**I have moved to Organ Pipe Cactus National Monument, long-ago hangout for Ed Abbey and a botanically more abundant, diverse desert but without the fascinations of rock and floral creativity that I saw in Joshua Tree. (I spent five days there; it has the great misfortune of being popular and within easy driving distance of Los Angeles. Yosemite and San Francisco have a similar dynamic but Yosemite seems less diminished by it [still crowded but somehow not as degraded], perhaps because it’s not as drivable, but it also raises the question of how people are differently affected by different landscapes.) It was a move from the Mojave to the Sonoran Desert, although I had been close to the subtle boundary between them, not that it’s evident to the average person, including me. I first spent time in each of the three desert areas, that I am once again visiting in one trip, all the way back in 1988 on what unexpectedly turned out to be a transformative journey that included both deserts and the Sierra Nevada, several weeks whose effects have lasted ever since—a statement I would not lightly make. My sense of self, my values, the things I most cared about were all reshaped. As a lapsed Protestant I can easily speak of it as a baptism, an immersion and renewal. I had given up my work in order to go to these places and write a dissertation, which happened but with benefits well beyond the academic result.

Cognition is often over-rated as the source of our ideas, judgments, and philosophies and certainly our ethics. The qualities described in subsequent pages that I found initially in Joshua Tree arose from my experiencing the landscape, receptive to percept and spirit of the place, and then organizing and putting words to that relational and inner encounter. Words are the way to remember, refine, think reflectively about, to analyze and share what has happened, sometimes hoping to foster similar experiences in others. The critical thing, though, and the reason I return, is to resurrect and deepen the experience and once again be affected by this landscape and ambiance and be enriched by it. Such natural settings evoke ways and reasons to live and to embrace nonegoistic engagement with the otherness of it that is meaningful in itself and that is context for what I mean by spiritual. All mutuality begins in presence; here in Nature that quiet being there is enough, yet carries on in its effects. As well, I believe that morality and ethics have their origin in encounter with an other—with any other when I allow it—in which I see that that other has value in itself and cares to be as it is made to be and that I owe it a debt of noninterference insofar as I can pay it. I never act with an effect on the other without ethical involvement. I am accountable for my part in the relation, for my effects on the other. I learned this in the natural world because that was where I felt spiritual recognition most strongly. Eventually I wanted to organize these recognitions and make them intelligible as a pattern, a way of life, and I framed them in terms of I-Thou morality with the virtues conceived as ethical and intellectual excellence, that is, I-Thou in relational attitude and excellence as goodness and truth. At root, I am one with the other and reverent toward the existence that opened these realms.

Stars: Speaking of Nature, I don’t usually extend its boundaries above the clouds and the bubble of Earth’s atmosphere in my mind. But I often use Nature interchangeably with natural world, which feels more wide-ranging—the stars are part of the natural world but not of Nature. A strange seeming locution but appropriate and leading to a conclusion that natural world and Universe are terms for the same place, micro to macro, seed to stellar infinity. If natural world is interchangeable with both Nature and Universe that may suggest unity of Being, at least in expression but I think points to more.

Desert is for stars as much as for cactus and creosote. Partially that is owing to human defilement of air and natural sources of light by pollutants. Since desert locales such as this are often relatively far from industry and population centers, there is less of noxious gases and particulates and artificial light to come between us and stars; also, there aren’t trees to impede vision. Forest has its own wonders but sky is not one of them if you’re not in the canopy or the edge. The night sky may well have been my initial introduction and invitation to the natural world and greater awareness, to deeper engagement with it. It was not at first in desert but at lakeside in forest so sky was open to me over the water. It was a place I could go to at will and I went frequently. That was over half my lifetime ago and what it was part of hasn’t ended and won’t till I die, as I said. From there I went to mountain, then desert, then ocean, and I found what I sought in all of them. What that was isn’t always easily speakable and wasn’t always clear, but those five natural world qualities listed below are surely a large part: Order, Beauty, Goodness, Rightness, Intelligence. I seek reliable occasions for these qualities and find them here.

Some time ago I was drawn to the notion of “reverence for existence” (without being quite sure where those particular words came from) and eventually used the term as name for a book. Later, I learned that Plato included Piety alongside the four “cardinal” virtues (making five), but I’ve not given it the attention I think I should have in light of my concern for reverence as the fitting response to sheer Being/Existence. There are two aspects of the matter that occur to me here: First, what Piety means, which I take to be composed of a fitting response of veneration, or reverence, for a sacred realm, much related to the gods for Plato and others of his time. And second, that as a virtue it constituted part of moral excellence, which was inherent in achieving a good life. As one who senses that the “divine” realm is the material realm in its deepest and most mysterious relational/unitive composition—by which reverence is evoked—and who shares the view that a good life is described as the life aimed at the pursuit of wisdom and the practice of virtue…with these, reverence for existence and especially for Nature is implicit.

Despite their distance, stars (and planets, galaxies, and all the rest) have felt accessible when I made the effort to connect. I don’t know how to understand that except as the consequence of infinity on the mind of its beholder. My first consciously unitive experience was with stars, better put as night sky since the perception was of darkness, pattern, discrete faraway objects, variable brightness, and excepting Polaris, their steady slow movements over the night. They sparked my imagination, expanded my world while contracting my focus. There is comfort in infinity from the perspective of my finite world. Just as there is in the geologic time scales of Earth and Nature’s perdurance and recovery through the assaults of asteroid, volcanic disruption, basalt flow, and humans. And on a smaller scale, in the eternal molecular recyclings and resurrections of individual lives ending and then transforming as part of new ones that take them up in new beginnings. I have spent many hours among stars.

I think that most likely the Universe has always existed, so when we say it is 13.8 b. years old we may only mean this iteration is that age. Which means time really is infinite, and presumably space. I have no idea what to make of this; it is settling and unsettling at the same time. Fortunately, the Universe has no need for me to make anything of it.

Not infrequently when I go to Nature, regardless of my state of mind, I become somber, not sad but serious. It no longer surprises me but does perplex. I am in a favored place but where is the usual joy and satisfaction? Is it what I felt a couple years ago traveling in the Nordic countries when I felt drawn to old cathedrals for their silence and beauty and sacred atmosphere? I explored, meditated, left always pleased and sometimes somber. Or do I feel the holiness of the natural setting and fear for its vulnerability? What the two places have in common is spiritual presence, which brings humility and absorption and toward which the pain of incompleteness sometimes strikes me. My limitations mean it will always be that way.

I usually camp for several weeks at a time and usually visit a few favorite places for the obvious reason that I like being there for the qualities of the landscapes and climate and getting to know them ever better. Secondarily, I enjoy aloneness and the time takes me deeper into myself and my place (in both senses). Last night it occurred to me, as it hadn’t before, that my purposes in living—at least many of them—have run dry and feel finished insofar as I care to pursue them. For instance, large parts of my life and work have been spent trying to understand humans and our place within the Earth biome and existential space. I now think I know as much as I can or want to know. Despite having loved and admired my share of fellow beings, I tend to believe that Homo sapiens is a failed species. Failed in the sense we might describe an organization or institution, state or individual, as failed: They betrayed, or at least failed, their purposes and capacities; they couldn’t get along with others; their ethical values were malleable, optional, or superficial; they wouldn’t recognize their true needs and interests and were heedless in relation to their crucial ones; they were self-centered and destructive and squandered when they should have preserved. I’m sure that with continued effort there’s more I could learn about Homo but I would be surprised if it were inconsistent with what I have learned already. It would waste increasingly limited time when I think my purpose now is mostly to detach from that part of existence. I am sad at what I see but this does not express depression or despair. There is more to existence than humanity, even though it will probably be humanity that turns out the lights on its own could-have-been-valuable opportunity to realize that.

