Cohabitation is the bête noir of some cultures and the realization of a belle époque for others. Lascivious as it sounds, it doesn’t necessarily exemplify freedom and liberation, though -it is a direct and unsubtle abnegation of long held moral and religious values for many. But why? Why would the decision to share one’s life need justification? Exculpation? And who should even dare claim the authority? Or, for that matter, the need to consecrate it? Given the rising divorce rate –even in strictly Muslim countries such as Iran where the rate currently sits around one in five- one would think it would make sense to recognize the need for more experience of the shared responsibilities of relationship, more knowledge of the partner, more time to adjust before a final commitment.

I have to admit that I approach the concept of relationship from a liberal Western perspective –more particularly, a Canadian view- where there are state-sanctioned civil ceremonies that bypass the need for a religiously approved union, and where once cohabitation has existed for more than 18 months, with dissolution, there are requirements to divide and allocate any assets –including children-  as if a legal commitment had been undertaken. A recognition, in other words, that because cohabitation is likely to occur whether or not sanctioned by some authority, there are still legal responsibilities that accompany it. From my perspective, that seems a fairly pragmatic and ecumenical way to mete out justice for something that, whether or not officially blessed, cannot be prevented.

So why the resistance? An unwillingness to acquiesce to moral depravity? A fear of loss of authority, either secular or religious? The all-pervasive concern of elders that the old ways are under threat? Or maybe just an underlying distrust of other ways of doing things, other ways of being in the world? After all, societies that have segregated themselves and become distinct have developed customs that are also distinct. Their foundational myths and folkways have hardened into inviolable practices that others don’t share. It’s what binds a culture together –like the nation state, like patriotism, like the sure and certain knowledge that the forbearers had a reason to think and act as they did- a deeply held belief that others are not like us.

We are all like this to a greater or lesser extent. We fear what is new, or different –especially if it comes to us from them. With their seal of approval. And unless we want to become like them, and assume all their mistaken and misguided beliefs –in essence actually become them- we must resist. And resist with the guidance and blessings of whatever authority we most respect. Indeed, it is their duty to justify and sanctify our resistance.

But I am drawn ineluctably to the notion of relational or relative values: the idea that what a society or group determines is appropriate, also determines the values of members of that group. A simple and organic concept to be sure, but one that is too often neglected in our assessment of the beliefs of the larger society to which the group belongs. Or perhaps more importantly, of the beliefs of the authorities who purport to speak on behalf of the state. Of the constraints they impose -or attempt to impose…

Of course, many will argue that some things are simply wrong; to think of them in any other way is self-evidently immoral –sinful, if the concept of sin as opposed to iniquity exists in the cultural framework. But that merely pushes the argument into another dark alley: why is something immoral in one culture and acceptable –or at least tolerated- in another? Is the other culture necessarily and unequivocally mistaken –even depraved- by default? If one side is right, is the other side therefore completely wrong? Partially wrong? Or just different?  It seems to me this is an important distinction: difference can be tolerated as a rule; being wrong cannot. It opens too many other doors. Escape routes for the less committed. The fringe-dwellers.

And yet, history has shown that if enough people begin to do something –even something that was anathema to previous generations- it can dwell unmolested in the shadows, camouflaged in the background and eventually emerge as something new and exciting for the young, its offence muted by a generational wink.

It seems to me that Iran, among others, may be changing like that.

Homogeneity is deceptive; immerse yourself in a culture, dive below the surface and it is boiling, fermenting, swirling with difference that is often invisible from above. Generalizations about it are just that: macroscopic observations that miss the microscopic, the constituent parts that are so essential to the whole.

So, is the cookie the result or the cause of the recipe?


Can we ever understand each other? Know what is being asked of us? It’s not just a medical problem; it’s universal, I suspect. And it’s one that entails far more than simply comprehending the meaning of a word in both its denotative (definitional) as well as its connotative (secondary, or evocative) usage. It involves apprehending -truly appreciating – whatever is intended in the communication.

In a sense it is often a relational concept: we are linked in a sort of symbiosis and inherent in that is the empathetic interpretation of what is being conveyed. Friends potentially have this: Don’t listen to what I say; hear what I mean. We all hope for this, I think -especially when things are hard to express, when words fail, as it were. When we need the other person to grasp something we cannot adequately articulate, we are at a loss -or perhaps more accurately, at a disadvantage- in terms of receiving their help or advice. Words, large or small, can be impediments.

And this is particularly salient in medical encounters where both unfamiliarity with appropriate terminology as well, perhaps, as embarrassment, conspire to camouflage the reason for the visit. Where you say pain, but really mean cramp, or perhaps irregular -referring to your menses, for example- when you actually mean totally unpredictable, or maybe that you’ve even stopped trying to keep track of them… Where cancer could mean something you think your grandmother had -but nobody would talk about it with you- or that in fact it’s what you think you have but are afraid to verbalize it. Heavy is what your periods are not -even though you are anaemic- because they’ve always been like that, and so were your mother’s: They are normal, doctor

I realize this is not usually a major obstacle to doctor-patient relationships, because over time doctors learn to listen to what is not being said; the encounter is frequently more valuable than the words in it -no matter how descriptive. It is also why it is often so difficult to address problems over the phone.

