Patient's Code of Ethics

Don't you think that ethics in medicine should be a two-way street? If there is to be a partnership between the patient and physician to work to heal the illness, shouldn't the patient have consideration of the physician's burdens and suffering in the process? You do? Good! From Belleview College here is the "Patient's code of ethics". Now stick to it. Your doctor will appreciate your behavior. ..Maurice.

1. Do not expect your doctor to share your discomfort.
Involvement with the patient's suffering might cause him to lose his valuable scientific objectivity.
2. Be cheerful at all times.
Your doctor leads a busy and trying life and requires all the gentleness and reassurance he can get.
3. Try to suffer from the disease for which you are being treated. Remember that your doctor has a professional reputation to uphold.
4. Do not complain if the treatment fails to bring relief.
You must believe that your doctor has achieved a deep insight into the true nature of your illness, which transcends any mere permanent disability you may have experienced.
5. Never ask your doctor to explain what he is doing or why he is doing it.
It is presumptuous to assume that such profound matters could be explained in terms that you would understand.
6. Submit to novel experimental treatment readily.
Though the surgery may not benefit you directly, the resulting research paper will surely be of widespread interest.
7. Pay your medical bills promptly and willingly.
You should consider it a privilege to contribute, however modestly, to the well-being of physicians and other humanitarians. It is sheer arrogance to contract illnesses that are beyond your means.
8. Never reveal any of the shortcomings that have come to light in the course of treatment by your doctor.
The patient-doctor relationship is a privileged one, and you have a sacred duty to protect him from exposure.
9. Never die while in your doctor's presence or under his direct care.
This will only cause him needless inconvenience and embarrassment.

Killing or Letting Die?

The patient who has the capacity to make autonomous decisions themselves may terminate life-supporting treatment. In most cases within hospital intensive care units where many of these decisions are requested, the patient may not have the physical ability to perform the act to discontinue the treatment. This means that physicians or hospital staff must carry out the act. The question then arises as to whether the perhaps lethal consequence of the act represents the act itself or represents the patient’s underlying disease; in essence, does “pulling the plug” by the healthcare professionals represent an act of killing the patient or allowing the patient to die from his or her illness which required the life-support? The current usual view that has been suggested to make the distinction is regarding the intent of the person who performs the act. Is the person simply following the patient’s legal request as an ethical responsibility with perhaps knowing that death is possible due to the patient’s illness but not intending that the patient should die? If so, this does not represent “killing”. On the other hand, if the intent was clearly that the patient should die, whether beneficent or not then the act would represent “killing”. Obviously, physicians who perform the act will do so with the former intent. That is one view of the distinction. However, there are some life supporting treatments which have been used as examples where the distinction is based on whether the treatment can represent a substituted organ. Applying this view, the action represents removal of a vital organ and death is no longer related to the underlying disease but in the act of organ removal itself. This distinction has been considered rather hazy but consider the following examples:

In a quadriplegic patient who cannot breathe on his or her own, if a ventilator machine has provided a period of life sustaining function that only normal lungs and normal spinal cord conduction could provide, the ventilator might be interpreted as an artificial and substituted “organ” which has become part of the patient’s body. Removing the ventilator function might be the same as taking out both lungs of a normal person, clearly a “killing” act.

Another similar example would be that of a patient who requests turning off of a cardiac pacemaker, which had been inserted to prevent the heart from stopping because of a diseased heart with a complete heart block condition. This pacemaker represents now a part of the patient’s body, in place of the diseased pacemaker mechanism, to keep the heart beating. Turning off the implanted pacemaker would be like the injection of a chemical into a normal person to stop the heart from beating.

One could argue that, as in the Schiavo case, the feeding tube inserted thru the abdominal wall and into the stomach to provide nutriments and fluids essential for life has become for the patient the new “organ” substituting for the patient’s own swallowing mechanism and esophagus, connecting the mouth to the stomach, which may be lost forever. If the tube were removed, it would be like disconnecting the mouth from the stomach in a normal person.

In each case, if one considers the proposition logical, then the act would represent the removal of a normally functioning but substituted “vital organ” and this act would not be considered simply allowing the patient to die from his or her underlying illness and could be considered “killing” regardless of the intent.

I present this issue to point out that the concept of the autonomous request by a patient for someone to discontinue an unwanted therapy is not a simple request devoid of any controversy. It is this uncertainty beween killing and letting die which may give healthcare providers a moral pause when considering whether to accept the patient’s request. ..Maurice.

