The Glory Years: Part Two

The Project of International Humanitarian Surgery came to pass into existence as a result of a confluence of events which inspired the participants to engage with patients and communities outside of the U.S.A. The project was extremely worthwhile since it brought through surgery an almost miraculous change in a person’s life. His body image and self-confidence were rapidly restored, and the many psychological problems associated with deformity quite rapidly reversed. This work has matured, evolved, and developed into a tried and true process of developing a two-way interchange program in the profession between counterparts in two countries. Here we will discuss how the process is successful, how the participants become friends, and that the process is successful and sustainable.

THE PROCESS

Once the decision was made to embark on an international medical trip, based on our experience in Mexico, we corresponded in depth with all institutions, hospitals, and foundations, as well as all persons that might be involved in our performing surgery in these Central American countries: the American Ambassador, the Chief Medical Officer in our US. AID team, then the Minister of Health and the President of the Colegio Medico (equivalent to our AMA), and also the plastic and reconstructive surgeons in each country. All the potentially necessary channels were tapped into in preparation. The team of Stanford University physicians and nurses undertook a medical journey in November 1967.

Initially, the program was supported by physicians from San Mateo, CA who in effect were surrogates and therefore engaged in the project from their homes in California. These San Mateo physicians had generously underwritten the project of bringing patients up here who were not suitable for surgery in Mexico because of repeated or staged surgery requiring longer post-operative care.

In embarking on these trips, we were very scrupulous in how we attained and transported resources. Our surgical supplies and equipment had been shipped by United Fruit Company in their banana ship returning empty to Honduras at no cost to us. Most of the sutures and surgical supplies have been donated by the pharmaceutical and surgical supply houses. There are so few funds available for this project, it is only with this kind of help that we could take the first step in our program, which was to be ever-growing and extremely worthwhile.

THE MOTIVATION

The idea for this project was first seeded by a patient in the U.S.A. He was a scientist working in Mexico on research, who’d taken it upon himself to provide rudimentary, Western-style medical assistance to the local population. From our association with David and his knowledge of the many unrepaired cleft lips and palates in his area, we were encouraged to plan a trip to Sinaloa.

In the future, we would follow this model and identify someone already on the ground who could connect the physicians with patients, as well as working in synergy with all the legal, political, professional, and community leaders, addressing personal problems with such foreign or “gringo” motivation. For example, it was a difficult decision then that San Pedro Sula has been chosen for the first surgical trip to Central America. Once we decided to go to the bigger city with more patients, we worked at the Hospital Dr. Leonardo Martinez V. with Dr. Rene Bendana and Dr. Luis Bueso. We anticipated many cases of cleft lip and palate.

We progressively developed a concept for embarking on these trips. This concept entails bringing plastic and reconstructive surgery to these developing countries, using the tremendous impact of immediate surgical rehabilitation of a severe and grotesque deformity as a manifestation of our country’s system, and the goodwill of American people. The change that takes place in an 8-year-old girl’s 1ife after the grotesque deformity of a widely cleft lip is restored to normal appearance is inspiring.

EDUCATION

An important part of the project is the training of the Mexican and Central American doctors and nurses, as well as the training of our resident doctors. We all, everyone from both countries, benefitted from surgical and research experiences not found in any other training program in the United States.

This model was accepted by the local government and professional members. In Managua, as in other places. We received the “red carpet treatment,” from the First Lady, the President’s wife, Hope de Somoza, Presidenta de Asistencia Socia1, among others. We were encouraged by the Minister of Health, Dr. Rodrigo Portocarrero, to come to perform surgery and institute a medical interchange. We also to presented lectures to the nurses, and trained nurses in fluothane anesthesia techniques. Training of the “recipient” country’s doctors and nurses is integral with the patient care and rehabilitation.

No other university plastic and reconstructive surgery training program in the United States offered these unique and worthwhile opportunities to their own and to these from the country with which we interchange professionally. We intend to continue to augment our clinical research as well as provide sophisticated medical care of exceptionally high impact value.

