Medicine as a Moral Practice

Something seems awry with the practice of medicine. For a profession that seems so inherently meaningful, where one accompanies another suffering human being through some of the most difficult times in their lives as a confidante and healer, physicians still remain at higher risk for burnout relative to other jobs.^[1] There have been a myriad of attempts to try to address the physician burnout question, ranging from restrictions on work-hours to wellness grants for residents, but nothing has clearly moved the needle.^[2]

It seems the issue is much more fundamental. Of course, the basics of ensuring that people can have time outside of work is important. But is all time outside of work equally fulfilling? Or are certain activities inherently fulfilling because they point towards an underlying understanding of what a meaningful life looks like, such as time with my children or watching a sunset? Meaning and purpose have to arise from a telos, or understanding what something like a “good life” is “for”. Without a compass for what a “good life” looks like, we may get distracted by many other things that seem attractive on the surface, such as money, power, or pleasure (as Aristotle would say) but are not truly fulfilling.^[3] The same is true for medicine. Having lost a sense of what “good medicine” is, we then lose a sense of the meaning of what we are doing, because we no longer know what the hours of work that we pour our souls into is really “for”.

That realization came not too long ago for me.

The family in Room 20 would like an update. I pause while going up the stairs and feel a rising sensation of anger reading the page. “I updated them earlier today!” I say to myself, as I turn around and make my way back to the 8th floor. I glance at my phone, and it’s hour 10 of my overnight 14 hour shift. I sigh knowing that, based on the number of pages I am getting and the admissions still pending, that I am not going to sleep tonight.

I get to the unit’s family room. There, I find the family of an elderly woman who has had a large stroke. It’s 2020 and we are in the first wave of COVID, and she is also on the verge of intubation. I had updated the patient’s daughter earlier in the day, but I now see her husband in the room, along with the patient’s brother, and her daughter on the phone. I still feel a moment of indignation, thinking, “Why didn’t they get the update from the daughter?”

As I enter the family room, I tell myself that I will end the update reminding them that updates should go through one person, when the husband turns to me with watery eyes and says, “We really appreciate you coming, doctor. I don’t think my wife can go through with a feeding tube. We’re thinking about hospice.”

With that, I freeze. I guide them through the difficult conversation of realizing that this woman, who was still healthy and vibrant earlier this week, was now likely to pass in the next few weeks, and that this was a huge change for this family.

When I step out of the room, I go into the stairwell and take a moment. What happened to me? I had gone into medical school wanting to accompany patients and their families in moments of deep suffering. But somehow, as a first-year neurology resident, I had lost that sense of meaning and purpose in my work.

The next few weeks are moments of deeper reflection. Of course, there were many external circumstances: I was socially isolated due to COVID, I had volunteered to work in the COVID intensive care unit where I was assigned to a month of overnight shifts, I was bearing the burden of seeing patients dying alone. I was also a “good” resident in the conventional sense: notes done before 1pm, consults called early, to-do lists cleared before afternoon admissions.

But even though I was a “good” resident in terms of technical skill, I was not a “good” resident in the sense of seeking the patient’s ultimate good. I had somehow lost what drew me to medicine in the first place.

In medical school, we learn medical ethics as consisting of four principles: autonomy, justice, beneficence, and non-maleficence. However, in practice, we should call it the “autonomy model”, given autonomy always comes out on top in any decision-making conflict. Given this, there has been a growing debate in medical ethics about how to honor patient autonomy without sacrificing the physician’s sense of what is genuinely good for the patient.

What has unintentionally happened with a unifocal autonomy-based approach to medicine is that physicians have stopped considering what the “good” is for a particular patient. If the “good” is equivalent to what the patient wants, then there is no room for the physician to discern the “good” for the patient. Over time, the physician no longer considers what the patient’s good may be. And this has had dire consequences in our healthcare system.

For example, a few weeks ago, my cousin called me from Korea. My elderly aunt, who has Parkinson’s, was found to have a mass in the roof of her mouth. They went to the top hospital in Seoul to meet with an Ear, Nose, and Throat doctor. He took a biopsy, and on the follow up visit, told them that the results were inconclusive in that, it was borderline between benign and malignant. The choice would be surgery to remove the mass or no surgery with the risk of the mass continuing to grow and potentially spreading, if cancerous. However, he told them that the surgery may have complications of my aunt permanently having difficulties with eating, and they’d have to use muscle from another part of her body to graft it to the roof of her mouth.

Now, that physician knew that even for local anesthesia for the biopsy, my aunt had a setback in terms of her Parkinson’s because she was unable to take her medications the morning of the biopsy. She has already lost 20 pounds from Parkinson’s. Being bedbound after surgery could hasten her decline significantly.

But he took none of that into account. He just presented this to my aunt and my cousin and told them, “You decide if you want surgery or not. I gave you the information.”

It was in this setting that my cousin reached out to me. “How am I supposed to make this decision?” she asked me.

And I agree. How could someone expect them to weigh all of the consequences of Parkinson’s, what stage of illness my aunt is in, how long she may have left to live, the challenges of total anesthesia on her, and the risks of delirium, being bedbound, etc.? A physician who is pursuing the “good” of the patient would have worked through this together with them. They would have seen the circumstances my aunt is in, guided them through their particular situation, and come up with a proposal, including an in-between one that I recommended to my cousin: to follow closely serially with imaging, to get a better sense of how the tumor may be changing over time, and to defer surgery, which has high risks, for now.

The autonomy model has left patients and families to fend for themselves. And it results in a physician who no longer challenges themselves to discern, “what is the good in this situation for this particular patient?” They no longer cultivate this moral discernment that is crucial to the practice of medicine, deferring to the easier solution of, “it’s up to you.”

It is in this context that the Hippocratic Society (HippSoc) was born, whose purpose is to cultivate in clinicians “the practice and pursuit of good medicine”. HippSoc believes that medicine is a moral practice, and that the care of each patient brings with it an opportunity to discern, through that moral lens, what is best and good for this particular patient, and how the physician can grow themselves, by trying to help the patient find, seek, and decide on that good. We do so in the context of community, modeling the tradition of apprenticeship in medicine, and helping experienced physicians to remember the ideals of young medical students, and helping trainees to learn from physicians who are trying to virtuously seek the good in their practice.

MacIntyre would say that the “good” can be understood in multiple ways.^[4] A “good” thief would be someone who is skillful at that particular craft. But a “good” father takes on a different meaning. He is one who understands what it means to be a father and pursues the traits and virtues of what that intends. It has an “end” (telos) to which fatherhood stands for. And a “good” physician also has this end in the context of “good medicine”. As a community, we seek to understand and grow as a profession together towards that “end”. In doing so, we seek to restore the “good” of medicine; for our patients, and for clinicians who are burned out, having lost the sense of purpose and meaning they started with when they first chose this path.