’21st Century Medicine, Aristotle And The Church’ by Dr. Andrew R. J. Tillyard

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 21^st 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 21^st 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
andrew.tillyard@pms.ac.uk

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“Newspeak (PART TWO): British Art Now is doubleplusgood!” by Dr Jane R Moore

A few weeks ago I visited the new exhibition at the Saatchi Gallery with my group of 4^th year King’s College Medical Students. Visits to galleries, museums and art installations are an integral part of the ‘The Good Doctor’ Special Study Module but I hadn’t included the Saatchi Gallery before.  Modern conceptual art is challenging and I was uncertain how this visit would help in our exploration of medical matters. I need not have worried; our visit was enjoyable, reassuringly accessible and it was easy to make links to the theme of goodness in contemporary medical practice.
Newspeak Two on display in the large bright rooms at the Saatchi Gallery, King’s Road, London continues the showcase of contemporary British Art started in June 2010 with Newspeak One.  All the original exhibits, including the widely advertised Pink Cher by Scott King, have been replaced and the new collection opened at the end of October.  Charles Saatchi’s Sensation! exhibition (Royal Academy 1997) had – sensationally -  brought late 20th century British Art to public notice. This was the outing of Damian Hirst’s shark, Tracey Emin’s unmade bed, Mark Quinn’s blood sculptures, Chris Ofili’s ingenious uses of elephant dung and the Chapman Brothers doing what they do best – shocking us into a reaction.  So what would we make of Newspeak?
George Orwell coined the term newspeak in his dystopian classic Nineteen Eighty-Four[i].  This was the deliberately duplicitous politicians’  language which removed all shades of meaning from words.  For example, “think” used as both noun and verb makes the word thought superfluous so it can be abolished;  if pleasure / pain becomes  ”goodthink” any negative connotations can be dismissed.  In this way the total dominance of the State was reinforced leaving the population passive and malleable.  By calling this collection Newspeak is Saatchi mocking contemporary art?  Or is he referring to present-day “artspeak”, an artificial, pretentious, hollow and at times unintelligible discourse?  For our group this was our first link to contemporary medicine as we considered the role of  “medicspeak”.
Our guide, a postgrad art student, showed us some of her favourite pieces and gave brief descriptions.    We appreciated this guidance which allowed us to move on to our own interpretations and make links to contemporary medicine and society. On our own I think we would have been at a bit of a loss. Though a description of all we saw would not be practical here are some highlights.
Gallery 3 contained three massive, detailed and beautifully painted canvasses of men and machines by Jonathan Wateridge.  We liked Space Program 2008, a group of men posed in front of a spaceship under construction.  However on close scrutiny you could see the spaceship was a milk bottle, the launch control panel a mobile phone key pad, and the astronauts ‘spacesuits’ ordinary workmen’s overalls decorated with bits of household tat. Yet the men, in reality the artist’s friends, give the appearance of authority and confidence. We were reminded of Luke Fildes’ iconic picture The Doctor (1887).  This picture, painted at a time of increasing mistrust in the science of medicine, managed to suggest that medicine and the establishment as a whole, had the power to confront the difficulties encountered by society[ii].  In the same way we are lead to think that Wateridge’s unlikely astronauts’ competence and skill will surely lead to a successful expedition to further man’s mastery of outer space and so all is well with the modern world.
http://www.saatchi-gallery.co.uk/artists/artpages/jonathan_wateridge_space_group.htm
Anne Hardy (Gallery 5) has a series of four photomontages of ‘depopulated rooms that suggest surreal fictions’ according to the exhibition catalogue[iii]. What we saw were detailed photographs of the same space, some frames showing a clutter of carefully arranged seemingly miscellaneous objects:
http://www.saatchi-gallery.co.uk/artists/artpages/anne_hardy_cell.htm
Other frames showed an empty space with the outside crowding in;
http://www.saatchi-gallery.co.uk/artists/artpages/anne_hardy_drift.htm
We found these images claustrophobic but compelling; reminding us of both the workings of the human body with tortuous nerves and blood vessels, and of the machinery of modern medicine which cuts us off from normal communication with our patients.
In Gallery 10 The Followers, Ximena Garrido-Lecca has produced a huge reproduction of a Peruvian burial wall. Each niche containing photos, mementoes, plates of food or a bottle of beer by which the deceased were remembered by their grieving ‘followers’.  This is a beautiful exhibit, but after a short time as observers we became uncomfortable; we felt that we were intruding or showing a prurient misplaced interest in intimate details of people who had had no choice in the display and what it revealed. It was easy to make parallels to the role of the medical practitioner and our patients’ narratives.
http://www.saatchi-gallery.co.uk/artists/artpages/ximena_garrido_followers5.htm
So how do I justify this visit to the Saatchi Gallery to look at contemporary British art?  How can such activity be a valid and relevant and relevant contribution to undergraduate medical education?
Artists observe, capture and record visual images; when patients describe events, feeling, concerns, they set scenes using their own imagery; in turn, doctors listening to patients’ stories and descriptions form pictures in their own minds.  Looking at paintings and any art installations increases our observational skills and allows us an opportunity to practice the interpretation of visual images.  By engaging with the story behind the picture we try to discover our own reactions and in group discussion we have the opportunity to explore these feelings further.
Our visit to the Newspeak exhibition stimulated important discussion about important aspects of contemporary medicine which may not be encountered elsewhere in the medical curriculum. We may not have been able to understand it all the exhibits but certainly some of the pieces we looked at in the Newspeak exhibition were wonderful. We came away feeling we had risen to the challenge that modern art had presented and as a result expanded our horizons.