THE PEOPLE

Of the fifteen surgeries we performed during this time, each one notable in itself, several were particularly unusual or interesting.

  1. A woman reconciling with her husband before being discharged and leaving happily with him
  2. A man who had a double lip which was removed with local anesthetic

Some of the cases we encounter are distressing – mature people still handicapped with cleft lip or cleft palate,  bearing the social stigma of this deformity (most of these people have never been to school because of the deformity), children with extensive burns, receiving limited treatment, many with severe scarring from untreated burns, and several cases of syndactylism.

Sternal Dehiscence

San Andreas Fault or Fissure

The visceral reaction that one has when one experiences the inside of the body – the guts are out on the sterile blue towels when the surgeon “runs the bowel” – he performs an exploratory laparotomy – is not pleasant; it is a time of fear, the fear of you not being able to take it. That fear is associated with your autonomic nervous system. Not your conscious system, by which you, for example, consciously command the big toe to move; which is the voluntary system. The other system is the automatic system, which runs itself – it controls your bowels and your time of awakening each morning, your stomach acid secretion, your blood pressure. Your voluntary nervous system can override your autonomic system to a certain extent. Although I had removed the heads of several hundred chickens, ducks, and geese, and a pig to boot, and had dismembered each with nary a hint of visceral reaction e.g. the queasy stomach, the inability to control yourself from fainting down to the ground in a cold sweat; nevertheless, when I was a second assistant on an exploratory lap, I felt that visceral thing. Here were the human guts right there an inch from my retractor, the abdomen open wide; I tried not to vomit, and not to faint. I bit my tongue; perhaps some pain would save the situation. And it barely did.
The automatic nervous system is very experienced. Perhaps two billion years ago, it began its development in starfish and sea life, which were very early in the evolution of an intestinal system. It is said that the G.I. tract has almost as many neurons as the peripheral nervous system has in the arms and legs, and approaches the central nervous system in complexity. So when I was in my first autopsy at Wood Veteran’s Administration Hospital in Milwaukee, Wisconsin, Department of Pathology, the dead human body lay naked, supine on a steel table looking up at the ceiling, and his huge relaxed penis there; it was difficult to take your attention away to the rest of the body. The smell in the autopsy room is a cross between the not pleasant formaldehyde combined with the inside of the bowels, which is the awful bathroom smell almost the same as baby shit. And when both the large intestine and the small bowel was opened, as well as the gallbladder and stomach, and thoroughly examined, each being weighed and described, my autonomic system reacted as if it had obviously had experience with that, perhaps 100 thousand years before my time at Wood VA Hospital. My autonomic system had a response embedded in its nerves and reflexes, and was putting into effect an upset of my intestines. My voluntary consciousness was barely able to override that colon. But not easily; a lot was on the line. You want to be a surgeon? Not someone who is flat out on the deck, having fainted, is a surgeon, nor one running to the vomit sink.

Contrast that with the open chest of a fat and alive dentist. The breast bone had been sawed open during the heart surgery 10 days previously and that opening spread wide with a screw type steel separator, all very sterile; but after the patient’s successful quad bypass, in which his leg veins were used to patch sections of the sclerotic coronary arteries to the heart itself, infection sadly occurred.

The dentist with his open chest- sternal dehiscense is looking at meanwhile I gaze out at the natural beauty in the San Andreas fault
The dentist with his open chest- sternal dehiscence is looking at me while I gaze out at the natural beauty surrounding  the San Andreas fault

There is always a battle in every wound, of every body, each of us, with  wounds to the body. The battle, which decides whether a wound, any wound, will heal, is between the three factors shown in this triangle:

infectivity-triangle

Here we depict the interaction, really a battle which is universal in every wound.