Which leaves me with what? Nature, spirit, other purposes, other learning, a beloved partner—these will occupy the best moments and for the day-to-day, my winnowed and trusted pastimes.

I walked among the cacti and their botanical companions this morning, out north of the campground, and heard a flute. I moved toward it and saw a woman playing, accompanied softly by an old “boom box.” Not wanting to intrude or disturb, I stopped farther than I would have liked but close enough to hear as I looked over her head to the hilltop and its spiked covering. When finished, she packed and headed for her camp along a trail near me, whom she hadn’t seen. I thanked her for the music and said that outdoor music always sounded different and better to me. She agreed, said she was practicing to play at her church, and that, yes, she felt closer to God (looking up) out here. We agreed about that also and she left. A nice little accident of time and place.

After describing mine as a failed species yesterday, I wondered if I thought it irreparable. Except for fits and starts, I do think it is probably permanent and eventually fatal. We became too many, too egoistic and materially oriented, too acquisitive and violent, for meaning and us to survive. Human nature is generally obscure in its particulars but one phenomenon appears universal and timeless—There are always a few who desperately want more than their share and who massively exceed others in their worst qualities, and will do what they must to cling to excess power and wealth and use it to the disadvantage of others while claiming the opposite. Malleability and gullibility of the masses unite with nihilistic self-seeking among the powerful and the collective deteriorates. I won’t say more: it’s a distraction, useless to talk about, but constitutes a large part of our failure and its consequences, I believe. Better to watch the stars at night and the landscape by day, which preserve equanimity and encourage quiet mind, and are inspiring.

My chief consolation, when I observe the terrible destruction wrought by humans on the natural world—which, seemingly unremembered or unnoticed, sustains them despite all—is to recollect that after we have delivered ourselves to extinction, never to return, Nature will heal and eventually return herself to plenitude even if it takes a leisurely million years or so. I have no doubt about this and smile when it comes to mind. But it’s also true that plenty of innocents will suffer and perish with the guilty as we make our way out. The great majority of humans didn’t ask for this, but they didn’t stop it. A minority, the morally worst of us, made the choices that sank the rest of us and we complied. None of Nature’s other creatures had anything to do with it but all will feel it and die early or not have their chance to be born. It was their bad luck that their time corresponded with that of the destructors, similar to the fate, over eons, of other transient beings living simultaneous with passing asteroid or volcanic events. Luck of the draw, one could say, and relatively brief and few in the multi-billion year cavalcade that many still say has no purpose, a conclusion with which I differ.

It doesn’t seem to me there are as many birds around here as I remember. Is it the season, or the times? I ask a similar question when I approach Tehachapi Pass from the east and face the gray-brown air: how much is fog and how much Central Valley air pollutants? And when I walk on the Pacific Ocean bluffs near my home: how much hurt do the waves conceal? Among the changes we have wrought is the frequent inability to distinguish what’s natural from what’s not and to know what’s been lost. In the somewhat esoteric debate over humans being or not being part of Nature, I tend to believe that insofar as any creature persistently acts against the interests of itself and its home and neighbors, it is unnatural. This doesn’t address the question of whether the uniqueness of Homo sapiens just happens to include this proclivity, i.e., their capacity for self-destruction is part of their nature (someone once said that humans were Gaia’s suicidal aspect), or looked at from a different perspective, they are an evolutionary mutation that carried the flaw predisposing them to failure. As a working hypothesis the humans-not-of-Nature postulate is good enough for me. Other creatures make mistakes but not methodically and persistently, and human actions can no longer be considered mere mistakes but more on the order of willful misconceptions and willful hurts imposed. The others of Nature seem to know who they are and what they need and quietly go about meeting the requirements of their being without extraneous damage to Earth itself.

I am reading Darwin’s The Voyage of the Beagle; he was clearly a remarkable man. Astonishingly observant and diligent, to the point of tedium sometimes (for the reader) although it was necessary for his purposes, which were both scientific (with even more detail no doubt in his formal scientific reports) and telling the story of his 5-year journey to a general audience. He seemed kind and gentle, an honorable English gentleman of the 19th Century and surely a good neighbor. I was disturbed to read of his probably normal (for his class, time, and purposes) treatment of animals—killing rampantly at times for food, fun, or science—but he says as he grew older he foreswore such behavior. (It is interesting how many men I read of who did this, seemingly becoming more sensitive and aware with maturity.) Also disturbing were his inconsistent racial attitudes, which he unconsciously revealed in his encounters with Black people in Brazil, some of whom were former or present slaves, and many natives. In order of occurrence over six pages early in the book:
• Regarding a story about runaway slaves who had been captured on top of a steep hill nearby, except for an old woman who threw herself from the top rather than be returned to slavery: “In a Roman matron this would have been called the noble love of freedom; in a poor negress it is mere brutal obstinacy.”
• He could see the appeal of retiring to such a place, “As long as the idea of slavery could be banished…”
• Of the workers on one estate: “I have no doubt the slaves pass happy and contented lives.”
• On another estate he nearly witnessed “…one of those atrocious acts which can only take place in a slave country.” In anger, the estate owner threatened to sell all the enslaved women and children but keep the males, but “Interest, and not any feeling of compassion, prevented this act…” Still, Darwin “…pledged myself, that in humanity and good feeling he [the owner] was superior to the common run of men.”
• Lastly, while in the company of a “negro, who was uncommonly stupid” and with whom he could not communicate, he raised a hand to make a sign that the man misread as the prelude to a blow and in response dropped his hands, half-closed his eyes, and looked frightened, “[although] a great powerful man…This man had been trained to a degradation lower than the slavery of the most helpless animal.” Darwin was horrified and ashamed.
How difficult it is for a person to resolutely stand outside his society even when its practices would be abhorrent to many of them except for their willingness to categorize people into subservient classes as inferior beings. Darwin was sensible and compassionate enough to want slavery banished but not able to see the enslaved as fellow humans of equal value, fellow “children of God.”

This points to another observation I have made about other good men such as Muir and Thoreau: they see Black or Native people who act so different than Whites (to the point, in some eyes, of seeming almost to justify their egregious treatment) and assume that is how they were made by Nature rather than recognizing the effects on minds, self-images, behavior, and emotions of the treatment they have suffered all their lives, the oppression, violence, and degradation, the demeaning curtailment of opportunity and respect. A stupid negro; a pathetically obstinate negress? Tragically, oppressor and oppressed and those in-between have been shaped to their roles, and human stuff, once formed and reinforced by habit, society, and interest, is not at all adept at self-repair. As I read further in Darwin, I see how pronounced was his assumption that people and types of people were born to be what they are with no suggestion that their environment and experiences had much to do with how they’ve turned out. This assumption would certainly support a class-based society. Underlying it, surely, was the unspoken notion that this was God’s design and intention. I recall that at one point he said that if the structures of society were not by such design then England had perpetrated great sins.

When camped I live differently than at home: superficially much the same—the same few pleasures and duties—but time organized and apportioned in other ways and a different mind-set. More time alone and for reading, for uninterrupted silence and thought, more for walking and talking to cactus and lizard, for contemplation and stimulus to write.

