It is 1 p.m. on a Wednesday, and 250 medical students are filing into the lecture hall to listen to a lecture on health care and society. The chatter is not one of excitement, but of disconcertment. Many students complain that their time would be better spent studying hematology. These are not uncaring students who disavow the needs of the disabled, but a generation that demonstrates a palpable reaction to the way that medicine is taught. We may be quick to fault them for their alarming aversion to a discussion on ethics, but we must also consider: is ethics meant to be force-fed?
Medical humanism and narrative medicine are the popular phrases du jour which buzz in the modern medical classroom. Most, if not all, curricula place emphasis on humanities in medical education, which is touted as a panacea to medicine’s current evils: lack of physician empathy, inadequate patient care, dependence on technology, et cetera. Despite this, our approach to implementing change has not, in fact, changed; like any good American system, rules are established, algorithms are followed and boxes are checked. By intention and on paper, we have “succeeded” in incorporating ethics into medical education. Yet, what have we really done?
What is humanism? According to Jean-Paul Sartre, “humanism is a theory which upholds man as the end-in-itself and as the supreme value.“ Man is the point-of-care, the thing-of-focus, and the centerpiece of our attention. Medical humanism, or humanistic medicine, is an interdisciplinary field which aims to address problems in health care. According to The Arnold P. Gold Foundation, it is “characterized by a respectful and compassionate relationship between physicians…and their patients” centered on several ideals, including integrity, excellence, compassion, altruism, respect, empathy, and service (I.E.C.A.R.E.S.). Some would argue that these values are, or should be, inherent in any physician who has obligatorily passed the numerous checkpoints — undergraduate, medical school, residency and beyond — where the absence of these qualities would have barred his or her advancement. The growth of a movement meant to instill, reiterate or reinforce these standards suggests that the humanities must be necessarily invoked to help doctors, or that humanistic ideals need be rendered. One must wonder the need for this overt reinforcement, especially the subtle implication that medicine requires a “dose” of humanities. Is medicine really lacking in humanism?
The central assumption is that humanities, the field proper, possesses a humanism that can be extracted and added to the biologism of medical science. Despite having been an English major, I cannot confidently assert that students of the humanities by nature or as a whole harbor any special qualities that make them more attune to a humanity which we all share. Nevertheless, this widely-regarded dose effect, rendering humanity to medicine, is a veritable anti-humanism that contradicts the nature of humanism itself by objectifying it. That some, are willing to believe medicine needs nothing more than another class, tenet or -ism does not humanize it, but — ironically — further subjugates it to the Western model of scientific and evidence-based thinking that is based in the assessment of outcomes. The scientific legitimization of the humanities betrays the purpose of instilling humanism in medicine, and makes humanism another area of study — alas, a Wednesday morning lecture.
We have fallen into the habit of manipulating medicine by instrumentalizing its humanism. The medical humanities, like medicine itself, is subject to instrumental thinking about humans; just as medicine instrumentalizes its patients, so do the medical humanities instrumentalize doctors. We have found ways to ensure that physicians are practicing some ideal humanism, rather than highlighting their very own humanistic qualities which may already make them excellent physicians. Humanism becomes something we give to students and take away from patients; we deprive our patients of a realistic approach to care. Narrative competence is no longer a quality of a humanistic doctor, but a quantifiable asset of his or her efficiency — and Western medicine is greatly prideful of the efficiency, pragmatism and utilitarianism that allow it to think causally and act empirically. Humanism becomes not something we naturally feel about our duty as physicians and towards patients, but something we must accomplish, prove or enact. The material (human) is devoid of meaning (humanism), and the subject of medicine becomes objectified rather than realized.
Though it is never the intention of medicine or the physician to manipulate the patient — turning him or her from the subject to the object — the medical community is susceptible to exerting this sort of power. Michel Foucault has commented on the deceitfulness of humanism and its function as a crutch for various power dynamics. “Narrative medicine then becomes the mechanism of increased effectiveness,” while humanism — disguised as the protector of the patient — serves as an instrument of controlling the physician-patient relationship, as well as the instrument of objectification. Medicine relies on categorization — of disease, demographics and others — but its very structure of order and its diagnostic paradigm often extend unwelcomingly into its anthropology, such that the people it serves are often compartmentalized, necessitating the invocation of a humanism that adds more personability to the cold estimations of a medicine based heavily, albeit importantly, in hard science. Though narrative medicine is often effective in reframing the individual into the biopsychosocial model, so does it act as another tool of categorizing people. When accepted as another paradigm, it will be no surprise for the physician to adopt a clean method of appealing to the “biopsychosocial patient” — asking the right questions, avoiding the wrong gestures, following the song-and-dance of the movement in a way that instrumentalizes humanism rather than truly absorbing it. Do physicians treat narrative medicine as a check list? Many do, of course. Should we be concerned that many are compelled to treat the model as such? Of course we should. The patient-centered model is a veiled effort to add agency to the patient who remains under the guise, “the medical gaze,” of medical decision-making. In this way, humanistic medicine is simply medicine that then treats the patient’s need for recognition in a system that has only tried to resolve his or her disease.