And somehow, the dentist had lost that battle. He had an imbalance in this magical, sacred triangle. And the wound, the median sternotomy, did not heal; he was re-opened in a take-back surgery, the purulence drained. His chest cavity and the heart sitting there were washed out with several thousand CC’s of antibacterial. You must not close an infected wound; the infection may thrive as it has the upper hand at this point.  Some wounds with infections however with the  may be closed over a drain system, which instills things to kill bacteria but not kill the patient. But, in this big wound, it was mandatory to pack it open and then change the dressing daily.

Plastic surgeons as a species arrogantly say that “we are able to close any wound in the body; we can fill any deficit. However the plastic surgeon has only six operations, and using only these six we are known for the ability to close all wounds.The art of plastic surgery is in the mixing and matching of the six in what we term a “symphony”. All comers, all wounds are able to be treated and fixed successfully. And we train 6 or 7 years after med school in order to be of service to patients who in turn “serve us”

Excellent and careful fine technic for

  • wound closure is the first of our six operations,
  • the second being split-thickness skin graft,
  • the third, skin and soft tissue flap supported with its own circulation (veins and arteries are not severed nor disrupted),
  • the fourth, free-flap transfer of skin and subcutaneous tissue separated from its nerve and artery but re-sutured with the artery and vein (and usually the nerve also) to another sustenance and another (nerve) artery and vein in the same person. Microsurgery usually is required for the free flap transfer of chunks of tissue from one spot on the same person to another site because the arteries, veins, and nerves are small in size and magnification is necessarily called into play. Microsurgery, a relatively new component field in PRS, was pioneered by our Stanford’s own Harry J. Buncke, of Clinical faculty, San Mateo, California, and his little group: engineer, former German wartime, probable rocket scientist (his resume is blank 1941-1947), nurse Nora Adams, and fortunately DRL himself in the infancy of his Stanford career. Werner Schulz “vass dee brilliant Chermahn” who invented then and there how to fabricate suture from human hair, and to swedge it onto a tiny needle. The surgeon’s tremor was abrogated with a pneumatic air pressure device operated by a foot pedal and a small air tube and air bag. Nora HAB’s ( Harry A.  Buncke’s ) nurse arranged for our experimental monkeys from the SFO airport. They were in 6 week quarantine on their way to Jonas Salk in Cincinnati. Buncke was the driving force and the “prefrontal cortex” of the experimental microsurgery, Laub was assistant surgeon, Greg Buncke was in high school and helped as needed in the Buncke family garage operating room, and in Peninsula Hospital basement during “operating room” hours, after usual hours.
  • Homotransplantation of organs from one individual person to another (different) human. This required medical science with basic research to alter the immunologic rejection of the organ in order to accept a foreign body, a transfer of a human part, person-to-person.
  • Complex tissue homotransplantation, for example a face transplant, which is attracting the many plastic surgeons with their usual psychologic profile. (FN 1)

These all are repairs which increase function and improve appearance; this is all we have as plastic surgeons. Our cognitive skills are said to be little in comparison to internal medicine, or the sister specialties of cardiology, immunology, infectious disease experts. (or God).  We are called upon to mix and match these six types of operation and to tailor a certain plan which is different and unique for each patient. Herein is the beauty and the pleasure of our field. But standing there, before a crystal blue October sky, I was looking out the window of the intensive care unit room. And also before me, was the ridge of the Santa Cruz, or coastal mountains, with the beauty of the ancient 100 year-old redwoods (not 1000 year old), and the long gulley in front of the mountains. And just beyond the back of the hospital was the San Andreas Fault, an actual earthquake fault line, moving Los Angeles north 1 inch per hundred years, or even faster at the times of active quakes. The vineyards were out there on the hillside just 11 miles off my ICU room. I was comprehending the history of my view, perhaps a billion years have elapsed since they were formed. And the history of the human DNA, the human being one specimen carrying DNA with its primary mission to perpetuate human DNA, and in turn, my responsibility in this whole scenario and scene; I had taken the Hippocratic oath to give my priority to single persons with pathology and cure them with the skill and science I had learned in my sacred profession. I felt the weight of my assigned job. Although the patient had an endotracheal tube to breathe for him, necessarily because of an open chest, voluntary breathing being impossible, I could see the personality in his eyes and face, and deduce details of his history. I had read his chart, the medical history – he was overweight, had arterial vascular coronary disease, had engaged in overwork, lack of exercise, and had no thought of preventative medicine in his life. No thought of wellness. I began to wonder about what is civilization contributing here?

