Humanism and the Physician
An Important Message to the Physicians of Today
EDMUND D. PELLEGRINO, MD
To Be a Physician
Wheresoever manners and fashions are corrupted, language is. It imitates the public riot.
Ben Jonson (1)
The world we perceive is the world we see through words...hence the importance of teaching language not so much as grammar as behaviour.
Ashley Montagu (2)
These essays have dealt in one way or another with the many articulations between the idea of humanism and the idea of medicine. Ultimately, these seeming abstractions must be related to something concrete and immediate in the physician's daily experience. Is there some moral imperative in medical humanism which binds simply by the fact that we are physicians? Is there an irreducible and uncompromisable dimension by which we can measure the authenticity of a claim to humanism in medicine?
Authenticity is revealed ultimately in what we are, and this, in turn, by what we think it means to be a physician. Our being is revealed very often by what we take the words to mean which we use to justify our acts.
If we are to know something about what it is to be a physician, four words in common parlance are in need of rehabilitation: the words profession, patient, compassion, and consent. They are so ubiquitous in the speech of physician and patient that we all imagine we know what they mean. Yet language, as Jean Paul said, is "a cloud which everyone sees in a different shape" (3). It is essential, therefore, for every physician to contemplate more closely the shape of the clouds these words make when he utters them.
This chapter is an amalgam of the following:"To Be A Physician," Convocation Address given at Texas A&M University in October 1977; and "Profession, Patient, Compassion, Consent: Meditations on Medical Philology" which was presented as the Commencement Address at the Hippocratic Oath Ceremony, University of California, Los Angeles, on June 3, 1977, and appeared in Connecticut Medicine, 42:3, March 1978, pp. 175-78.
The four key words I have chosen all have Latin derivations. Latinity is no longer respectable since it is easier to ignore what we do not comprehend. These four words entered the Anglo-Saxon language with the massive infusion of foreign words which followed the Norman Conquest. The entry of these words enriched the language because they expressed certain precise notions. As the feeling for words declined, these original meanings have been corrupted over the centuries.
But we must try to rescue those meanings because both Ben Jonson and Ashley Montagu are right: we do act in accordance with what we think words mean, and when our acts become morally dubious, we do distort their meanings to suit the aberrant act. What the enthusiasts for laxity of language see as enrichment may, in fact, be a mere excuse for submerging the stronger, and richer, earlier meaning.
The first word is profession (4). With the receipt of the M.D. degree, the student officially becomes a member of a profession. In sociological terms, the student joins a body of individuals sharing certain specific knowledge, rules of conduct, ideals, and entry requirements. Some are impressed with their entry into a privileged social group which automatically entitles them to a certain respect, a wide discretionary space in decision making and considerable authority over others. The more crass may even rejoice in the license to charge fees for what only yesterday they did for nothing.
While each of these construals of the word has a certain truth, the original meaning is much more powerful, and specific, to being a physician. It comes from the Latin word profiteri, to declare aloud, to make a public avowal. It entered English in the thirteenth century, or thereabouts, to signify the act of public avowal and entry into a religious order. It was a public declaration of belief and an intent to practice certain ideals. In the sixteenth century, it included the public declaration of possession of certain skills to be placed in the service of others, as in the profession of medicine, law, or ministry. The word was visibly distorted in the nineteenth century when the language of an industrial society infected our parlance. A profession became simply a prestigious occupation. Instead of commitment, we began to talk of efficiency, productivity, utflity-in Marxist as well as capitalist societies.
When a student consciously accepts his degree he makes a public avowal that he possesses competence to heal and that he will do so for the benefit of those who come to him. In that declaration, he binds himself publicly to competence as a moral obligation, not simply a legal one; he places the well-being of those he presumes to help above his own personal gain.
If these two considerations do not shape every medical act and every encounter with the patient, the "profession' becomes a lie: the physician is a fraud and his whole enterprise is undiluted hypocrisy.
These are strong words, but they derive ineluctably from the ex- pectations engendered in others by the act of profession-the personal and public voluntary acceptance of the obligations one is willing to assume in accepting a medical degree. This is the essence of the oaths-whether of Hippocrates, Maimonides, or any of the others-traditionally administered at graduations. These oaths are not meaningless condescensions to tradition but living witnesses to society of a personal commitment.
A few years ago, it was popular for medical graduates to refuse to take any oath. To their credit they took the oath seriously enough to resist when they could not agree with its content. I hope the more placid acquiescence of today is not evidence of moral lassitude or lack of the courage to dissent.
The physician remakes his profession every time he dares to offer himself to a patient. The obligation is unavoidable. It leaves little room for incompetence, selfishness, or even legitimate personal concerns like fatigue, lack of time, or the demands of family. It is inconsistent with the prevalent bureaucratic ethos which buries individual acts in the faults of society, institutions, or, the "team." We must not be "auxiliary bureaucrats," the term Gabriel Marcel used for those in a mass society who excuse themselves as mere functionaries (5).