3-19-2005 Addition to My Posting

Today DB's Medical Rants wrote about my discussion here of this issue. I posted the following comment to that fine medical blog:

I should make it clear (and I only used the word "hazy" in my piece)that the concept of the removal of an "artificial organ" that was functioning as the life-supporting natural organ representing a "killing" is NOT generally considered and is NOT the current ethical consensus. However, this view has been discussed in ethics literature in the past. The currently, the ethical consensus accepted as distinguishing betwee "killing" or "letting die" is simply that of the intent of the one performing the act. I also should make clear that the word "killing" is a term used as the opposite of the condition where the patient is dying because of the lethal effect of the underlying illness ("letting die"). I don't think the ethical view is that of a homicide if the patient cannot perform the act on his/her own. Whether one wants to consider this act "assisted suicide" depends on whether one wants to ignore that the act is NOT one of directly causing death but following the autonomous patient's decision to stop unwanted treatment with the death being caused by the underlying illness.

In "assisted suicide" such as practiced in the state of Oregon, the immediate death is due directly to the pills prescribed and not due to the patient's underlying illness. I hope this explains the current understanding of the issue. In the Schiavo case, the issue is not one of "killing", it is simply one of a legal surrogate requesting that the patient's wishes be followed regarding unwanted treatment. ..Maurice.

What is Death? (5): Do Not Stand at My Grave and Weep

I found this poem, "Do not stand at my grave and weep" by Mary Elizabeth Frye and the history of how it happened to be written at the Businessballs.com website. This poem, too, tells us again, like the poem by Walt Whitman in my first posting, that death may not be the end of some sort of existence. I think because it has been difficult to ascribe a finality of life to death, this may contribute to the difficulty in defining death itself. In fact, physicians know about families who have taken their dead family members home from the hospital to maintain some sort of continued “support”. ..Maurice.

Do not stand at my grave and weep

Do not stand at my grave and weep
I am not there; I do not sleep.
I am a thousand winds that blow,
I am the diamond glints on snow,
I am the sun on ripened grain,
I am the gentle autumn rain.
When you awaken in the morning's hush
I am the swift uplifting rush
Of quiet birds in circled flight.
I am the soft stars that shine at night.
Do not stand at my grave and cry,
I am not there; I did not die.

What is Death? (4) More on Personhood:View of Peter Singer

I hope my visitors got the idea from my last posting that the concept of personhood, which is an important element to consider when discussing both life and what is death is complicated and controversial. One side of the controversy are the views of the Australian ethicist, Peter Singer who is currently at the University Center for Human Values at Princeton University in Princeton, N.J. He has supporters of his view of personhood and,of course, many detractors. But for those who haven't formed opinions, his view definitely should be heard. He has a Princeton website where you will find much information about his academic background, positions and rewards and you will find a very interesting FAQ section from which I extracted the portion below to portray his views regarding the definition and significance of personhood, not by my interpretation, but in his own words. Don't write comments to him. I am sure he has heard plenty good and bad but write them to my blog. I myself and I am sure other visitors would be most interested to read them. No, this is not a college ethics class and I am not grading you, but I hope you will think the concepts out carefully and provide a rational basis for your particular views. ..Maurice.

From FAQ by Peter Singer


Q. I’ve read that you think humans and animals are equal. Do you really believe that a human being is no more valuable than an animal?

A. I argued in the opening chapter of Animal Liberation that humans and animals are equal in the sense that the fact that a being is human does not mean that we should give the interests of that being preference over the similar interests of other beings. That would be speciesism, and wrong for the same reasons that racism and sexism are wrong. Pain is equally bad, if it is felt by a human being or a mouse. We should treat beings as individuals, rather than as members of a species. But that doesn’t mean that all individuals are equally valuable – see my answer to the next question for more details.


Q. If you had to save either a human being or a mouse from a fire, with no time to save them both, wouldn’t you save the human being?