Civilization came to America, the Spanish, the English, the French, following the Iniut and others, who were more original stakeholders here. Civilization, as far as medicine is concerned, centers itself about the caring of guys in awful health, who have been successful in gradually killing themselves with the goal of the “good life.” Why not spend a billion or two, on preventing these cases, with education and great programs? But who should do it? The government, with taxes? Or 501.c.3 foundations, with their donations? Both have responsibility to transform health, from those who have it, to those who really need it. And this dentist is a so-called success story of civilization, which has engulfed California. This man is really a poster-boy for the re-alignment of resources.

But these emotional times must be spent on planning wound closure. I was, myself, alone in planning the wound closure. I felt great, in the sense that Dr. Gaudiania, legendary heart surgeon, had called me in. And I knew how to fix this patient! This was going to be a great case!

My professional life, ever since the day I was called to be an extern, staying overnight at the veteran’s hospital in Milwaukee, Wisconsin, to take call for any patient problems, I had been totally directed and had made myself the goal of obtaining good cases. Good cases would make me a great doctor with great experience. I desired to have more good cases than other doctors, in a competitive sense that I’ve had ever since first grade. The good case was quite similar to obtaining the Holy Grail for others. After a clinic, for example, I would always answer to the question, “How was clinic?”

“Great, I had three good cases.”

(1) Those in each specialty in medicine are characterized with a distinctive and typical psychologic profile. In plastic surgery, the profile is:

  • Please the patient. Attempt to do what they ask of you in their CC (chief complaint)
  • Do the impossible; nothing is impossible
  • Any wound can be closed
  • Your result, sir or madam, is really good

rev. 2/15/15

The Devil’s Fool – American Naïveté Manipulated

The was full but we had to make time for her.

The schedule is full. This is the story of Anita Gajardo. A girl from the mountains around San Pedro Sula, Honduras. The patient was kind enough to teach the surgeons a lesson regarding the complexity of South American politics and culture.

The naiveté of the “bleeding heart type” American surgeon. Of course, there are four types of American surgeons. First, there are the ones motivated by overwhelming compassion. The second are surgeons whose purpose is to build up gold coin in heaven by proselytizing and converting souls; they make an exchange, quid pro quo, of “join my religion, my philosophy,” in exchange for surgical care. Third are those from developed countries whose motive is neither compassion nor religion but a deep spiritual way of life. Fourth, like those from Stanford, who formed Interplast for the medical purpose of finding advanced human pathology, are those who follow their mandate from Hippocrates, “perfect the science and skill in yourself, and apply it for the good of the other person.” It is probable that all four of these surgical types would be subject to the guiles and social skills of the other culture.

Little did we know that our culture, only 300 years old, was unquestionably inferior to a 3,000 year old culture, springing from Aztec and Inca wisdom, and modified by the Spanish cultural soup. Our culture was hopelessly in-equipped, poorly matched for the situation. Arrogance, imperiousness, neocolonialism. We had been taught to follow the rules, do a complete social history, follow holistic principles. Be sure you’re doing the right thing. What would Hippocrates do? What would your mother do? What would Jesus do?

Anita Gajardo’s sponsor was the pastor of her church. The pastor was stumped by our saying that we were currently filled, to go home, and to return the next day with the patient, making sure she did note eat in case there was a vacancy. The pastor had to reach deep into her bag of tricks in order that her own purpose could be satisfied. She was successful in defeating our rebuke by adding drama, almost repulsion to us do-gooders.