I have been reading conservative intellectuals recently (Kirk, Babbit, Scruton) and trying to identify their liberal counterparts. This morning I thought of what appeals to me in each side of the discussion. I decided tentatively that one way to look at them was through the frame of the Four Cardinal Virtues, and that conservatives were focused on Prudence and Temperance and liberals on Courage and Justice. Not an absolute division by any means but a good provisional one, I think, and food for discussion. Discussion is probably more productive than debate and depends more on values of civility and respect that will serve us well if generalized.

I have also been re-reading some essays by Wendell Berry, who as it happens makes a good bridge between the two orientations just spoken of. I doubt another writer has values so consistent with mine or a way of life and of expressing those values so compatible. He represents well what I tried to express in Reverence for Existence. I still believe that that single change to an attitude of reverence, or respect for intrinsic value, would necessarily lead to others that foster our being a better kind of people living in kinds of communities we loved, and that the capacity is widely spread but largely neglected.

One of the Berry pieces came from his 1977 book The Unsettling of America, which I read long ago but had forgotten the part I’m going to talk about here. He was describing the industrial mind-set and its ideology of exploitation, and as metaphor he uses the presently effectively banned word “nigger,” which has been replaced in polite language by “the N-word.” I have always objected to this and will be curious to discover if his usage survived into later editions.

I grew up in rural Texas during the ‘50s and heard the word used as an aggressively pejorative label frequently and knew as I think most people did that it was a uniquely ugly and insulting way to speak of or to another person, so much so that it was sometimes used between whites as an insult. As one who considers racism and other bigotries among the greatest evils that the fertile human mind has ever fashioned, the word offends and grates on my conscience and sensibilities. I would not be sorry to see it die of disuse. But banning it by “cancellation” or fashionable fiat does not strike me as progress, even though I understand and also care about not offending the sensibilities of those among whose historical harms it has been an emblematic part of the language. Still, I cringe when I hear or read “the N-word” more than I do, albeit for different reasons, on the very rare occasions I hear or see “nigger” used. Which is why it caught my attention when Berry used it (48 years ago) and I read it today. I don’t think it made a good metaphor as he used it but I get his point and wasn’t offended; I imagine he considers the word as ugly and offensive as I do and wanted to put the power of that behind his abhorrence of industrialism. “Nigger” has too much history, too many heavily loaded associations, behind it to be effectively used outside the racial realm, but for it, say, to be banned from illustrative uses in favor of “the N-word” gains us nothing and wastes its power, and frankly strikes me as precious, contrived. Who is going to be moved by historical accounts, for example, of racist thought or behavior in which “the N-word” is inserted in lieu of uses where “nigger” was the chosen epithet and used presently to illustrate that? Do we exchange its power to make a positive point for the delicacy of avoiding that power’s negative application? Should lynching become “terminated with extreme prejudice.” Racism is far too destructive and pervasive and persistent an evil in human societies and word-banning almost frivolous in response, no more effective than book-banning by the right-wing to promote right-thinking (or no thinking at all). “Nigger” still has rare anti-racist uses and I would prefer banning “the N-word” to banning the real word when one of those uses comes up. Which is not to say that as many writers prefer to use “f…” for “fuck” out of delicacy, there will not be others who prefer “N…” over “Nigger” for similar reasons, and I respect that—it’s the banning, the imposition, that bothers me because in banning the word the question of sincerity and pretension in the user simultaneously arises, as does the potential for using symbol to avoid hard reality. (I would add that I have similar concerns with the contemporary pronoun fetish among my fellow liberal types, but this isn’t the time for it.)

I have attended silent retreats and am always newly surprised at how much easier it is being with people when talk isn’t expected. Instead, we smile, nod, feel closer to others and are inclined to like rather than measure them. This morning I sat in an arroyo a mile or so from camp and enjoyed that same kind of silence. I still worry about the paucity of birds—Is it seasonal or part of the worldwide major drop in wildlife numbers?—but aside from that, the silence is a large part of what brings me here; it is delicious, and too little available (libraries try but swim against the current) and too little appreciated. Silence is one of the reasons I always hike alone; when two or more are gathered tongues will wag. I passed two groups of four on the hike today and both were a verbal clamor, within the context. The difficulty of finding outer silence is paralleled internally by the difficulty of silencing the mind. Almost daily I find times to sit alone, silently, motionlessly, but moments when I escape the inner dialog are too few. Even so, I feel refreshed by it and think it helps with equanimity and perspective, perhaps especially as I grow old. I’ve always thought that line admonishing us “not to go gentle into that good night” was childish. One should go out with dignity and grace; if friends are present a few words and looks and touches will be added, but what place has “rage against the dying of the light”? Ending must follow beginning at some point.

Three small wishes for before I die: I want to camp in a desert during the rainy season and experience gentle, persistent rains for a few days and see a dry creek rise and flow. I want to be in the Sierra and have a few days of gentle snow. I want to camp in a migratory flyway at the right time to hear and watch the multitudes go on their way.

**Looking back on Joshua Tree where I began this trip, I realize how much it shares with Organ Pipe as an ecosystem but that its comparative austerity lets stand out certain aspects of that. When there, I see and feel an Order like that of other places I camp and spend time, but in ways more pronounced, as if the lack of embellishments exposes it: the rock piles and boulders weather and fracture and assume relatively lasting positions as they change; erosion and exfoliation never cease, earthquake, gravity, and chemical interaction push things into new settlings. The piles look as if purposefully assembled but actually are the result of disassembly, having changed continually but very slowly since their emergence from far below. Even the rubble of exfoliation, the scree and talus, seemingly chaotic, seems in place. Bush and cactus, juniper and pinyon, each finds space to root, not haphazardly if they want to survive, but where niches open and seeds arrive and grow and existing flora accept them along with shade and sun, moisture and soil, to nourish them. The whole perspective is one of fit, of harmony and balance leading to sensory appeal: an otherness to recognize, enjoy harmlessly and respectfully, to revere. When I came for the first time in 1988 I was intimidated by the unfamiliarity and fierceness of it; I was still an innocent out here, but have matured and now it feels inviting. The order—organization, distinctiveness, assembly, conjoinings, contrasts, peculiarities—was part of that and part as well of other qualities I will note.

Beauty through the senses and into the soul, where I am most aware of it and carry it when I move about or leave. Beauty persuades me to want more, non-appropriatively; to feel improved in its presence, enlightened, uplifted; slightly less ordinary in an extraordinary world and in an unselfed way. Natural beauty seems effortless, inherent to the being it composes, simply born with it. Under its influence arise love and mutuality and desire, even duty, to exert care for its gifts. These are its effects, but what is it, what makes it beautiful? I hold with the notion that it is made of such stuff as revelation is made, brief openings of the sacred—in the theological context where I don’t go it is part of the mysterium tremendum, fullness to overflowing.

Goodness speaks for itself and is implicit in beauty; Earth is better for the presence of what’s here, desert beauty, best known directly in silence. Of course, everything natural that Earth and life have given is good; I highlight the goodness of this desert place out of particular love.

Rightness as: “Of course, what else could be here? or be better, more fitting? could possibly do it with equal fervor?” I am invited to join and be part of it, with the manners of a guest.

The Intelligence to attract and engender in communion, knowing its place and needs and what belongs to it. Through its assemblage of parts a unity: giving, receiving, living and dying in rhythm.

