On the Profession and Practice of Medicine

Remarks by Farr Curlin, M.D., at the 2018 Paul Ramsey Award Dinner March 24, 2018

Receiving the Ramsey Award is a delight, an honor, and a privilege. It’s humbling to receive this award and to be here with you tonight. In particular, I thank Jennifer for her long and faithful service in the same direction, and for the work of the Center for Bioethics and Culture.

My work in the world of medicine has been concerned with what I call the demoralization of medicine. Since ancient times, physicians have recognized the perennial problem of not living up to one’s profession—not living up, we might say, in Ramsey’s words, to the covenant one has made to serve those who are sick. This ancient problem continues in our day.

Today, however, we also find a new problem: the problem of denying (or forgetting) that there is any such profession or covenant that calls us to account. Instead, physicians have come to substitute for that profession, for that covenant, a contractual commitment to provide healthcare services to satisfy the wishes of the patient or the state or whoever else has authority to direct the physician.

From this new problem, three results follow.

First is a crisis of bioethics. We live in a time of widespread skepticism about anyone having authority to say what morality requires with respect to medicine. In this crisis of bioethics, clinicians default to proceduralism—following a set of rules to figure out who has authority to make a choice, then getting out the way and letting that person make the choice. This pattern is found, in my observation, even among those who decry what is going on. People have largely come to accept that no one can say what is right for another person. That’s the first problem.

The second problem is a crisis of professional identity. Over the past few decades, there has been a steady uptick in burnout rates among physicians, among nurses, and among other healthcare practitioners. Among physicians, burnout rates are now twice what they average in other professions. This crisis of professional identity suggests that many physicians do not experience their ordinary, daily activities as obviously good. Physicians are increasingly ambivalent about whether their work as a doctor is worthwhile. And, of course, related to that is deep dissatisfaction among many patients with what they experience when they encounter these burned out physicians. So there is a crisis of bioethics and a crisis of professional identity.

Third, we see growing inducements and pressures to set aside ethical norms that have long guided the practice of medicine, as well as pressure on practitioners to set aside their conscientious judgment in favor of accommodating patients’ wishes. We see that, of course, in the area of assisted reproductive technology, an area my mentor Mark Siegler referred to as the “Wild West” of medical ethics. But we see this dynamic across medicine; for example, in in the push to respect patients’ wishes by helping them to die through assisted suicide and euthanasia.

A few months ago in Ontario, as some of you may know, the provincial court affirmed a rule by the College of Physicians and Surgeons (the College has legal authority there) that requires physicians to refer for all legal “medical” interventions, including abortion and euthanasia. In its decision, the court said that there is no qualitative difference between euthanasia and other medical practices. The court’s reasoning was that patients have a right to healthcare, that no one can say one intervention more or less healthcare than another, and that, therefore, physicians must accommodate patients’ requests for any legal intervention.

We can think of this demoralization as a symptom, within medicine, of the fact that we’re living in what Alasdair Macintyre described as a kind of moral and intellectual ruins of a prior time. We are still talking about being “ethical” and pursuing “beneficence” and thinking about “justice” and so on. We’ve lost the moral framework, however, in which those terms have meaning and in which they can actually guide our actions. What’s left is what Macintyre called emotivism, where we reflexively affirm the idea that the most important thing for each individual is to live out their authentic self-development by making the choices that they feel is right for them. This idea is felt deeply in our culture—You be you; no one can tell you who to be—and its results are seen in medicine. Medicine becomes palette with which to paint one’s identity using available technology.

What can we do about all of this? We certainly can’t fix the problem, because it’s too deep. It’s a problem that Ramsey saw 50 years ago, and it has only gotten worse. I brought my copy of Ramsey’s best-known book, The Patient as Person, which comes from his 1968 Beecher lectures. He saw the problem and he was much more capable of addressing it than I or many others would be.

That said, we can work toward what I would call the long reversal by helping to sustain a community of those capable of giving a winsome and true account of medicine as a moral practice, a rational art oriented toward the patient’s health, which can be pursued in ways that respect the nature and dignity of human beings, including their intrinsic orientation to God. Macintyre said that cynicism and despair are luxuries we cannot afford, and that renewal begins in sustaining communities where we can recover truer modes of practice and speech.

I’m going to read a quotation, and then I’ll close. The quotation is from Ramsey, and it’s quite telling. He writes:

“Only a being who is a sacredness in the social order can withstand complete dominion by ‘society’ for the sake of engineering civilizational goals—withstand, in the sense that the engineering of civilizational goals cannot be accomplished without denying the sacredness of the human being. So also in the use of medical or scientific technics.

It is of first importance that this be understood, since we live in an age in which [the Hebrew term] hesed (steadfast love) has become maybe and the ‘sanctity’ of human life has been reduced to the ever more reducible notion of the ‘dignity’ of human life. The latter is a sliver of a shield in comparison with the awesome respect required of men in all their dealings with men if man has a touch of sanctity in this, his fetal, mortal, bodily, living and dying life.”

His next line is this: “Today someone is likely to say: ‘Another ‘semanticism.’” In 2018, someone is likely to say: “Another way of imposing your personal values on what should be standard professional practice.”

So what do we do? I think we do what the Center for Bioethics and Culture has been doing for many years, what I and others have tried to do in our own domains. That is, we nurture and support those who will contend for good medicine in this and the next generation.

To look at the people who have won this prize is for me humbling and also exciting because it reminds me of the community I have been invited into. Edmund Pellegrino is someone whose work was among the first things I read in medical ethics. I’ll not forget the opportunities I had to speak with him. Dan Sulmasy, another awardee, is Pellegrino’s best-known student. Dan has had a deep impact on me through his writing as well as through his friendship. Gil Meilaender’s little book Body, Soul, and Bioethics was the third or fourth thing I ever read in medical ethics, and I pored over it. Friendship with Leon Kass, as well as his remarkable essay, “Regarding the End of Medicine and the Pursuit of Health,” taught me to see the moral orientation of physicians towards something real (health), not merely the satisfaction of patient wishes. Grisez and Finnis have, through some of their students, including my friend Chris Tollefson, helped me to understand the natural law and our orientation to health as part of our orientation to things that are genuinely good for us. I am a product of these people.

I look around the room at the current Ramsey Fellows, and I have great confidence that they are going to go on and practice medicine with integrity, with fidelity to covenant, with a beautiful witness to what a sacred work this is, what a sacred privilege it is to show up to, to walk alongside and attend to, those who are sick and debilitated, seeking to be helpful in some measure. So I encourage you to be generous tonight because the people that you’re investing in through the Ramsey Institute and other efforts of the Center here are going to help to sustain this good work of medicine into the future.

Thank you so much for inviting me to be with you.