She also heaped on to the plot, her way of mining the compassion in us: this defenseless girl lives in a wood shack with a locked door, she doesn’t have key, it’s kept by men who rape her repeatedly, she doesn’t have a job. It was such a compelling story that I not only wanted to do the case immediately, but the other 6 surgeons in the team immediately volunteered and insisted that they be the surgeon. We were dreaming of becoming the hero in this drama and perhaps, we subconsciously thought of newspaper, radio, television, spotlight and self interest. We all were proud that Dr. Furlow, who we worshiped as the most experienced and wise surgeon, should be our champion. He did the case.

After this was done, Fran Falces, wife of one of the plastic surgeons, went over and interviewed Anita. She got the back story and data, and to our surprise, came back laughing. There’s no raping, she has job doing laundry, she does contribute to society in that way. In a way, she needed no rescuing, her own culture had already found a good place for her. It was story made up by pastor. She even told our translator that she was a pastor of the Church of Satanical Practice. Nurse Falces was suspicious that the pastor would go back to the mountains telling people that she had made a miracle for the patient by being able to access the devil’s power. Latin American politics is more complex than we could ever imagine.

What did we learn by this? We must remain humble and discard our arrogance. Arrogance is our enemy even though it is an extension of our skill and knowledge. An extrapolation we must avoid. All people are equal, a lesson we hope the residents and students who were present also embedded into their body of social and surgical skills.

rev. 3/19/15

How to Act on an Internationational Trip, 101

Ready to take the post-op patients from Mexicali to Calexico. A light and silly air about us.

The goals of the trip are to help spread the accumulation of knowledge that we have, to those without access. We achieve this through direct patient care, teaching our international counterparts, as well as the American students, and forming lifelong professional relationships. At the heart of this is the personal exchange of cultural values and ideas that lay the foundations for the relationship with the persons involved. The validity of these statements lies in the fact that the people with whom I interacted with 30 years ago are the speakers for the International Humanitarian Opportunities course, Surgery 150.
Remember that the purpose of the trip is to form long lasting professional relationships – it’s all about the people.
Here is the “How-To”:

Ask how they are doing.

Learn how you can help them rather than talk about yourself or your organization, or what you intend to do in the country.

(Perhaps they can help you.)

Smile at each person, especially those in the hallway, or on the sidewalk. In other words, use the smile on anyone who has eye contact.

When talking, show appreciation for all things, although not incessantly.

Stay with the positive things in conversation, and be sure to be interested in them.

Your common ground can be anything: family, the weather, compliment the weather even if it’s bad, food, their job, and ultimately, lastly, our mission.

Be a little outgoing, take a little initiative.

Talk to the person in the seat next to you on the airplane.

Meet everybody, from janitor to king.

Learn to put the other person before your questions.

Instead of asking “What time is it?” ask “How are you?” and “How is your uncle in Los Mochis?”

Be prepared for more physical contact: a hand-shake, a hug, or a tap on the shoulder.

Give eye contact and always smile.

The business card is a necessity. Give one to every single person, even those you think don’t want one. The business card is not for business; it is you. It’s the piece of you that stays after you leave, and it keeps alive the interpersonal relationship you have built while you were together. Keep it handy. Give it with sincerity, and pause to give them time to read it, then ask if they have one and show that they see you looking at it. This is also the easiest way to get their email and physical address.

Formatting the business card is important. In order of importance to the business card, it should show: 1. You and your qualification, 2. Stanford, 3. Global Health Volunteers or equivalent, 4. Something catchy

Finally, find your counterpart. In a natural way invite one of them to your home, or to your area. And mean it.

