So what, they didn’t know the meaning of an exotic Greek word. But hubris, like many a ten-dollar word is more than pedantic vocabulary. It is a metaphor, shorthand for an understanding of the pride that goeth before a fall and the story of Icarus who flew too close to the sun with disastrous result. Closer to home, it is the story of Asclepias, born of Apollo and a mortal mother who was killed by Zeus because he raised the dead. The metaphor is clear: monkey with the forces of life and death and risk grave consequence. I often notice that physicians shrink from ethical conflict and political debate and this is good reason to ponder our past and current place in society.
I read a dissertation on the “art” of medicine by a physician attempting to translate the analog intuition of clinical acumen into a digital construct using statistics and probability theory – not unlike the goals of the “evidence-based” medicine movement. But the intuitive diagnostic leaps that good physicians make are only a small part of the art. The public needs us to be reservoirs of humanistic cultural evolution. For this, and to flirt with matters of life and death, we each need to develop principles, intuitive ethics and facility with a cultural metaphor that flows from millennia of critical thought and inquiry.
The Renaissance Man was the product of classical education. Classical education included not only the primitive technology and science of the time, but facility with the prior sapience. Hippocrates, the “father” of modern medicine (460-377 B.C.E.) worked on classical mathematical problems such as squaring the circle and duplicating the cube. The Greek physician Galen (130-200 C.E.) had interests in agriculture, architecture, astronomy and philosophy until he concentrated on medicine, and then his thoughts dominated European medicine for a thousand years. In the 12th century, Maimonides was a physician, scholar and philosopher. These were models for the Renaissance, and post-Renaissance medical development was replete with Renaissance Men.
The Problem
Physicians used to be classically educated people, savants who then focused on medicine. To some extent, this is still true, but in recent years, those who aspire to become physicians have been electing to narrow their foci sooner and sooner. A firm basis in the classics of Western Civilization and a survey of the breadth of existing non-scientific knowledge is no longer emphasized in pre-medical education. We fool ourselves into thinking that ethical discretion can be taught in a medical school short course on “nurture-craft” or “cultural sensitivity.”
One can passively absorb ethical and moral constructs from religions or professional codes and these will be, by and large, tried and mostly true. However, over time, just as Western religions require reformation, so do moral and ethical codes for professionals. It is the nature of social evolution that new problems arise and solutions flux. To be stable and flexible at the same time, ethos must come from within, supported by a firm foundation in the historic cultural metaphor and tempered by individual effort and creativity.
We are slowly but surely chipping away at each new physician’s important knowledge of the roots of civilization that enables the public to respect us as more than technicians. Technicians have a place in the provision of medical care, but they cannot lead and they should not guide others’ decisions. Some doctors feel more comfortable as technicians, perhaps because they have become educationally ill-equipped to delve into the underpinnings of what we do. They may know the facts of life, but are they conversant with the ideas, ideology and philosophy that elevate our existence and make it worthwhile?
The ability to make ethical decisions, the kinds of things that patients and their families expect of us, requires foundation. The classical education is meant to be a sturdy framework for more intensely focused inquiry. Aristotle defined virtue as the ability to act in accordance to what one knows is right. Rigorous study develops virtue. Focus can occur with concentration or exclusion, and the difference is crucial. It is insufficient to skip to science and then narrow the field of inquiry to internal medicine or surgery and then subspecialty without having mastered a broader historical perspective.
The Reasons
All professions are not created equal, and all do not have the same ethical underpinnings. It is the duty of physicians to offer people only the services we believe they need, not necessarily those that they want. In other professions, the duty and relationship to the client is a focused advocacy. For us, the gray zone is broad and treacherous. To be cogent, our expertise must convey enlightenment drawn from eclectic scholarship; and this makes all the difference.
While they may coexist, cost and time pressures can create an inverse relationship between science and art. In medicine, financial rewards are diminishing, while medical education is increasingly expensive both in money and time. One’s Weltanschauung suffers when these pressures apply. We have been beaten down by the forces of business and “health maintenance” schemes. The need to make a living can drive us to divest ourselves of the obligation to enlighten the public with our particularly cogent views that are based on what we do.