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Oncologist Sam Guglani wonders what medical care really means

Care infuses medicine. Well, the word ‘care’ infuses the language of medicine – Healthcare, Intensive Care, Palliative Care, Standard care, Standard of care, Best supportive care, Care Quality Commission. But what actually is medical care?Good medical care perhaps primarily describes the quality delivery of evidence-based therapeutic interventions, for example drugs, operations, scans, anaesthetics, and the organisation of services to permit these. It must also necessarily refer to the judgments around such interventions, that is to say the ethical consideration towards appropriate medicine. A skilfully performed pneumonectomy may not reflect good medical care in a patient dying from advanced lung cancer, for example. It seems reasonable then, to suggest that good medical care demands quality clinical medicine and ethical judgment. That the former requires rational thought may not come as a surprise, but the latter? In fact, contemporary ethics and moral philosophy place reason and rational thought at the core of what it is to make moral judgments and act ethically.
However, schools of ethical thought don’t always agree on what it is that constitutes the basis for moral action in medicine. For example, lying to patients may be considered to be bad because lying is bad in principle, or good if the lying perpetuates good outcomes such as hope, or bad again if the consequences, despite the good outcome of hope, generalise towards the negative, such as an erosion of trust.  Further to disagreeing on the basis for moral arbitration, the centrality of ‘reason’ may be questioned. ‘Care ethics’ gives weight, beyond rational thought, to the place of sympathy, emotional understanding and relationships in informing ethical judgments (Beauchamp and Childress 2001, p. 369)
Jonah Lehrer, in his book ‘The Decisive Moment’, describes the place of emotional understanding in morality:  ‘At its core, moral decision-making is about sympathy. We abhor violence because we know violence hurts. We treat others fairly because we know what it feels like to be treated unfairly. We reject suffering because we can imagine what it’s like to suffer.’ (Lehrer 2009, p 174) He goes on to elaborate on the evidence for emotion having a central role in ethical judgment and paints a very interesting picture in aligning often very rational thinking with clear acts of immorality. Even so, what about this, the idea of sympathetic and compassionate care in medicine?
Well, firstly, it seems as though, unlike the parameters of clinical/ technical care in medicine, compassionate care is harder to measure. Technical care is relatively easily measured and to a certain extent such data form the basis of the new outcomes framework for the NHS.  Healthcare staff in general and doctors in particular recognise this and to a certain extent aspire towards it. For patients and relatives, these data may be more opaque, unless significantly removed from the mean. As such, responsibility for judging, monitoring and delivering technically good care may be readily handed over to the profession.
Compassionate and empathetic care is harder to measure and in many respects therefore it just isn’t. Where currently is the section in our appraisal folders entitled compassion?  Doctors seem to value it much less and indeed we almost feel uncomfortable when discussing it.  Patients and families though, recognise this much more readily and indeed are generally very sensitive barometers of it.  Their assessment is probably more reliable, consistent and reproducible than any parametric measure we might use.  We all know (and can recognise ourselves when we become patients) the health worker who cares.
Such care can be a simple and empirical prompt towards good medicine, through sympathetic imagination: how would we want our family or indeed ourselves to be managed in such a situation? Of course this isn’t enough and is potentially open to abuse. But so is a version of medicine informed simply by good technical skills or good ethical judgment.
Compassionate and sympathetic care is arguably a primary prompt and governing steer for the entirety of good medical care. And it is the platform for engaging patients at times of often profound vulnerability. It might motivate finding the bed, asserting the need, chasing the results, over-booking the clinic, calling the family, developing the service, asking for opinions, clarifying all the evidence, seeking consensus, admitting the uncertainty and withdrawing the treatment. It is antithetical to hubris and necessarily connected to a proper medical professionalism, one founded upon a duty to patients rather than the rights of a privileged set.
How do we teach and foster this care? By recognising its importance – now more than ever in a resource -constrained, exponentially more technical NHS with increasing demand and possibility. By selecting students, training doctors and consultant appointments with this in mind. And, perhaps most challenging, but also most pressing, by decanting it through professional example.

References
Beauchamp, T. and Childress, J. (2001) Principles of Biomedical Ethics, Oxford, Oxford University Press
Lehrer, J. (2009) The Decisive Moment, Edinburgh, Canongate

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