Terminal illness is a sobering education.

When I underwent physical therapy after an operation to insert a two-foot titanium rod in my leg, I experienced both the worst and the best of medical care. My first therapist was close to being a sadist. She took no note of my low-blood counts, which could have told her that I had little strength for exercise. She dismissed the muscle spasms I was suffering from a broken back and told me to get on with it--tote that walker, lift that leg. I finally exploded in her face, telling her to haul her sorry ass out of my room because I had enough to handle without having to confront a Nazi twice a day.

Providentially I got in her place a new therapist--a gentle, wise woman who made all the difference. She taught me how to get out of bed. She showed me how to move the walker. In her repertoire of aids, breathing deeply and consciously was a large item. She taught me to move on the out breath and to relax by slowing my huffing and puffing, filling my lungs fully, and letting my muscles go limp. This was a great help in dealing with the muscle spasms, and it boosted my confidence. "You can do this," I can still hear her say.

The first therapist was a bully. I dreaded her arrival and sighed with relief when she left. The second therapist picked up my spirits. I looked forward to her coming and to the progress we would make. She departed as a friend. Two therapists. Two different versions of medical care and healing. In my view one was despicable and the other exemplary. How could they exist side by side and shape co-workers in the same hospital?

Having needed medical procedures while traveling, and then after moving to a new part of the country, I have been struck by the nakedness, the grossness, of the reach of economics into health care nowadays. In three different medical situations on the East Coast and three different medical situations on the West Coast, a single pattern has prevailed. The first question I have had to answer in each situation has been what insurance I have. This economic question has preceded any inquiry into how I was feeling, what my illness was, or what questions or problems I might be experiencing. I have not existed as a patient worthy of attention--I have had no standing as a human being needing care--until I could slap down my insurance card.

When dealing with the clerks who actually execute this policy of insurance first, treatment later, I have tried to keep the disgust in my voice and bearing under control. Some of the hospitals with which I have dealth have been Catholic, and their policies have been no more enlightened than those of secular institutions. There is panic loose in the land. I know that, as we have let things evolve, U.S. medicine has become expensive as well as marvelous. It is in danger, though, of losing its soul. To make the first questions one puts to a sick person (in my case, to a person terminally ill) bear on money is showing oneself and one's institution retarded in basic humanity. Try to imagine Jesus asking the man born blind for his insurance card. Try to picture Jesus sending Peter to assure that the widow of Nain will pay for the resuscitation of her son on time. As you fail, you will discover most of the lesson. God help everyone concerned with the sick.

I was put into an ambulance alone when my back broke, and I had to wait, largely alone, for four hours or so until I could get painkillers. When I was in the hospital, my wife and I had to work out the meaning of what was happening to us alone, with no significant help from our religious community. Several times I have thought about the pros and cons of these alonenesses and this kind of solitude.

On the one hand, we were partly to blame for our aloneness. Our view of the world, including suffering, is sophisticated, as one should hope it will be in university professors of religious studies. Often the Taoist precept prevails: those who know do not speak; those who speak do not know. Good pastoral ministry to the seriously ill is a matter of listening more than speaking, or presence more than teaching. Unless you yourself are in the throes of a terminal illness, you should be modest in what you say. Otherwise, literally, you risk not knowing what you are talking about. This will make you seem a jackass, but, even worse, it can make you a burden. The last thing that people worn by terminal illness need to suffer is some fool bending their ear with nonsense.

So solitude in hard times can have the virtue of not having to keep fools at bay. On the other hand, it is not good for people to be alone, Genesis tells us. The poverty of the many shows in their inability to handle serious illness--indeed breakdown of any sort. The wisdom of the few shows in their quiet acceptance, their faithful standing by.

We could not have predicted ahead of time how our friends would sort themselves out. The fault line separating helpers from cowards runs through self-concern. Helpers are more interested in you, the sick person, than in their own feelings about your illness. Cowards either flee because they cannot abide the intimations of their own mortality or babble on and on about their own hangnails.

Terminal illness is a sobering education, post-doctoral seminar, in human nature. Many days you learn more than you wanted to know. I leave for another day what you learn about God, who tends to speak softly and carry no stick. Sometimes I have cursed the silence of God, but more often, I have been amazed at God's sustenance.