[An addendum: By coincidence, a few weeks after I was drawn to the above observations, I read a planning document for a new nonprofit group that I support and have a strong allegiance and affection for—undoubtedly because I had considerable familiarity from thirty years before with the people and events that motivated its formation—and in a section stating their Values I found these listed: Intention, Simplicity, Beauty, Respect, Community. I was struck with the compatibility, the continuity, between these values and my observations, which seem as suggestive of a modern version of Aristotelian-type goods and virtues as I can imagine. All reach toward a Eudemonic vision of lives lived toward flourishing and excellence in ethical and intellectual dimensions. I discovered my five qualities implicit in a desert landscape; those from the plan I referenced mean to guide a new group of people forming themselves into a community aimed at doing good work for good reasons purely because it is good that it be done.]

**Arrived Death Valley yesterday, entry from south on 178, my favorite approach. It seemed, after I crossed the mountains and moved north in the valley itself, that there was way more bright white mineralization covering more of the valley floor than I remembered. Must ask about this. Lucked into one of the few good campsites within the Furnace Creek area, not including the reservation-only campground. It has always seemed to me there’s too little of plant growth within these camps and insufficient thought went into their layout. Good campgrounds should be simple while abundant with native vegetation and not crowded and ugly. I’ll stay for six days.

From Joshua Tree to Organ Pipe Cactus to DV: each so different—rocky granite prominence and Joshua trees, then floral riot (relatively speaking), and now extreme austerity bounded by high mountains and strange colorful geologic productions. After three desert weeks I’ll be ready for the Sierra Nevada but I fear it won’t be ready for me. There are still many areas snowed in with more on the way and cold along 395. Weather allowing, I’ll drive it slowly north, cross the Sierra at Carson Pass, and be home late next week.

A few weeks ago I happened to read someone’s recollections of Jonathan Schell, the good man he was, and the fine and important books he wrote, so I ordered the re-released The Village of Ben Suc, his 1967 account of American destruction of a Vietnamese village of 3,500 people thought to be infiltrated by, if not allied with, the Viet Cong. Like the whole damned war it was calamitous, violent, and clumsily done, not to mention unnecessary, counterproductive, and wrong. I was six months from graduation and first marriage (its own calamity) and had spent the last couple of years protesting the war and knew I would soon face the draft and might be ordered to add my efforts to the disaster, which I didn’t think I morally could do. A very difficult time that probably doesn’t need review; after four years, two refusals at Army induction ceremonies, two rejected applications for classification as a conscientious objector (my rural Texas draft board couldn’t fathom my ignorance of the Communist menace we faced), one appearance in court, and untold anxiety, I turned 26 and was no longer eligible for drafting under the rules of that time. My belief is that the nature and ultimate fate of the U.S. was largely determined at its beginning in the early 17th century when European colonists began importing slaves and killing Natives, and the more proximate shove toward its fate began with the growth of American militarism after WWII that led to this war—a disastrous lie-fueled fraud that demonstrated just how violent, ignorant, and vicious we could be and, once again, as with slavery and genocide, never reckoning with what we’d done and just blundering on in the same fashion. The size of the calamity and the deceptions, I think, were enough to wreck trust, optimism, and even hope and, combined with subsequent socio-economic changes, lead to gross inequality and the virtually exclusive valorization of wealth and power accumulation at the putative leadership level, eliminating anything morally good as a national goal and further fragmenting society. And now it’s 2025, and look at what we’ve come to!

I don’t have phone access here so went down to the developed area to email Lynn and let her know I’d arrived safely. As the news-related emails landed in the inbox after my ten days of innocence I read headlines and felt my spirits fall. The incessant display of opportunism, seediness, and degradation, of violence, grasping, and lying—what a sight and what a contrast with what I’d been part of the last couple of weeks. One of the few articles I opened and read was about corporate CEO types and their take on Trump so far. Some supported him and always had, some had converted into a supporter, others were withholding judgment, but all appeared to agree that while he might be a buffoon, moral vacuum, and bad for the country, he was good for corporations as he would cut taxes and regulations and obviously sabotage governing and administrative effectiveness. Party time, in other words, and not exactly patriotic or ethically-minded were they. Don’t know how I could have been even a little bit surprised but I was. These people are part of the leader class and have turned out consistent with its traditional low and self-centered character, just like their compeers in the petrochemical industry who are intent on wrecking the climate, reaping the profits, and passing the consequences on to their children and grandchildren. In response, I intend to terminate all my news subscriptions and avoid as much awareness of current events as I can. What I can’t change I must accept, but I don’t have to read about it. My equanimity is too important to me, especially at 79.

I don’t know how common it is historically, but it seems to me that those of us born at the end of WWII (I arrived only a few days after Hiroshima and Nagasaki and have always been anti-nuclear [even pacifistic] politically, a coincidence, I suppose) and looking over the decades since have to wonder what we accomplished: on balance, has it been to the good or not of life that our cohort passed through? I have a hard time avoiding the conclusion that it’s a worse world than we entered with war (briefly) ending and relative peace at hand. I like to believe that my work as a clinical social worker and later in animal protection were some small counter-friction (in the Thoreauvian sense), visible in individual instances but not on the whole. If, as I speculate, the die was cast 400 years ago (in the U.S.; among Homo sapiens as a whole it may have been a few thousand years ago), there’s been time for a better kind of people to see what was happening, to face themselves and reject delusional interpretations, and to correct course. But we wouldn’t earlier and won’t today. So instead we’re fractured within and without, irredeemably I suspect, with lots of talk about religious convictions but no evidence of their active ameliorative presence, and no serious talk about ethics and the essential mutual care and respect that keeps a citizenry intact, healthy, and happy. Those CEOs I mentioned are the model for how things collapse.

I want to think about what it means emotionally, even “existentially,” to a generation such as mine that approaches our end time with this knowledge and the responsibility that goes with it. Accountability is too diffuse and perhaps pointless, although self-awareness means that many individuals such as myself cannot avoid wondering and shaking our heads with sadness. If others feel as I do, that we’ve lived mostly responsibly and ethically and that our lives were a “success” and mostly satisfying, we have to consider that our picture of the whole is missing something, that it’s more complicated than a summation of individual lives can measure. And of course, it is. For instance, some lives are more determinative than others. Systemically, a few are given more control by far than others. Thousands of satisfied lives don’t neutralize one President set on conquest or grossly wrong in his decisions or engulfed in corrupt self-centeredness. (The moral of this story: never let anyone accumulate excessive power or wealth and when authority is needed and vested monitor it scrupulously if you want to protect your society.) So, 80 years after WWII and massive changes—often called progress by some—I am saddened and almost out of words. The number of “X-risks” allowed to lurk over us may be the greatest indicator of the spiritual emptiness and passivity of our culture.

On a different note, the answer to my question about the seemingly vaster extent of mineralization on the DV floor this year is that it’s not much more extensive than in the past but rains have caused more to percolate up where it is and winds have kept it swept of dust and whiter than usual. This, compliments of a volunteer in the Visitor Center. (I did her job in the Yosemite Valley Visitor Center for many years during the aughts and enjoyed it immensely. Being helpful is very satisfying.)