A. Yes, in almost all cases I would save the human being. But not because the human being is human, that is, a member of the species Homo sapiens. Species membership alone isn't morally significant, but equal consideration for similar interests allows different consideration for different interests. The qualities that are ethically significant are, firstly, a capacity to experience something -- that is, a capacity to feel pain, or to have any kind of feelings. That's really basic, and it’s something that a mouse shares with us. But when it comes to a question of taking life, or allowing life to end, it matters whether a being is the kind of being who can see that he or she actually has a life -- that is, can see that he or she is the same being who exists now, who existed in the past, and who will exist in the future. Such a being has more to lose than a being incapable of understand this.
Any normal human being past infancy will have such a sense of existing over time. I’m not sure that mice do, and if they do, their time frame is probably much more limited. So normally, the death of a human being is a greater loss to the human than the death of a mouse is to the mouse – for the human, it cuts off plans for the distant future, for example, but not in the case of the mouse. And we can add to that the greater extent of grief and distress that, in most cases, the family of the human being will experience, as compared with the family of the mouse (although we should not forget that animals, especially mammals and birds, can have close ties to their offspring and mates).
That’s why, in general, it would be right to save the human, and not the mouse, from the burning building, if one could not save both. But this depends on the qualities and characteristics that the human being has. If, for example, the human being had suffered brain damage so severe as to be in an irreversible state of unconsciousness, then it might not be better to save the human.

...

Q. You have been quoted as saying: "Killing a defective infant is not morally equivalent to killing a person. Sometimes it is not wrong at all." Is that quote accurate?

A. It is accurate, but can be misleading if read without an understanding of what I mean by the term “person” (which is discussed in Practical Ethics, from which that quotation is taken). I use the term "person" to refer to a being who is capable of anticipating the future, of having wants and desires for the future. As I have said in answer to the previous question, I think that it is generally a greater wrong to kill such a being than it is to kill a being that has no sense of existing over time. Newborn human babies have no sense of their own existence over time. So killing a newborn baby is never equivalent to killing a person, that is, a being who wants to go on living. That doesn’t mean that it is not almost always a terrible thing to do. It is, but that is because most infants are loved and cherished by their parents, and to kill an infant is usually to do a great wrong to its parents.
Sometimes, perhaps because the baby has a serious disability, parents think it better that their newborn infant should die. Many doctors will accept their wishes, to the extent of not giving the baby life-supporting medical treatment. That will often ensure that the baby dies. My view is different from this, only to the extent that if a decision is taken, by the parents and doctors, that it is better that a baby should die, I believe it should be possible to carry out that decision, not only by withholding or withdrawing life-support – which can lead to the baby dying slowly from dehydration or from an infection - but also by taking active steps to end the baby’s life swiftly and humanely.


Q. What about a normal baby? Doesn’t your theory of personhood imply that parents can kill a healthy, normal baby that they do not want, because it has no sense of the future?

A. Most parents, fortunately, love their children and would be horrified by the idea of killing it. And that’s a good thing, of course. We want to encourage parents to care for their children, and help them to do so. Moreover, although a normal newborn baby has no sense of the future, and therefore is not a person, that does not mean that it is all right to kill such a baby. It only means that the wrong done to the infant is not as great as the wrong that would be done to a person who was killed. But in our society there are many couples who would be very happy to love and care for that child. Hence even if the parents do not want their own child, it would be wrong to kill it.


Q. Elderly people with dementia, or people who have been injured in accidents, may also have no sense of the future. Can they also be killed?

A. When a human being once had a sense of the future, but has now lost it, we should be guided by what he or she would have wanted to happen in these circumstances. So if someone would not have wanted to be kept alive after losing their awareness of their future, we may be justified in ending their life; but if they would not have wanted to be killed under these circumstances, that is an important reason why we should not do so.

What is Death? (3)

As I noted, the issue of what is personhood and who are you and what are you worth if you don’t have personhood is contributing to the controversy of when a person is dead.
Why is personhood up for debate? Well, philosophers have felt that personhood defines who is a human person. Not just a human being or homo sapiens but a human person. What makes a human person important? Well, certain rights and legal protections are given by society to a human who is also a person that are not given to those who do not possess personhood. That means that if a human person becomes a corpse, personhood no longer exists and the rights and legal protections are gone. So what makes a person? That’s the problem and it starts from the very beginning of life, from the fertilized egg. Some view this zygote as a person and should be given all the protection that is given to an adult human. And that means it would be immoral and could be made illegal to hurt or destroy the egg. And this philosophy of personhood continues as an implanted embryo develops into a fetus. But some have suggested that those who hold this view are conflating a human being with a person. It is argued that personhood represents a being who has a conscious awareness of self so that the being can set personal values and goals. It is impossible to consider an egg or zygote or embryo or an unborn fetus to meet that criterion. So where does personhood begin? Is a newborn infant a person? One view is that it is. What about a baby at term who is yet to be born into this world? How much consciousness and self-awareness are present in those individuals? Complicating this topic further is the status of the anencephalic child.