Latin American Protocol

In Latin America the culture is different, the person is more important than the thing. This has certain implications in our behavior. In conversation you stand closer to the other person than in America. In America, the distance is commonly 26-29 inches and in Latin America it is 18. When you meet a friend, the greeting is not necessarily an American hand shake, it is just as likely to be the Latin hug. The left arm is up, the forearm is bent at the elbow at 90 degrees, the hand and forearm straight up. The right arm is shoulder height and outstretched. You hug with the left, and put the right arm around and tap the scapula two times. You do not kiss the man usually, but certainly the woman if she is known to you. Some Anglos say “No way!”

When entering the room, especially the living room on Sunday afternoon at a family get together, proceed right to the alpha and shake the hand or kiss and hug. At that point, do the same with every single person in the room. This is “making the rounds.” Be verbal, and a little more outgoing than your usual. Be sure to ask how they are, and how is their family and things like “When did you arrive.” Be sure to express your happiness. “Muy contento,” with being there with them and in their beautiful city. In 50% of the cases you might even invite them to visit you. “When might they be in the United States?” I have had over 60 friends, old and newly formed, stay at my house. In one year, i had 110 such experiences, overnight stays, recorded on my tax return. This was to my benefit.

How to Act in the Hospital

On rounds or in clinic, the job is assessment of the patient and to record it in the chart so that the next person seeing the patient, is completely up to date.

The “How-To”:

1. Smile at the patient and say “How are you?”

2. Say something light, a little joke or something silly. “Do you feel lighter today with that heavy gallbladder our?”

Physician, Executive Director, and Patient after 22 operations
Physician, Executive Director, and Patient after 22 operations

3. Observe:

psychologically if they are UP, DOWN or NEUTRAL.

have an adjective to describe in writing

a male or female aspect

happiness? evaluate the smile.

4. The Verbal:

Do you have pain? The question “does it hurt” may not work in rural Latin America, because the man will say no.

Then ask, where does it hurt? They will point directly and groan.

Read into the position they have in bed and whether they’ve been out of bed.

5. Cultivate your power of observation and put meaning into everything.

6. Metrics: BP, P, Weight, HTC, I&O

7. Next is a formal exam. Wound bleeding? Drainage red or clear? Observe skin, eyes, heart and lungs, abdomen, extremities, genitalia. And use the info.

8. Charting: use the SOAP method

S, subjective

for example: “AOA”, Ah-Owww-Ah (moaning sound)

O, objective

for example: “great improvement”

A, assessment

for example: “no complications, a success”

P, plan

for example: “discharge to husband”

rev. 03/19/15

The Seven Psychological Levels

Ideally, the doctors who participate in an Interplast trip, are doing so for the psychic income, and not for any other motivation, therefore would fit into the Seventh Level.

Psychological Development of the Value System

When I was president of The American Society of Plastic and Reconstructive Surgery, 1981 &1982, the leaders of the society were counseled by a psychologist who was also adviser to the White House in regard to how to manage different people at different levels of psychological development. Here is his theory:

The first level of psychological development is the vegetative level.  It is quite similar to the life of a vegetable or a tree.  This basic level consists of mere existence only, simply life as an individual without group interaction.

The second level consists of being a member of a tribe which is usually 9 persons (7 to 11) under a single leader.  The tribal members stay alive because the strength of 9 accomplishes more than one could ever.  If they pull together, and they do because they have learned through the centuries to do exactly what the leader says.  Thus they survive.  Their key to life is to follow exactly what the leader says—no questions asked, nor ever thought of.

The example given is the janitor cleaning the marble floor in the fanciest office building.  The high executive working into the night, says, “Hello,” and gives his greetings to the night janitor as the exec leaves the down elevator.

Noticing an inefficient practice, he suggests, “John, use the mop, that is twice that width, because you will be finished sooner.”  “No, Mr. Genioso, that only sounds good; my boss told me to use this narrow mop. And he told me just today.”  “Use the wide one; it’s better, faster, not heavier, and it makes you feel good.”  “I can’t, Mr. Genioso, the boss told me different.”  “Well, I’m telling you how to do it right and better.”  “You just don’t understand.  He told me this way, not your way, don’t you understand?”