Back to my thread of thought, I was going to begin with “western cultures” but since I know the American version best I’ll use it (also it tends to be more extreme in its follies since at least WWII). It seems to me we have a conflicted relation with limits and the idea of limits, especially moral limits, mostly seeing them as impediments to be gotten around. For some limitations that is surely true, ignorance for example. But more often than not we need limits and unconsciously seek them. It’s a matter of how they are built or accepted and understood. I think of this now because three weeks living in this van camper is a series of lessons in spatial limits and the awareness that must arise else spillage and breakage will. Also external limits like weather, which may make me alter my route home from 395 up the eastern Sierra, often at high elevation, along which I had hoped to dawdle until turning west to cross at Carson Pass and go home. It’s still winter up there, cold, snowy, and windy: too much for my van to risk. And there are the limits implied by commitments and membership in communities, in the obligations of friendship and ethical consciousness. And many more, of course.

I looked north this morning and saw a fierce black cloud that I thought might bring deluge to DV but that instead cleared (sort of) leaving heavy snow on the mountain tops. This is a disappointment but perhaps compensated by spending a day in Yosemite Valley if I have to go the southern route across the mountains. Closer contact with natural limitations brings closer contact with natural reality and that is good: it helps with perspective and humility and respect for the world we inhabit although not at present in the most fruitful, benevolent, and spiritually mindful of ways. In fact, we don’t so much inhabit the Earth as pause to exploit it as if on the way elsewhere.

Yesterday Twig and I hiked up my favorite nearby little mountain. About three miles roundtrip and 4-500’ high. It has horizontal lineaments, is dark brown in the top layers, and has prevailing sandy-colored gravelly surfaces below with buttress-like extensions and a fairly flat top. The trail winds up on the back side of what I see from camp starting out. It didn’t used to be particularly strenuous but in my present condition it is (speaking of limits). Over the years there’s no counting how many times I’ve gone up. I love its perspective. (Taking Twig of course breaks the no-dogs-on-trails rule but she is small so I think only venial sin if caught, but we never are.) There was a large raven on a rock column separated by a few feet from where I usually sit on top. I gave him additional space as I could see he was uneasy. As he moved to walk around to the opposite side from me I saw that he was injured: hanging wing on left and feathers disturbed on right one. How did he get up here; how will he get down? What happened to him? He didn’t seem able to fly. He stayed on the other side and I didn’t see him again. He may well die up here. When taken by a predator animals resist, up to a point, and when dying like this raven for whatever reason (attack by hawk?) I am convinced of their calm acceptance that death has come. They are fully embedded and in tune with Nature and death is no aberration at any time. It’s an attitude I’ve long striven for and I think accomplished. The human kind of consciousness, however, is always able to imagine alternatives and tends to feel exceptional, and it is probably these that cause people to suffer so as they contemplate their death. For me, the known process of changing from intact me to dissolution into parts and being taken up and carried on in other lives is enough to negate fanciful flights and accept reality, to embrace it.

Whenever the precise date of onset was, I am more interested now in considering aging alongside its better-known siblings: dying followed by death, or in the popular parlance, Death and Dying (I always wondered why they had them out of order). The pattern of transit out of my natural form of existence, unless interrupted by calamity, would be aging and then suffering (dying) and then death. Suffering should not necessarily be treated in overwrought fashion—It can mean simply experiencing intensely, enduring, accepting such losses as forecast a likely imminence of death. Or, being frank, it can be agonizing, physically and/or mentally, but not always. All clear enough conceptually. In my case, though, and that of a couple of other elders with whom I compared notes, all of my earliest attention focused on steps two and three, dying and death. Beginning in my thirties I became aware of them as treatment issues in my work as a clinical social worker and psychotherapist and followed that with what I considered existential querying of death as an assured event in my life—who knew when? —asking what that should mean to me and how I lived. Also, how would this exploration affect the anxiety that often attends death’s serious contemplation, and more to the point, the anxiety of its indisputable appearance. The knowledge of eventually and ineluctably passing (back) into nothingness can be strong drink but has to be swallowed somehow. I drank via much reading in philosophy, and autobiographical sketches of a number of individuals’ own dying process, and through working as therapist and hospice volunteer with dying patients. I felt I accomplished a lot and was, and still am, comfortable with “the work” and with the reality of my life’s conclusion hovering nearer and nearer, even though I’ve not entered dying territory yet.

It seems odd to me now that I didn’t pay more attention to aging, the first step and the one I have come to think of as perhaps the most crucial. I’m sure that’s at least partially due to the paradoxical fact that aging is virtually impossible for a healthy man in his thirties to imagine while death is not. How could these strong legs carrying me up the mountain not always be strong? he says to himself. Yet we hear about people dying all the time, are aware of accidents and mortal illnesses, see obituaries, but where are exploratory accounts of aging and who, when young or even youngish, would read them or believe they applied to themselves? They can be depressing stories with few wins and many losses. Wisdom is offered as a sop but it’s less often encountered than spoken of. We do know more things, how could we not, but that does not amount to wisdom. I recommend taking what portion you have and being grateful (few but you will find it engaging) and seeking instead for equanimity. There is much to relinquish, much for adaptation and acceptance, a new form of loss around too many corners; there will be deaths of those you know, and in the 21^st century, I say sadly, the death of hope for a better world bequeathed in part by you. Aging is, in short, a largely unpleasant process of losing capacities and gaining vulnerabilities. But by no means must it be miserable or even altogether aversive (despite aging’s toll, I’m still usually content). Equanimity will be a reliable friend and one hopes there are a few others, including a life partner, good books, satisfying avocations, and for me, large doses of Nature, preferably daily. We are required to die and should do it well, with integrity and dignity insofar as possible. But there’s more to the story.

Gaslight is the name of a 1940s movie starring Charles Boyer, Ingrid Bergman, and Joseph Cotten. It is well worth watching. As far as I know, it’s from there that the term came to be used as a label for behavior by one person intended to engender self-doubt in another, doubt not grounded in reality but fabricated by the gaslighter. As a former therapist and present elder, it is a term of particular interest to me. My observation has been that there is much in the situation of those aging that can gaslight them. Meaning their existing, though perhaps only beginning and still realistic, concerns about what they see aging doing to them can become exaggerated to the point of over-caution and self-doubt.

Coming from friends and family, it is mostly well-meaning. They want to ensure you don’t get hurt and to demonstrate care and they overdo it, not realizing that in so doing they can plant seeds of doubt unless you are vigilant. “Who said I’m so damned fragile,” you mutter to yourself, and then, but now in doubt, “Have I become fragile and not known it and am therefore at risk? Do they see things I don’t?” I suggest telling them to lay off until after your first fall, and maybe well beyond that.

From clerks and such met in the course of going about your business at banks, restaurants, doctor’s offices, and so forth it may be unconscious but nonetheless pernicious. It is nothing more than fake concern demonstrated through a tone of voice that suggests you may be dribbling on yourself like a child or doddering. These are offensive people and usually young and vacuous (or so they act). I ignore them, unless the falsity comes out in the now common form of “Do we need help with that?” or similar nonsense, in which case you might ask if they’re seeing double or if they themselves need help.

From one’s general situation and often from publications aimed at the aging, it is intrinsic and predictable and can be more readily fended off by being more attentive to circumstances or, in the case of publications, taken for what they are worth (thus not being gaslit), which I acknowledge is sometimes a lot. The fact is that those aging wouldn’t be aging if they weren’t facing losses and deficiencies compared to former abilities. Therefore, a bit more caution is often warranted. There is, after all, illumination without gaslight. While I was without much fear, although not foolhardy, when in addition to those miles running, I hiked frequently in the mountains, there are surfaces and trails and downed snags across streams and much more that I won’t undertake anymore. I don’t sufficiently trust my leg strength, reflexes, or balance. I worry that I may become too conservative but also at the consequences of imprudence, always a balancing act (in both senses of the term).

