I recently attended the funeral of the local parish priest and this led me to consider many of the similarities between what I do in medicine and the role of the ‘Parish Priest’ as well as the ‘misrepresentation’ of 21st medicine. I work in intensive care, a setting of immense emotional stress for patients and relatives, and not infrequently for staff as well. Intensive care can appear more like the cockpit of an aeroplane – full of machines that bleep and flash as they keep patients alive. This, however, can belie the true meaning of what we do. There is an evolving mis-interpretation of what medicine is: that good medicine in the 21st century is skill based technical wizardry, where ‘good’ doctors are people, who can diagnose, treat and cure using magnetic resonance imaging (MRI’s), gene therapy, or laser guided scalpels and the like.
I believe that what a patient wants first and foremost is a physician who is compassionate, honest and committed to their cause. Without these under-pinning attributes, their drive to find the best treatment for each of their patients will be diminished. William Osler said in 1907 that “You (physicians) are in this profession as a calling, not as a business, as a calling which exacts from you at every turn self-sacrifice, devotion, love and tenderness to your fellow-men. Once you get down to a purely business level, your influence is gone”.[1] And for ‘business level’ one could insert ‘disease or diagnosis’. The patient is just one part of the whole person just as the successful treatment is just one part of an illness journey (al-be-it a vital part). Knowing the physician is compassionate, committed and honest forms the foundation upon which the scientific wizardry starts to work. It also has a very real beneficial treatment effect (placebo). And this is where Aristotle returns to the fray of modern medicine.
Aristotle’s Nichomachean Ethics sets out the three stages of virtue ethics: arête (knowledge), phronesis (practical wisdom) and eudaimonia (flourishing – performing as an expert).[2] Part of knowledge is an understanding of what personal attributes (dispositions such-as compassion, humility, justice and courage which Aristotle called ‘virtues’) are required to ‘flourish’. As doctors (and I assume clergy) become more knowledgeable and experienced, the good virtues (dispositions) that make them strive to do the best for patients becomes in-grained in how one performs as a physician. Put generally, we professionals, sailors, gardeners, mothers, etc have a duty to do what we do with good intentions. And the more we do this, the better our abilities will be. Comte-Sponville has said that to flourish is an individual’s accountable task; virtue and especially that of compassion are pre-requisites and to be without them is to be ‘inhumane.’ [3] Virtue is ‘a force that has or can have an effect’: it gives the person their distinctive excellence. It is this acting well that makes a person ‘more humane’. In Immanuel Kant’s terms, it is one of the individuals duty’s to others. [4]
An Aristotilean ‘good doctor’ or ‘good priest’ will not always make a good decision. Indeed, there is a circular argument here: it could be considered morally presumptuous to assume a consultant physician is a virtuous, or good doctor just on the basis of training or level of seniority, and therefore will always make good decisions. But, this in-part misses the point. It is the underlying virtues of a doctor that will make them reflect and study, coupled with experience and a desire to determine what is in the patients best interests, that will lead to good decisions. Put more simply, it is the underlying virtue to help that is necessary to start being of help.
As our lives become ever more technological (internet, texting and tweeting), there is a risk to three necessary elements of living well: communication, listening and understanding. There is a cliché – time heals all wounds, but I would argue based on my experience with patients and their loved ones that, providing them with understanding and a chance to voice their views, will heal those wounds more quickly. Thankfully, as technological advances allow us to preserve the heart beat of patients ever longer, the Department of Health is also starting to recognise the importance of understanding the person as a whole, as evidenced by the drive to allow patients to say what they would ideally like or not like when they come to the end of their lives (the “Preferred Priorities of Care” and “Advance Decisions” (living wills) documents that people can complete). This is first and foremost though, a role of family, friends and professionals.
References
1: Osler W. The reserves of life. St Marys Hospital Gazette. 1907; 13:95-8
2: The ethics of Aristotle: the Nichomachean ethics. (translated JAK Thompson, revised Hugh Tredennick). London, Penguin Books, 1976
3: Compte-Sponville A. A short treatise on the great virtues. London: Vintage, 2003
4: Ameriks K. ‘Immanuel Kant’ in The Cambridge Dictionary of Philosophy. Ed. R. Audi. Cambridge: Cambridge University Press 1999
Dr. Andrew R. J. Tillyard
Clinical Academic Lead for Medical Ethics and Law, Peninsula Medical School
Consultant in Intensive Care Medicine, Derriford Hospital