There are generational issues. Those who begot the intellectual tradition of medicine in the mid 20th Century were influenced by the Great Depression. Now there is the culture of “me,” and a practical approach to the profession that diverts us from aggressive and public pursuit of more lofty, but more compromising ideas. Some of us have emulated our corporate oppressors and have taken a quarterly approach to the job; and learn to ignore the societal impact implicit in every decision we make.
Yin and Yang
Plato (427-347 BCE) in his Republic, analyzed the educational and experiential prerequisites of a “Philosopher King” by dividing education into music (from the root muse and referring to all of the “arts” and the subtleties of metaphor, as in fables) and gymnastics (athletics, but in this case representing craft and technology). He felt there was a delicate balance between gymnastic and musical education and that overemphasis of gymnastics produced “savagery and hardness,” while excessive music spawned self-indulgent “softness and gentleness,” not so different from the Eastern (Taoism, Han dynasty synthesis, 207 BCE - 9 CE) concept of Yin and Yang. He said the two “may be fitted together in concord, by being strained and slackened to the proper point;” begging the question, what is the proper point? And is the proper point the same in all eras and at all stages of cultural evolution?
Medicine is a complex business that balances the best of the Yin and the Yang. Women are nurturers, well suited to half of the physician equation. Men are well suited to the other half. To be a physician, each must supplement his/her gender propensity with the appropriate learning to create harmony. Not a unique thought: music and gymnasium, Plato.
One might think there is just too much to know and we must specialize to a point where a classical education is excess baggage. The sheer volume of data, the difficulty of the material and the desire for a cost-effective curriculum that keeps the pre-medical process within a four-year paradigm seems a seductive excuse for truncation or elimination of the college level classical education. When my Sesame Street sound-bite afflicted children complained that a particular teacher didn’t make the subject matter fun, I told them that in the vast intellectual sea upon which their scholarly boat must float, learning is an engine that is only occasionally fun, more often work; but there is something that is always fun: KNOWING.
Leaders should have prior ethical and philosophical insight to draw upon when encountering something new. College should be where we learn the “wisdom of the fathers” and practice the manipulation and augmentation of antecedent thought to solve modern problems. For physicians, erudition is critical so that we do not devolve into mechanics, purveying the technical result until our patients sense that we are without philosophy and perceive us as not caring. We cannot abandon this role to non-physician bioethicists and the art of medicine (sans much science) cannot become the realm of alternative and holistic practitioners.
I lament the demise of physicians as effective societal thinkers and thought leaders. It is not that we do not have the capacity; the selection process assures that most of us do. But we should not squander our brilliance on mere technical feats. Classical knowledge and perspicacity can shield us from the doctrinaire and the demagogue. All of us need to have well-founded, well-reasoned opinions on issues such as:
- Is relentless indiscriminate medical care green (good for Gaea)?
- In the largest sense, medical care is a narcissistic business which primarily consists of the services of others for the one. Does medical care really belong among the basic necessities of food, shelter and clothing or is there an element of privilege as there is in housing, transportation, plumbing and the like?
- There is no perpetual motion, no cold fusion and there cannot be open-ended medical care for everyone. Can society afford us to think otherwise?
- Abortion, euthanasia and the death penalty.
- Quality verses quantity of life; the demise of the extended family and its support of the elderly – good?, bad? Does it even matter . . . and why?
$ Commercial advertising of medical procedures and prescription medications. - Professional-ism, generalist-ism and specialist-ism.
- The world fundamentalist movement and its effect on scientific inquiry.
No one can do this for us and we have an obligation to society to vociferously press our special point of view. We need people to respect our opinions on these issues at least as much as they respect those of politicians, lawyers, pundits and wonks. In short, our leadership must be supported by a respect for our erudition.
We must re-institute much of the classical education in pre-medical education and then retain a working knowledge of the ideas of our forefathers so that we can build on them, not reinvent them. We need to have the comfort of KNOWING that kindles the enthusiasm of open discourse, cultivates a valid ethos, and makes our arguments compelling. We must regain the hearts and minds of the public and assist, if not lead our society through difficult times ahead.