From oneself as a result of the onslaught just described, gaslighting can be doubly dangerous. As I just said, one can overdo the caution piece. Sometimes a bit of risk is worth it. I think that as long as I can have discussions with myself about whether to do or not to do something, and not know the answer beforehand, I’m holding my own against self-gaslighting. The truth is there are real-world changes that I don’t like but am required to accept, and it behooves me neither to minimize nor exaggerate them.

An abiding concern of mine since I was young has been self- and other-awareness, the ability to penetrate somewhat the veils that obscure ourselves and our perceptions of others. I’ve had times of painful revelation when what I thought I knew about myself was wrong or more limited than I had realized, and similarly toward others. It seems always a slippery business and my particles of wisdom have as often come through ignorance revealed as from anywhere else. The process grows more complicated with age. I often have occasion to ask, for example, whether something like the lost stamina I mentioned is a consequence of age or of poor conditioning or of the heart arrhythmia. I’ve not found an answer and it leaves me perplexed and frustrated, but knowing I can control only one of the three possibilities: I can improve my conditioning and see what the effects are. Belaboring the age or dysfunction factors only distracts. Strangely, it seems we may be more complicated, or just more difficult to read, than when younger. Self-awareness is almost always good (if not overdone to the point of self-absorption), and I’ve come to believe it is more important as an elder than ever.

But often more difficult to trust. The same connection that’s always existed between body and mind processes has no reason to change now. I believe that the mind is not only a brain function but a brain plus whole body one. With the physical diminishments of aging, I lose confidence in my body and for good reasons. The damned thing isn’t as reliable and capable as it once was. It seems that along with that goes confidence in accuracy of self-awareness, acuity of judgment, and perception of the social and political worlds. I think it may be one of our more fraught challenges to get on top of this. There’s little beyond mitigation, and not always much of that, and adaptation when it comes to managing physical losses, but I don’t see why the parallel mental function has to follow, though I allow that it can hardly be oblivious; they’re too closely linked. But this is a time when I want the mind to help compensate for the body’s losses, to assess ramifications of the changes, and to rely on wisdom, experience, and good sense to sustain me. This is a time when second chances are far fewer, decisions made are decisions I must either live with or live with the consequences of changing but can rarely make a really new beginning. I sometimes think of those projects or excursions I had assumed I would do and see now there’s not the time or the physical ability to do them. Disappointments. Accomplishments. Life for an elder is on a deadline. Making mistakes or hurting someone now feels worse than it used to. I sometimes feel as if I’ve moved into a new country where I don’t understand the locals (What the hell gives with millennials anyway?), but know it’s just altered rules, same country. I adapt.

Such thoughts bring the dimension of time before me. It seems rare to find people at any age who use their time consciously and well, and it’s a habit that can easily carry to one’s end. I tend to think without evidence that I didn’t adequately use far more of mine than I should have, but did I? Am I doing better now when there’s less of it left in the store room? One thing for sure about aging’s losses is that they can serve as decisive reminders of brevity. I used to say humorously that illness and dysfunction were Nature’s way of making death less aversive, which I now think is actually true. But short of stage three, those events that don’t kill me but slow me down or cause me pain should help to stimulate alertness of where time is taking me and it’s best I pay attention not only to that but to the possible stops and journeys along its way that could matter to me, both positively and negatively. Dying will take care of itself without my help, but what I do until I reach that point is up to me, even facing serious illness, where attitude and interpretation make a great difference. Aging is not just losses but call after call to take life more seriously, more wonderingly and gratefully and fully.

Who could talk about aging without including doctors? I avoid them as much as I possibly and responsibly can. A friend once told me he’d seen a doctor who told him that if he wanted to stay healthy, he should stay away from medical people. Ironic, but point taken. I give immense credit for the good they do when they do it, but there is a sort of medical morass one can fall into that can begin to seem like the safest place to be when it’s just the opposite. In the years before my parents’ deaths, I saw them retreat into what they thought of as medical protection against their mortal anxieties and failing health. They oriented their lives around medical appointments and since I delivered them to many of these, I saw how they were shuffled from specialist to specialist not seemingly according to a carefully organized treatment plan but rather to keep trying by passing the buck (let somebody else do it this time). Corporate medicine in particular tries to squeeze the time-consuming drops of the more compassionate forms of medical care-taking dry while encouraging quick billable procedures and encounters. Even aside from that there is a well-intended internal force within most medical practitioners that aims to try-try-try, go for broke, never say die, in the hope of cure or mitigation. The notion that hopes should never be allowed to lapse is irrational and insensitive when what is called for is letting alone or palliation and acceptance. Most of all, I intend to stay out of hospitals, which are good places to get sick(er), to lose control of your fate, and to be truly in the belly of the beast of medical practice. One cannot always avoid them (although I have so far) but be clear if the time comes, I say to myself, why you’re going in and for how long and why your need can’t be met as an outpatient. And by the way, do they have my end-of-life documents in hand and will they respect them?

Aging’s deprivation of much-loved earlier activities like mountain hiking is sometimes discouraging but I have been more likely to get depressed when I’ve had to spend excessive time in medical facilities. The road of losses is necessarily rough and pot-holed, and occasional raging at necessity can be gratifying, but not a productive and satisfying place to hang-out for long. And neither would be effectively turning myself over to medical supervision.

I don’t doubt that for many of us who are aging the issue of control over the management and direction of our remaining life is among the paramount concerns. For me, it’s as important as any other matter, except perhaps food and water, and not far back there. After a lifetime of autonomy, while allowing for chosen or accepted obligations and duties, the prospect of having someone else, even if well-intended rather than bent on other motivations (increasingly profit after modern corporate moves into what should be “helping” or service fields)…someone else making my choices is anathema. I have witnessed, and on rare occasions of physical distress even come close to feeling, the pull of dependency, which in some cases becomes a street of no return, and I will resist it until death, necessity, or dementia. This is one reason, by way of comparison, why I object to excessive state restrictions on abortion—I imagine what it feels like for a woman to have her autonomy in such a deeply personal sphere of existence snatched away, or her life perhaps endangered, by those who think they know best, or as likely, merely enjoy the practice of power. (Which is not to say that I don’t find abortion about the most challenging of ethical quandaries.) To exist is to exist as a solitary unit, in one aspect, and as a participant in circles of membership and obligation in others. The communal dimension is altogether as vital as the individual, perhaps more so, but there are a few regions within each realm that are sacrosanct. In areas of conflict, needs that can be met in no ways other than relinquishment of a minimally necessary degree of autonomy have to be accounted for but the presumption is always for leaving well enough alone and respecting and supporting autonomy. I value this all the way up to and including a decision about whether my life continues being worth the trouble of living it after I’ve entered the stage of dying, a stage that can easily become onerous, humiliating, and meaningless. It would be amusing if it were not so offensively intrusive to observe our country, which has little true regard for life, suddenly become ever-so-vigilant when it comes to “protecting” people who are ready to self-euthanize from doing as they choose after thoughtful deliberation. Ironically, it seems to me just one more case of our society interfering with expression of the life-force, in this case acting for its own good at its own end, while imposing society’s own death denial and anxiety on those who don’t feel them. So, I have been sure to assemble all the available documentation related to end-of-life decisions, even knowing how possible it is that prejudiced, recalcitrant “protectors” may not be cooperative, in the hope my preference under certain circumstances for death over impaired life will be respected. Respect and kindness are essential to both give and receive life-long, but at its late stage it seems all the more crucial and fitting. I have given up many of my early romantic notions of a good or dignified death, having learned how rare these are owing to the frailties of the body (not to mention these days the perseveration of medical interventions when allowed to take charge), but I insist on doing it my way as long as possible, and benefit of the doubt should be mine.