If our professions had, up to now, been authentic in the pristine sense, we would have less malpractice, governmental regulation, and consumerism to worry about. It is in the actual or perceived failure to act in accordance with the full meaning of the word profession which underlies much of the public disquietude with medicine today.
The next to examine is patient, another badly tortured word whose original meaning has also been seriously attenuated. The Latin root is patior-pati-to suffer, to bear something. It was first used in its medical sense by Chaucer. A person becomes a patient when, in his perception of his own existence, he passes some point of tolerance for a symptom or a debility and seeks out another person who has professed to help. The patient bears and suffers something, and his expectation is that every act of the physician will be to relieve him of that burden and restore his lost wholeness-which is, incidentally, the meaning of the Anglo-Saxon word heal.
The patient therefore is a petitioner, a human in distress, and an especially vulnerable human. He enters a relationship of inequality. He is in pain, anxious, and lacking in the knowledge and skill necessary to heal himself or to make the decision about what is best for him. The person who has become a patient thus loses some of the most precious of human freedoms-freedom to move about as he wishes, to make his own decisions rationally, and freedom from the power of other persons. The patient bears, in a real sense, the burden of a wounded and afflicted humanity.
The patient is not a "client," a word appearing with distressing frequency in medical and medico-legal writing. Client is from the word cliens and has a lineage dating back to Roman times. The word referred to a plebeian and in the Middle Ages to a vassal under the protection of a patrician or lord. The client paid certain homage and performed services to the lord in return for this protection. Today, the client is a customer. It is alarming to see how the spirit of this word has come to pollute the relationship of physician and patient and how insensitive we have become to the original sense of what it means to be a patient.
Physicians all too frequently interpret the word "patient" to mean long-suffering or enduring trouble without discontent or complaint, a trait they ascribe to a "cooperative" patient. There are even a few physicians who see patients as their vassals, patemalistically protecting them in the distorted notion of their own moral authority, making decisions for rather than with the patient, and demanding compliant behavior from those they serve. We even talk, in a distorted way, of "educating" patients, meaning that they must conform to our notions of how to behave in illness.
If we understand, and feel, the full meaning of the word patient, then we can also understand another word so often tortured on the rack of misuse-compassion. This word is simply a derivation of the same root, patior which gives us the word "patient.' It means, literally, to suffer with, to bear together, to share in another's distress, and to be moved by desire to relieve distress.
Compassion is not some facile combination of talents in public relations under the rubric of bedside manner; nor is it some mystical quality or charisma which radiates only from the gifted; nor again is it synonymous with mawkish or demeaning pity for the sick, or a saccharine piety and self-righteousness. These construals are all offensive to true compassion and an insult to the wounded humanity of the patient.
Compassion means to feel genuinely the existential situation of the person who is bearing the burden and who has undergone the insult of sickness to his whole being. We can never enter wholly into the state of being of another human, but we must strive with all our might to feel it to the fullest extent our sensibilities will allow. It is our failure to feel along with the patient that leads to the complaint we hear so often today of humiliation and being demeaned.
If we understand the full flavor of meanings of profession, patient, and compassion, then we can easily understand the last word so prevalent in current legal and moral discourse, consent. Here, the Latin root is sentire, a word which has two senses: one in the emotional and physical sense and the other in an intellectual sense. Therefore, con-sent is to feel together and to know something together.
Con-sent grows out of a human interaction between someone who seeks to know what to do and one who advises what should be done. It is not the mere satisfaction of some legal formality, a signature on a piece of paper duly witnessed. Con-sent demands, rather, that action be taken from the ground between patient and physician. Both must feel the action is the right one, and both must agree on the basis of knowledge that it is a rational choice as well.
It is not appropriate to undertake a detailed consideration of the moral and legal dimensions of consent which has become such a tendentious issue in medical relationships. It is necessary only to iterate that the word demands a joint and not a unilateral experience; it cannot be valid where one party, physician or patient, decides for another; it does demand that both parties feel the decision as their own.
Consent of this quality is morally indispensable if we only think of the vulnerable state of the patient and the inequality of the relationship with the physician. The obligation to obtain con-sent flows from the fact of being a professed healer, one who purports to repair wounded humanity. The physician must restore as much of the patient's lost freedom as possible. That means making available the knowledge -the alternatives and probabilities-necessary to a free and human decision to take one course as opposed to another, or to reject what the physician proposes.
It has been said that one picture can replace a thousand words. But we forget that one word can also paint a thousand different pictures in our minds. Pictures are static while words undergo constant change. If we destroy a painting, it no longer communicates; if we mutilate a word, it still has great power and can corrupt, where once it enhanced human existence.
But even these crucial four words express something which is still peripheral to the innermost center of humanistic medicine. Two more words must engage our reflections: being and having, and the difficult but crucial distinction between them.
Gabriel Marcel, the French philosopher, critic, and dramatist, said that 'Everything really comes down to the distinction between what we have, and what we are' (6). This is not one of those meaningless messages so appealing to the minds of middle-aged moralists. Rather, it is a distillation of the dilemmas we face as persons and institutions in forming an authentic image of ourselves, one in which we and others can believe.