One of the sad abnormalities that can occur is that of an anencephalic child who is born with no brain tissue where all the consciousness, awareness and all the complex interaction with the environment takes place, the cerebrum. Thus the child misses the “higher brain” as described by Kenneth Kipnis in the last posting. There is only a brain stem present which controls the vegetative mechanisms such as breathing and control of the heart and blood pressure. Should this infant be given the status of a person without the higher brain? Is this infant considered a person and is this infant considered alive? Currently, the legal answer in the U.S. is yes to both. The anencephalic doesn’t meet the criteria for brain death since a functioning brainstem is still present. As a person, the anencephalic must be given treatments if necessary in emergency room visits. As alive, vital organs necessary to maintain existence cannot be procured for transplant.

And now we must consider whether those who are apparently not aware of themselves or conscious, not just reflexly, of their environment still maintain personhood. For example, for those patients in a persistent vegetative state are they as good as dead based on the definition of personhood? They maintain brainstem function and therefore can’t qualify as dead on the basis of permanent absence of whole brain function but they might qualify if the criteria for death was the permanent absence of higher brain function and thus fail the personhood test. And then one can go on to speculate about those patients who are severely demented and what the criteria for personhood and death means for them.

As you can see by the discussion by Kenneth Kipnis in the last post and mine here that the definitions of personhood and death are not fully satisfactory to everyone. Concerns, ethical/philosophical, political, legal and religious, still remain to be resolved. Issues regarding use of embryonic stem cells, in vitro fertilization with residual embryos, treatment of the not yet born, the newborn, the anencephalics, the status of those who are severely demented or in a persistent vegetative state all remain to be examined and resolved. And these are not just theoretical issues for philosophers to contemplate but issues which all society has to contend with.. matters of what represents life of a human person and what represents that person’s death. ..Maurice.

What is Death?( 2)

Did Walt Whitman and his poem, in my last post, explain death to your satisfaction? No? Maybe Ken Kipnis, who is a philosopher/bioethicist, can explain it better in the following article he wrote for The Philosophers' Magazine. My thanks to Ken and his publishers for allowing me to post the entire article here. ..Maurice.

______________________________________________________________
When Are You dead?
by
Kenneth Kipnis
Department of Philosophy
University of Hawaii at Manoa
kkipnis@hawaii.edu


It is, alas, one of the most familiar things in the world. Alive one
minute, dead the next. But what exactly happened?

On the surface, there has been a dramatic change in social standing: a
living human being has become a corpse. The former might have enjoyed
rights to health care and legal protections against an array of
wrongs. Death makes an end to these, and to marriage, citizenship, and
even legal personhood. It is perhaps the most complete and final
alteration of status known to law. We can now cut open the body out of
intelligent curiosity, burn or bury it; hand it over to medical
students for dissection; gather up personal property and distribute it
to others, all of which would be grave wrongs if ever done to the
living. It is no wonder that premature burials and twitching body bags
are the stuff of horror stories. It is no mystery why communities take
exquisite care to avoid mistakes that are beyond embarrassing. Because
so much hangs on the official pronouncement, only the most
knowledgeable are authorized to certify that death has occurred. But
what exactly is the warrant for their judgment?

Conversations about the definition of death are commonly plagued by
ambiguity in the level of analysis. Beyond the social account set out
just above, it is useful to distinguish among four other levels:
biological, physiological, clinical and legal. The stories we tell
about the nature of death have to have at least that many chapters.

We begin, at the deepest biological level, with the nature of animal
life. Herewith a thumbnail history of biological metaphors for the
living body. If, as an animal, our essential Aristotelian nature
involves locomotion, then we cease to exist (as animal-natured beings)
when our capacity for locomotion ends. But if, as Harvey discovered,
we are pulsating, vascularized circulations of life-giving blood, then
we cease to exist as living creatures when the vital flow stops. And,
finally, if we are wet computers, neurologically connected to input
and output peripherals (as many have come to believe) then we cease to
exist just when our central processing units fail, permanently and
completely.

Within each of these three conceptions, the next task is to draw upon
physiology (the second level) to define biological death. Breathing
is a most subtle locomotion, perhaps the most essential and the last
to disappear. We still speak of people "expiring." So understood,
death occurs when respiration ceases. Later on, for theorists
following Harvey's discovery, a person could be said to have died when
the essential cardiac pump stopped beating. No pump, no blood flow,
no life. Finally, for most contemporary theorists, death occurs
decisively when the brain (or some substantial portion of it - the
jury is still out) dies, even if the heart continues to function. The
phone can ring but nobody is home.