Oftentimes, we do not quite know what exactly humanism is, much less how to procure it. In some, it must be encouraged; in others, in must be instilled. Central to humanistic medicine is altruism, which is also the quality that is most psychologically problematic. Altruism is that quality which extends farthest from the core of the individual; it is an act that concerns others and that raises questions about motivations towards fellow human beings. Physicians are, by nature, regarded as altruists: should it matter that it is encouraged in some and instilled in others? “Many of medicine’s most successful interventions…work whether the doctor has a human connection with the patient or not…it is precisely in the domains of medicine that are most scientific, and therefore most effective, that humanism is least important.” Efforts of a humanistic education aim to cultivate in young physicians a greater sense of unity with those whom they seek to serve. While no doctor should be nonplussed about this principle, there are still those whose tenderness will always pale in comparison to their skill. The neurosurgeon who rushes to the operating room at three o’clock in the morning to respond to a ruptured cerebral aneurysm may be acting out of pure altruism or self-interested behavior (money, personal responsibility, recognition, etc.), but few — especially the dying patient — will care whether his humanistic interaction (the smile, tasteful history or creation of comfort) was unparalleled as much as was his art with a scalpel. It is not to say that this physician’s sense of humanity is not pertinent or relevant, but that it should form the foundation for his technological business — whether or not the appearance of humanism is overt or useful, secondary to the job he must set out to do. Humanism is an essential component of the art of medicine that allows the science of medicine to prosper. Without humanism, medicine is no longer; without medical science, medical humanism has no vehicle.
There is no doubt that humans are narrative beings and that the person is the sine qua non of medicine. The main problem, however, is that the human is intimately tied with his or her medicine. The physician is incapable of seeing past the sickness, but in many cases is not privy to it; treating the disease concurrently, or in addition to, the illness is no small feat. One could argue that in some instances (e.g. a surgeon attending to a trauma), it is unnecessary or exhaustive to embody the medical gaze any further than what directly benefits the patient. And surgeons, for obvious reasons, are known to be immediate, blunt and matter-of-fact characters in a medical system that thrives and relies on their down-to-earth, matter-of-fact and overall sensible — not sensitive — practices. Where the narrative poses no extant benefit to the physician or patient, it becomes superficial or artificial, brought to light by social mores rather than medical models, thus further belaboring the instrumentality of enforced humanism. Nothing is less humanistic than feigned humanism. Medicine will be mechanistic where there are clear and direct goals, and more humanistic when the true nature of the patient harks on the illness at hand. Humanities in medicine is not a diagnostic tool as much as it is a way of treating patients with their due respect. Humanities in medicine is not universally applicable, but frequently helpful to the physician who must better understand the context of the patient, and for the patient who deserves personal and individualized care. Humanity must come from the person — the physician himself or herself — and not from the demand of administration. In this way, we must ask ourselves why physicians are not more humanistic, rather than questioning how we might instill more, quantitative, or greater, qualitative, humanism in our physicians. Humanism is neither an object that is given nor taught, but a way of being that must be experienced or lived.
It is of great importance that we not only select future physicians who possess humanistic qualities, but also that we preserve or encourage those same qualities in our present-day providers. Despite the excellence of ethics instruction in our medical schools, we must question whether the methods of instilling an ethical mindset are truly effective, and be willing to challenge our education, be it in ethics or hematology, if need be. Though the humanities may salvage medicine, we must learn to acknowledge humanism as something that comes from within rather than from without, that is learned rather than taught, and that is meant to benefit the patient rather than our own sense of good-will. Once we learn to retreat from using humanism as an instrument and begin to approach our patients as subjects, we may then call medicine a humanism.
Photo credit: Photograph taken by D Sharon Pruitt.