Without indulging in all the complex subtleties of Marcel's thought, what he seems to be saying is this: to have something is to hold ownership and control over a thing acquired from without. Whether it is a profession, an idea, an education, or a fortune, what we have is always external to our being; it can never enter into or define the infinitely greater mystery of what we are. No matter how impressive the things we have ,, they must not be our identity. If they are, then we lose the chance to be something. We lose the freedom of a personal choice and testimony. It is we who put our possessions to use and not our possessions that use us.
Physicians have a medical education, an M.D. degree, a set of skills, knowledge, prestige, titles. They possess many things by which they may mistakenly identify themselves and their profession. Many of the health professions-medicine included-confuse the possession of packets of knowledge, a white coat, or a technique with being a physician or healer.
Far too many who possess these things fail to be authentic healers. It is a daring and transforming experience to attempt to heal another person. To do so is to penetrate in some way the mystery of the person's being, and that becomes disastrous unless we are clear about our own being.It is the disjunction between having and being that outrages patients with their physicians, and similarly sours students with their teachers and congregations with their preachers.
The matter is so difficult because there are so many conflicting conceptions about what medicine is. Is the only true medicine equated with radical cure, high technology, and specialization? Or should we believe the polemicists like Ivan Illich, who believes that "the medical establishment has become a major threat to health" (6)? They urge us to deprofessionalize medicine and return to self-care. Or, should we heed the romantics of the 'back-to-nature" school who advise a return to yesterday's remedies, diet, exercise, and vitamins? Maybe truth is with those who want medicine to alleviate all the more unfortunate consequences of being human and want medicine to be the ultimate guarantor of human happiness. Is there something more fundamental than this cacophony of salvation themes to tell us what medicine is, and what it is not? What is medicine for?
Medicine is something of all of these things, yet none of them ex- clusively. Having these attributes does not make medicine what it is, anymore than having a medical education is being a physician. Whatever else it may be, medicine comes fully into existence as medicine only in the moment of clinical truth, in the act of making a clinical decision. In this act, the physician chooses a right healing action, one that will restore health or contain established disease or prevent new disease. Among the many things that can be done, the focal point on which all medical activity converges is a choice of those that should be done for this person, at this time, and in this life situation. The right decision is the one that is good for this patient-not patients in general, nor what is good for physicians, for science, or even for society as a whole.
As soon as we introduce the word right with respect to action and good with respect to an end, we introduce morality-some system of strongly held beliefs against which behavior is, to be judged as good or bad. Medicine is, therefore, at the root a moral enterprise because values enter into every decision. The physician's art and science are necessarily shaped by the special human relationship between a vulnerable person seeking to be healed and another person professing to heal.
To be sure, medicine derives content and methodology from a wide range of primary studies as varied as biochemistry and ethics. But medicine itself cannot be equated with any one of them or even the sum of all of them.
All health professionals participate to some degree in this central function of medicine. But it is the physician who stands closest to the point of convergence of the whole process, and thus he has the broadest moral responsibility. The closer we are to this moral center, the more we are physicians; the further from it, or the narrower the range factors to be integrated, the less we are physicians, no matter how sophisticated our technical knowledge.
Whichever of the many conceptions of medicine one selects, one can be a physician only if one satisfies the essence of the medical act: to make a right choice that is "best" for this patient. Others may carry out the procedures required-and they need not be physicians at all -but what medicine uniquely is, is the capability morally to manage the clinical moment.
To be a physician is freely to commit oneself to the moral center of the relationship with the patient and to do so with one's whole person-that is the only condition for freedom, as Bergson so rightly observed. This is neither too harsh, nor too simplistic a judgment. The malaise of medicine-the moral desuetude so many see in us and the bewilderment of our students about what we are - is rooted in our failure to sense the dimension of being a physician.
Without this dimension, even the idea of service can become degraded into mere performance of a function. Many of us function, but few serve. To transform functions into service we need what Marcel called attachment: "dedication to the intrinsic quality of what is done, its adaptation to the needs of the person served and personal accountability for its quality. (7)"
We cannot distinguish having from being without the capacity for critical self-examination. This is what the humanities-philosophy, history, literature at their best-have always taught the educated man. These studies are, therefore, tools of that intellectual and moral honesty which gives the lie to self-assurance and forces a constant reexamination of motives and values. There is no more effective antidote to the overweening pride that can so easily beset the physician.
The most authentic humanist in that very great novel The Plague, by Camus, was Rieux the physician. He possessed the modesty to resist self-justification. He was a symbol against the moral indifference of the citizens of Oran who allow the plague to take possession of their fellows while they pursue their possessions and pleasures.
If we can educate humanists like Rieux, medicine may help to treat not only the personal plague of disease but the pestilence of moral indifference that seems, like a cultural plague, silently to have possessed our spirits.