The third level is clinical. In practice, how should health care
professionals determine that the critical physiological state is
present. One very old test involved a mirror held near the nostrils.
The patient was alive if the glass fogged, dead if it remained clear.
Following Harvey, the stethoscope allowed physicians to ascertain the
absence of heartbeat, the cessation of circulation and, therefore,
death. But the cardiac criterion became problematic perhaps fifty
years ago as advancements in resuscitation, life support and surgery
allowed patients to survive the stilling of their hearts. People joked
about having been dead for twenty minutes, reveling in the patent
contradiction. While no dramatic changes in social standing were
occurring, it was time to revise the cardiac conception of death. The
transition to death by neurological criteria is still evolving.

The process began shortly after the first heart transplants, with the
1968 publication in JAMA of the Report of the Ad Hoc Committee of the
Harvard Medical School to Examine the Definition of Brain Death. The
Ad Hoc Committee urged that death be understood as the irreversible
loss of function of the whole brain, including the brain stem. This
medical conception was quickly and widely adapted as a legal criterion
in the United States. By 1981 the American Bar and Medical
Associations had endorsed the Uniform Determination of Death Act which
held that:

An individual who has sustained either (1) irreversible cessation of
circulatory and respiratory functions, or (2) irreversible cessation
of all functions of the entire brain, including the brain stem, is
dead. A determination of death must be made in accordance with
accepted medical standards.

Notice how the new standard is piggy-backed onto the Aristotelian and
cardiac conceptions of death. The added definition effectively
eliminates the inherent legal risks associated with harvesting
transplantable hearts.

Notice also how the language of the Act sets out a procedural
criterion for brain death as well as a substantive one. Though
irreversible cessation of all brain functions is essential, the
determination of brain death requires physician compliance with
"accepted medical standards." As doctors became comfortable with the
new definition, gold-standard confirmation by brain-wave and
blood-flow analysis fell out of use. Along with some other clinical
observations (absence of a gag reflex, unresponsiveness of the pupils
to light, etc.), the most dramatic assessment tool has been the apnea
test. The unconscious, brain-injured patient is removed from the
ventilator for several minutes. If breathing does not begin as the
seconds pass -- as carbon dioxide builds up in the blood stream --
doctors can infer the destruction of those brain stem regions
governing unconscious respiration. While the law is clear enough about
physiology, it hands off the clinical practicalities to physicians.

But islands of neurological activity can persist even when brain death
is established according to the accepted tests. The regulation of
temperature is one example. When certain neurological structures are
disabled, body temperature destabilizes. Clinicians must then use
thermal blankets and sensors to heat and cool patients. Despite the
legal requirement that there be "irreversible cessation of all
functions of the entire brain . . ." death is often pronounced when
some brain functions are evidently unimpaired. In these situations, do
the physiological or the medical standards have priority? If some
activity persists, exactly how much of the brain has to be
irreversibly lacking in function before death is present? And how
certain must clinicians be that this condition is met?

Michael Green and Dan Wikler offered some useful analysis in their
1980 paper, "Brain Death and Personal Identity." They begin with a
rough distinction between the lower brain (including the brain stem)
and what we will term the higher brain (including the cerebral
hemispheres). The lower brain manages many autonomic biological
functions: movement of food through the intestines, breathing while
asleep, temperature regulation etc. The higher brain is where
personhood is lodged: memories, skills, emotional traces, knowledge,
etc. While many have thought that a higher-brain criterion is superior
to a whole-brain criterion, in 1968 EEGs could not reliably determine
whether weak electrical impulses were emerging from the brain stem or
elsewhere. As a practical matter, it made sense to include destruction
of the brain stem in the definition of death. It is always safer to
err by treating a corpse as a living person rather than risk treating
a living person as a corpse.

Green and Wikler challenged several standard justifications for the
neurological criterion. Some had defended it by pointing out that
those declared "brain dead" would shortly be dead by cardiac criteria.
But even if some present condition were invariably followed by cardiac
death, that would not entail that one were dead already. Some had
defended it by noting that those declared "brain dead" could no longer
have lives that were subjectively valuable. But even if one no longer
cared about being alive (or anything else), that would not entail
that one had died (though it might mean that one could no longer be
harmed by dying).

Drawing on John Perry's work in metaphysics, Green and Wikler argued
that, despite errors in the standard justifications, the death of the
higher brain really is death. Their reasoning can perhaps be
succinctly captured in two thought experiments.