Reasoning, self-interest, rules, enjoyment, are no match for the world of the boss.  He is a type II, a member of the tribe.  The boss will take care of him, not the executive.  It’s not a difficult decision for John.

The third level is the leader of the tribe.  For example, the leader of the motorcycle gang.  In this chief’s mind and in the mind of the tribal members, this type III man is not only right, but he is absolutely infallible.  Furthermore, he is immortal.  He not only commands others, but he disobeys you when he is in the emergency room waiting room.  He takes your advice, “You mustn’t sit there Rosco.”  He retorts, “I want to sit here, I won’t sit there, go f*** yourself.”  The only way to manage him is, “Sit where I told you, or I’ll kill you with this sharp knife in my hand, and if that doesn’t do it, I’ll pump six bullets from this 45, I will then cut you into little pieces and throw the pieces out of that window just behind you.  Those rats will take care of whatever is left.”

He moves.  But using money, good reasoning, ethics, friendship, a joke, or the kind hand around the shoulder, does not have any chance at all with type III.

Another example is, “Don’t ride that motorcycle anymore, it’s dangerous, you’ll end up in the E.R. and die.”  He answers, “No.  I’ll never die.  Look at me.  I’m alive, and being alive is proof that I will never die.”

The fourth level is the bureaucrat.  The boss, the tribal leader, is not here, they’re gone to rest.  But he has left us his rulebooks, he is in these books, and I’ll read these laws and obey them down to the last footnote.  You see, when the tribal members have no leader alive, they invent a virtual leader saying, “This is what the leader would have said or done in this situation.”  And the bureaucrat, a human being, codified what he thought the leader would have said. He is acting in a level really close to level II, but he has a different function in our society. Religions perhaps started in the same manner when the prophet died, the religion was the virtual leader and the pope, or bishop, or whoever then interpreted what the leader would have done, and you all know how human nature tends to alter what the deity might really desire.

The fifth level, wheeler-dealer self-interest.  This is a modern day refined Level III.  The example is the guy in the airport in the salesman’s uniform (nice suit), the phone with the microphone on the wire hanging from the ear, talking loud about trying to get another 1/4% on the deal and 1/8% will go back to you.  The wheeler-dealer, the hyper nice, slap you on the back, grab your trapezius between thumb and index finger, the big smile.  He has the ultimate self-interest, and knows how to work with the modern world.  He will grow up to be a CEO of an abusive corporation.

These characteristics maybe extended into abuse as a sociopath, or even a psychopath.  “Hi, I’m Larry your salesman, may I get you a beer, my friend?” He accomplishes good to society because he pays at least 1/2 of the taxes due.  “Enlightened Self-Interest.”

The sixth level, modern-touchy-feely genuinely concerned over the fate of the world, over society, the community, his family, the planet, the species.  Business interest is secondary to common good.  Oil, logging, fishing, agricultural decisions, are not made for profit.  These decisions are made by all, for the good of all, for equality and justice.  Social justice comes before shareholders.  Man does not exploit man.  Man does not exploit any species.  Because if you cross nature, she will win out against you anyway.

The seventh level, both self and other are integrated.  Accomplishment is achieved without taking advantage.  Those, whom you pass on the ladder of success going up, are the same that you will pass on the ladder going down.  The highest level of self-interest and the highest level of social responsibility are integrated.

Ideally, the doctors who participate in an Interplast trip, are doing so for the psychic income, and not for any other motivation, therefore would fit into the Seventh Level.
Ideally, the doctors who participate in an Interplast trip, are doing so for the psychic income, and not for any other motivation, therefore would fit into the Seventh Level.

The eighth & ninth levels are thought to exist in the afterlife.  Recall that a level V may masquerade as a VI for the purpose of self-interest, using sixth’s appearance to achieve his own agenda.  And IV may appear to be a V, and also a VI may appear to be a VII just as a VII may try to be a VIII or an IX (claiming preternatural abilities or properties).