To see reality—not as we expect it to be but as it is—is to see that unless we live for each other and in and through each other, we do not really live very satisfactorily.... —Frederick Buechner

The child, Ember, comes into foster care on his first birthday. His bright blue eyes are open wide; he always looks surprised. He is stiff, his muscles tense, his feet and hands splayed out. His round cheeks grow rounder with his frequent “aw, shucks” smile at the biological children in his foster home. Ember is difficult and lovely, and the children love him. They reflect on his easygoing nature, unlike previous foster children in their home. This is a sadness for the foster parents, who know what such quietude means: children who have suffered neglect learn it is useless to express their needs.

The system in this state encourages foster parents to act as mentors for the family of origin as the latter works through court-ordered steps toward reunification. As the foster family walks alongside Ember's parents, the simplistic story of neglect grows more textured and complex. Ember's parents want what is best but don't know how to provide it. In time, the rest of the story is woven around the thread of neglect: hopeful intentions, a desire to do right, broken coping skills, generational poverty, capital-T trauma, and intellectual disability.

Every fall I ask our PA students to read a short piece of fiction. The story, Puppy, by George Saunders, is narrated by a woman living with an abusive partner; and along with that, she is abusing her child. Yet somehow, we can tell she is doing her best to love her son in earnest. Her internal monologue provides the texture and complexity that Ember's foster parents have come to understand: affection, brokenness, naivete, and severe limitations of coping.

Every year, the students respond along a wide spectrum of opinion. Some recoil with disgust, sadness, or indignation; others show curiosity, humility, and empathy. Nearly all demonstrate some degree of confusion in their responses. Readers are faced with crossed moral wires. Is this person unequivocally bad? Or can I look deeper, broader... can I be more curious? What if I allow myself to stand in the tension between an individual's immoral behavior, loving intention, mental and emotional brokenness, and an ecosystem of complex trauma? In short, how far should my empathy take me?

An intentional bias is built into the medical admission process to select candidates with strong moral frameworks, beneficence, altruism, and intention to act—and for good reason. These are our highest and best qualities. It is right to love what is right. But these qualities come to bear on a world that is not morally simple. Our medical culture often tells simple stories, ones that help us survive the moral confrontation by lifting our line of vision above the world's complexity and texture.

Just before Ember's second birthday, his foster parents find themselves exhausted. Their strong moral framework, beneficence, and intention to act have them overcommitted at home, at work, and in their community. They sit their children down to tell them they have decided to move.

“What about Ember?” their 9-year-old asks.

“He'll go to live with the foster family who is caring for his half-sister,” the mother responds.

The next day Ember's mother and father have a meeting with the magistrate for a routine check-in. His foster parents attend these meetings and, as always, plan to spend time with them beforehand. Today, they will break the news about the move. Ember's biological parents also have news to share.

Ember's father sits on a park bench outside the downtown courthouse. He holds Ember's hands aloft, propping him up to stand on his lap. They both laugh. With his bright blue eyes and untamable hair, Ember is undeniably his father's son. His mother watches with something more complex in her countenance. A kind of restless contentedness...or a melancholy happiness. She knows what Ember's biological dad is about to say. He looks up from Ember's eyes at the foster parents, pauses. “We saw how Ember did with your family this past year. We talked it over. We really love our boy, but we can't seem to do right by him. So we thought maybe, well...maybe you could make him part of your family, permanent like.”

There is a long pause. Ember's mother's eyes look down, spilling tears.