, yet sometimes I think I could shut down that bugger entirely, look away from it and towards my patient, truly seeing him or her, and know the most important thing I need to know simply by assessing

Generosity.