1. The Getaway: Pursued by the police for heinous crimes, Moriarty
engineers the ultimate escape. Using science fiction technologies, he
arranges to have his higher brain transplanted into the skull of
Alfred, a kidnapped dustman. Recovering from the surgery, he
eventually opens what used to be Alfred's eyes and continues writing
his autobiography using what used to be Alfred's hand.

It would appear that the police should now be looking for a man with
Alfred's body: i.e., Moriarty. The philosophical implication: personal
identity follows the higher brain.

2. The Mishap: In the operating room, Moriarty's higher brain has been
removed and is being carried in a basin to what had been Alfred's
body, with its now vacant cranium. Suddenly the basin-carrier trips,
the grey mass launches into the air and breaks into moist fragments as
it plops onto the floor.

Though what used to be Moriarty's body is still robust, Moriarty has
ceased to exist. The philosophical implication: the death of the
higher brain marks the death of the person.

Considerations like these, and the scientific findings that make them
relevant, are persuasive in showing that higher-brain death marks the
end of personal life.

But what about those islands of neurological activity in patients who
are brain dead according to the tests in current usage? Alas, there is
no reliable, quick, cheap and simple way to rule out the presence of
potentially functional regions; no neurological analog to the mirror
and stethoscope. And even if we could locate and identify the tiniest
active areas, we are far from being able to decide what kinds and
amounts of neurological activity are compatible with a determination
of death.

Though neurology has made enormous progress in recent years, we are
still importantly in the dark. Our legal systems and medical
professions are muddling through the most consequential judgments we
will ever face. But while clinicians are probably doing well enough.
there is a troubling concern that we have left behind the old
paradigms without fully appreciating the life-and-death issues arising
out of the new one.

First published in The Philosophers' Magazine, Issue 27, 3rd Quarter
2004. Reprinted with the permission of the author and the publisher.


================

RECOMMENDED READINGS

McMahan, Jeff. The Ethics of Killing. Oxford University Press: New
York, 2002. Chapter 5, pp. 423-503.

Green, Michael, and Daniel Wikler. 1980. "Brain death and personal
identity." Philosophy and Public Affairs 9:105-133.

John Perry, ed. Personal Identity (Berkely and Los Angeles:
University of California Press: 1975).

Stuart J. Youngner, Robert M. Arnold, Renie Schapiro, eds. Definition
of Death: Contemporary Controversies, (Baltimore: Johns Hopkins
University Press: 1999).
_________________________________________________________________

What is Death? (1)

Defining death should be simple. It used to be simple but now it is very complex and controversial. To start out this thread and “get into the mood”, I would like to post a poem by Walt Whitman “Song of Myself” Part VI where he talks about the grass of the graveyard to help him understand what is happening to those buried there and what they are now representing. The discussion of what is death also deals with the issue of what is personhood. And this is one of the elements of the complexity. ..Maurice.

A child said What is the grass? fetching it to me with full
hands;
How could I answer the child? I do not know what it is any
more than he.
I guess it must be the flag of my disposition, out of hopeful
green stuff woven.

Or I guess if is the handkerchief of the Lord,
A scented gift and remembrancer designedly dropt,
Bearing the owner's name someway in the corners, that we
may see and remark, and say Whose?

Or I guess the grass is itself a child, the produced babe of
the vegetation.

Or I guess it is a uniform hieroglyphic,
And it means, Sprouting alike in broad zones and narrow
zones,
Growing among black folks as among white,
Kanuck, Tuckahoe, Congressman, Cuff, I give them the
same, I receive then the same.

And now it seems to me the beautiful uncut hair of graves.

Tenderly will I use you curling grass,
It may be you transpire from the breasts of young men,
It may be you are from old people, or from offspring taken,
It may be if I had known them I would have loved them,
soon out of their mother's laps,
And here you are the mothers' laps.

This grass is very dark to be from the white heads of old
mothers,
Darker than the colorless beards of old men,
Dark to come from under the faint red roofs of mouths.

O I perceive after all so many uttering tongues,
And I perceive they do not come from the roofs of mouths
for nothing.

I wish I could translate the hints about the dead young men
and women,
And the hints about old men and mothers, and the offspring
taken soon out of their laps.
What do you think has become of the young and old men?
And what do you think has become of the women and
children?

They are alive and well somewhere,
The smallest sprout shows there is really no death,
And if ever there was it led forward life, and does not wait
at the end to arrest it,
And ceas'd the moment life appear'd.

All goes onward and outward, nothing collapses,
And to die is different from what any one supposed, and
luckier.