Is aging unrelentingly dismal, or should dismal be seen as a good day under the circumstances? As I see it, the first proposition is surely false while the second sometimes makes sense. There are rare occasions when I have a poignant sense of missing an activity I once cherished (too thoughtlessly I think now) and remember the feeling of doing it and, afterwards, of having done it and am indubitably saddened. But they pass swiftly. Everything in its time, the saying goes, and it is not time for that anymore. One of my perduring questions as an elder is suggested by that recognition. What is it time for now? Since I reject the notion that aging is only loss and misery and find that its satisfactions are just as common and meaningful as they were in earlier stages, even while the choices are fewer, I want to answer that. To help, I begin with mentioning what has been gained through aging. It is not uncommonly spoken of among men, and even appears early in Plato’s Republic in conversation between Socrates and an elder, that at last the fires of lust have dimmed. (Or, as Leonard Cohen put it more colorfully in his song “Leaving the Table”: “I don’t need a lover/The wretched beast is tame”.) Other fires, too, have quenched or moderated and I am more readily at ease. Drives and tensions and needs to stand out or accomplish this or that have lost their tang, their motive-force. One can relax, if they have welcomed or at least accepted the change. Pleasures come in different forms. I spoke lightly of gains in wisdom but didn’t mean to imply that it is not sometimes real in some people and valuable when present. Wisdom is perspective, a longer view, broader context, deeper understanding, appreciation and tolerance of differences, knowing better what to care about and when and how much. For many years I have found reading the old Roman Stoics valuable. Self-mastery, interpretation and moderation of emotion, acceptance of necessity, equanimity—All invaluable, particularly for elders. We gain, if we choose to, time, freedom, leisure, better judgment. If we’re determined and fortunate we pay attention better than before, although it’s hard to break old habits, to see the details and frequent beauty. When I was a young therapist, I once sat with an elder man next to his depleted fall garden, both of us knowing he wouldn’t be there to see it next year. Thinking to be wise, I noted the sad look of the mostly dead garden, to which he demurred and reminded me that when spring came it would start its seasonal course again.

So what is it time for now? Well, it could be time to close up the mobility shop and read quality literature and nonfiction, listen to music that moves you, and watch your favorite teams playing on television. I say that seriously if a person’s losses have taken them to the point where that’s what makes most sense physically according to their best judgment. Most of us aren’t there or aren’t there yet. I think it’s not usually time to set off on a brave new course except occasionally following critical thought about it. Those parents of mine I mentioned earlier, when they retired and thought it adventurous, bought an RV and headed out of town—This despite never having had a particle of interest in camping before but liking the image. Within a year the RV was sold and they were at loose ends. My direction, not necessarily based on any conscious insights, was to continue what I had long been doing but in altered forms. As I have for 40 years I still camp, nowadays 2-3 months/year, always alone because my wife doesn’t enjoy it and we both have no objection to time to ourselves. I hike but at different elevations and for different distances; instead of covering the miles I find spots that speak to me, or that seem as if they might, and sit and contemplate the scene. I’ve always read a lot and still do, but have tilted more toward fiction (preferably from the 19^th century) and less toward political and cultural analysis and history (there’s nothing new under the Sun and humans continue making a mess of it). I’ve not grown misanthropic but certainly deeply skeptical of the human enterprise. I enjoy watching sports but less than before. And I live on the North Coast of California, a beautiful region, and have easy access to many wonderful parks and conservation areas and try to visit them several times a week for a couple hours’ walk and sit. Based on my experience and observation of friends, I suspect this sort of continuity with modifications is a way that works well for many elders—Changes but moderate and within the context of what’s been meaningful and satisfying before.

I begin to feel I’ve said my piece—the one on my mind when I woke up and began writing yesterday morning. But I suppose I can’t not say a word about the dreaded dementia, which is so much on people’s minds (or what’s left of them?). I admit to ambivalence, obviously not about its relevance but whether, in the three-stage picture that begins with aging and ends in death, dementia belongs with aging or more properly falls into dying. People may live up to ten years after diagnosis so I am inclined to see it as a bridge between the two, although it is perhaps unique in the nature of its impacts. I know not everyone will agree but it seems to me that loss of mind is in effect loss of life. That we allow it to fall within the Catch-22 trap of my not wanting to self-euthanize while still alert and compos mentis and then, after onset, not being taken seriously about wanting death because no longer competent to choose (which, of course, is the reason I’d want to die), strikes me as a great failure of compassion and moral imagination. Once dementia has delivered a person into “incompetence” they won’t be taken seriously, but they certainly should be for what they proclaimed when competent. A complex matter, I don’t deny, but our moral obligations to one another preclude escape into complexity and staying there.

I sometimes make light of my dementia prospects (whistling past the graveyard?), but I too think about it and watch for signs. As things often go in this reeky, rankly capitalist society, dementia has become an industry and as usual when that happens it isn’t a pretty sight, except on the surface. Commonly naming its institutions “memory care” when memory is one of the first of dementias deprivations strikes me as bad taste and lying euphemism. More to the point, however, like all my fellow elders I would dread its definitive appearance on my mental horizon, but have chosen not to worry about the possibility. My memory has gone to hell but that’s an inconvenience more than anything. I also notice a bit more difficulty retaining facts as I read and have to attend more deliberately for full conceptual understanding. And to be honest with myself, I’m probably not as “smart” as I once was, meaning not as quick, retentive, associative, and likely more, but I get along. One of the worst things about it for me would be that Catch-22 I spoke of. My horror would be life as an elder with the mind of a deliriously happy two year old. Life like death is most seriously diminished when it lacks dignity and much possibility for self-respect. At any rate, I had to bring dementia up and now I have. It would surely be a bitch, but for now is more an inspiration for my earlier self-admonition to live well as long as I can.

As I’ve said, aging caught me unawares while I was focused on eventual dying and death. No longer. In a way, it has become my second to last project.

Craig Brestrup, PHD
October 2024

1. When I read the ADA Code of Ethics I was surprised to find approximately a half page of guidelines pertaining to confidentiality of patient records but comparatively little about privacy and confidentiality of patient communications: “…to protect the patient’s confidentiality…[and] privacy” (III.1). A glance around dental consultation/treatment rooms, however, reveals the intrinsic impossibility of achieving this. Alone among medical practitioners in my experience, dentists’ offices are built to prevent privacy and thus confidentiality. I have yet to see one that was a closed and private space; they usually lack doors (and these are rarely closed) and typically have openings at the tops and ends of the walls separating these spaces. You will not find privacy, or even the opportunity for it, there. The result of this type of construction, I believe, is that both dentist and patient are constrained, consciously and unconsciously, from communicating freely since there could easily be a half dozen or more patients and staff listening. Considering the universality of dental offices built in this manner one has to wonder if lack of privacy was not their purpose. But why? What is its history and rationale? Does the profession assume that its patients have no need or desire for privacy?