Through the years, I have struck by the need not only to be a good listener, but a good and careful observer. There is as much meaning in silence as in conversation; as much information in examination as description. Words are susceptible to challenge, or misinterpretation; unimportant ones can be uttered with emphasis, significant ones mumbled sotto voce. Comfort level is privileged and not summonable at will. Words escape from the top of the tongue, or are inadvertently trapped behind the teeth; meaning is sometimes a prisoner to safety -be it cultural, or personal. And it can be as unpredictable as the weather; as fickle as a mood…

So then, how can we understand each other -especially in moments of crisis? How can we ensure that others know what we intend -what we need to convey? Is it as simple as choosing the right words, the right syntax? Is it a vocabulary issue, or something more complex? More profound? From the doctor point of view, I would argue for the latter; I think that the essence that underscores all communication, that underlies all meaning, is engagement: being present in the situation at hand; imbedded in the message -both obvious and covert, intended and accidental; alert to context; aware of the unspoken. Words, after all is said, are just drawings in sound; to understand, to really comprehend, we must listen with more than our ears, see with more than our eyes. To listen fully, we must hear.

It is not an arcane prescription, not something requiring years of training; it is what we all attempt when we truly care; it is what is missing when we do not… And absence of the effort is something Shakespeare noticed so many years ago (Henry IV part II):

It is the disease of not listening,
the malady of not marking,
that I am troubled withal.


As time harvests the years and winnows my memories, I find I no longer sift through dictionaries looking for new and unusual words. The thrill of finding one is still there I suppose, but more often the discovery is in an interesting book or magazine and it is not so much the originality of the word as the novelty of its use -its evolution. And Medicine, as always, is rife with examples.

Of course some words needed to change completely and not merely evolve: Mongolism, for example, or maybe Venereal Disease. Anything that unfairly stigmatizes a person with the condition is appropriate for renewal -although I’m still puzzled about why Venereal is more offensive than Sexually Transmitted. Or for that matter, died than passed on. But I do not argue against euphemisms -they involve literal changes of words, new descriptions that better serve the currents of contemporary culture. I may not understand the reasons for the change, but eventually get used to them as accepted colloquy.

Some changes, however, are more difficult for me. The use of the word client instead of patient, for example, I find particularly vexing. I suppose this shows my age and era, but I still think of client as very much akin to customer –someone to whom one sells a product or a service. It implies qualitatively different expectations and relationship than would be present between, say, a store owner and someone who walks in the door to buy something. One expects service, yes, but relationship, no -or at least not the type of relationship necessary for the entrustment of life or limb: a personal, almost intimate relationship of belief, hope, and of course fear.

A comparison frequently utilized is with a lawyer; you become the client of a lawyer for advice and for assistance in matters pertaining to the law -neither requiring a particularly intimate relationship to accomplish. There needs to be trust, yes, but surely of a different type and magnitude than what is necessary to let another person -a stranger, by and large- tinker with your body, your health and your temple.

I know there is an argument that even to label someone a patient implies a power relationship and one that doesn’t admit of equality or sometimes even the ability to adjudicate the opinion sought and in particular the advice given. It is one-sided, and by and large non-negotiable. Client however, almost by default, purports to correct these defects by distancing the seeker and the giver by a more commercially understood transaction. The person signs a contract after an initial discussion, and both parties are thereby bound to whatever the agreement stipulates. I will  give you some money and you will give me a car, say. If you don’t, I understand that I can take action against you according to the terms of the contract that has not been fulfilled. In the case of a lawyer, it might be his advice; for a product, there is a warranty.

Ah, but there is one of the similarities with a doctor, you might say: I can sue him if he makes a mistake. He is for my health, what a lawyer is for the law. But if that is the basis for the use of the term client versus patient we had best be careful. The law is written and although open to different interpretations in some cases, is still the same law. Precedents may alter the way it is enforced, but it is still the Law and barring exceptional circumstances the outcome, with a little research perhaps, is usually determinable beforehand. The job of the lawyer is to apprise you of this beforehand and in some cases seek to alter the interpretation in your favour.

At first glance, this may seem similar to how the doctor operates: an investigation is conducted, a diagnosis obtained, and a treatment proposed -as with the law, all very logical and contingent. Except that a biological system is not subject to the same type of law as is a country. It is inherently variable, predictable only statistically; and even then, the context is different because of genetics, environment and personal choice of life-style. A person may have a heart disease -a heart attack, say- but so many factors may have contributed and continue to contribute to the problem that the necessary treatment will vary accordingly. And the outcome will vary as well. Underlying diabetes, smoking, blood pressure and obesity to name only a few, will continue to play a role in the outcome.

Like it or not, the person with the heart attack, is entering into a unique relationship with the “authority figure” -one that I suspect is entirely distinct from that with a lawyer, or a social worker, or a cosmetician… Or a teacher. Those with whom teachers interact, are pupils; the word is unique and the relationship recognizable. It does not denote inferiority or pejority any more than the word patient should. A pupil is a distinct, if evanescent, entity and so is a patient. Neither is intended as a permanent name, or an all-encompassing descriptive; it is merely an attempt to uniquely characterize a temporary relationship -one that admits of little need for further definition. For each there is a temporary abdication of personal power in exchange for something more important at the time.

I do not think of it as surrender of rights but rather a yielding of perspective, an exchange of fear and despair for hope and anticipation. It is a positive word that best describes a distinct alliance in a time of need and I, for one, will continue to use it.