2. Picture yourself being led into the treatment room, ushered to the patient’s reclining chair, having a bib hung around your neck, and the chair tilted backward. In walks the dentist, these days almost always masked, and conversation begins. Since it is well known that spatial/physical positioning can reflect relative power positions and either facilitate or impede open communications, how would we appraise the likely nature of words shared between a prone and bibbed patient and a standing (maybe masked) dentist looking down on him or her? Having occupied that position as a patient more often than I would wish, I can say it feels inhibiting; one could, if susceptible, almost feel childlike, but in any event it does not encourage a conversation between peer adults in which discussion can flow readily, especially about difficult treatment decisions and possibly different treatment inclinations between patient and dentist.

(I have discovered another source who commented more colorfully on this scene: “When you’re in the dentist’s chair, the power imbalance between practitioner and patient becomes palpable. A masked figure looms over your recumbent body, wielding power tools and sharp metal instruments, doing things to your mouth you cannot see, asking you questions you cannot properly answer, and judging you all the while. The experience simultaneously invokes physical danger, emotional vulnerability, and mental limpness.” [from The Atlantic, May 2019, Ferris Jabr, “The Truth About Dentistry.”])

I say nothing new or surprising when I note that the quality of medical practitioner relations with their patients has well established effects on treatment cooperation and outcomes. The lack of privacy in these dental interchanges combined with the typical up-down positioning of dentist and patient in the consultation/treatment room has been for me, and I suspect many others, a significant impediment to satisfactory assessment and treatment discussions. Which leads me to…

3. I suspect that in any medical setting practitioners find the matter of “patient autonomy” and patient partnership in treatment planning and execution among the most challenging. Patients feel entitled to a place at the table, so to speak, and to be heard and taken seriously. Patient “recalcitrance” and “care-resistant behavior” are readily available descriptors, whether more or less accurate, that can be drawn upon to avoid or disregard opinionated or otherwise inquisitive, challenging, or unpleasant seeming patients. But once it is agreed that they have a right to participation in decisions about their treatment, it is incumbent on practitioners not to resort too quickly to such dismissals.

Here is the relevant section of the ADA Code, from Principle III, which I drew from above:

Section 1 PRINCIPLE: PATIENT AUTONOMY (“self-governance”). The dentist has a duty to respect the patient’s rights to self-determination and confidentiality.

This principle expresses the concept that professionals have a duty to treat the patient according to the patient’s desires, within the bounds of accepted treatment, and to protect the patient’s confidentiality. Under this principle, the dentist’s primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient’s needs, desires and abilities, and safeguarding the patient’s privacy.

These are fine words; I have affirmed and tried to live up to them as both a professional and as a patient, but their meaning is often less than self-evident and in the dental office, I submit, their implementation is often resisted by the dental professional. One of the dilemmas they are susceptible to is structural: experts have inherent authority in the occurrent subject matter and it is natural they could be chary about “less informed” opinions and even, sad to say, sometimes play the expert card to end the discussion. Which of course must be avoided if the ethical principle is to mean anything. “Standards of care” are essential in any medical practice but rarely point toward only one option with a particular patient, and options are always subject to change based on experience and research.

Here is another hard one for patients and dentists: “within the bounds of accepted treatment.” Accepted by whom and based on what? The journey that led to my writing this article began with my multiple dental problems and then took some unexpected turns when I began discussing alternatives to conventional filling of my unceasing cavities. I explored and found this statement on the ADA webpage (https://www.ada.org/resources/ada-library/oral-health-topics/silver-diamine-fluoride): “Biannual application of 38% SDF for advanced cavitated lesions may be relevant if access to care is limited, for uncooperative patients, or for patients when general anesthetic is not considered safe.” The above source also linked to a major review conducted by the ADA Center for Evidence Based Dentistry that said, among much more, the following: “Although the recommended interventions [with SDF and others] are often used for caries prevention, or in conjunction with restorative treatment options, these approaches have shown to be effective in arresting or reversing carious lesions. Clinicians are encouraged to prioritize use of these interventions based on effectiveness, safety, and feasibility.” (https://jada.ada.org/article/S0002-8177(18)30469-0/fulltext) This was good enough for me so I began suggesting use of SDF for those of my cavities that weren’t visible (because of the staining caused by SDF). I discovered that most dentists had had no experience with SDF and were not interested in trying it; others labelled it a “band-aid” or otherwise deficient for the job to be done. Which naturally made me wonder how any professional would dismiss an addition to their treatment armamentarium that was accepted by their professional association, based on sound research, and sought by patients. I found only one dentist ready to apply it. The dentist-shopping I mentioned above began here, partially because I wanted SDF as an option in managing my seriously beleaguered, remaining teeth, but also out of curiosity about how extensive the rejection went. Some simply said they were unfamiliar with SDF and not interested in learning (even when I offered myself as a learning module) and two said they didn’t think they could work with me, period. I have been forced to abandon hope in that area although I continue to believe that “bounds of accepted treatment” can, and often should, be a more flexible and commodious concept than it seems generally to be seen as.

I could offer examples about other points of contention, but I’m not interested in seeming to seek castigation of a profession whose services I rely on and appreciate. Suffice it to say that my futile experience seeking competence with SDF was not an anomaly. Even so, while I highly value dental services the common reluctance to consider “treating the patient according to the patient’s desires” so long as they aren’t unethical or dangerous has been a large disappointment. No doubt in many situations there is a conventional approach and it may in fact be the best, but what about second best or unconventional if that is the patient’s desire? (To this day not a single dentist has recommended what he/she considered the preferred treatment and followed that with a stated willingness to work with me on something less than preferred if that was my choice.) How often is the conventional approach supported by solid research and why not provide information on such research for those who seek it? I don’t mind being shown the error of my preferences and  will correct them in response; the courtesy of receiving references and links is always appreciated but never, so far, offered. Even the willingness to go along with a patient who prefers a second or third rate option should usually be accepted when he or she has been fully informed of the likely consequences or predicted limited effectiveness. Patient age, dental and general physical condition, values, and predilections should be acknowledged and respected and, again, if patients are satisfied with and prefer the “second best” treatment, why not concede the point and collaborate? It is respectful to do so and, thinking again about the potency of the relationship, it lays the groundwork for future treatments, some of which might even be the dentist’s first choice. (And who’s to say that “future treatments” might not be more likely, in light of the generally reported level of dental-related anxiety among patients and patients-to-be, within a more collaborative setting?) As I was taught early in my career as a psychotherapist, “It doesn’t matter if you’re right if the patient won’t listen to you or breaks off contact.” This is by no means an adjuration to bend the knee to every patient whim, regardless how nonsensical or unethical, but to accept that part of the duty of a practitioner in what used to be called the “helping professions” is to find a way to help that is acceptable to the patient.

I want to end with words from a book I recommend to every person working in any medically related field. They were written over thirty years ago by a man dying of cancer and thus arose from that treatment milieu. But their applicability is far broader than that:

Not every patient can be saved, but his illness may be eased by the way the doctor responds to him—and in responding to him the doctor may save himself. But first he must become a student again; he has to dissect the cadaver of his professional persona…It may be necessary to give up some of his authority in exchange for his humanity, but as the old family doctors knew this is not a bad bargain. In learning to talk to his patients, the doctor may talk himself back into loving his work. He has little to lose and everything to gain by letting the sick man into his heart. (Anatole Broyard, Intoxicated By My Illness: And Other Writings on Life and Death; Ballantine Books, 1992, p. 57.)

Craig Brestrup, PHD

August 2024

Photo by Jackson Hendry on Unsplash

Photo by Volodymyr Hryshchenko on Unsplash