Speaking about dignity

Several years ago, while on the verge of delivering the baby of a seventeen year old, I was taken aback by the number of friends that she had asked to accompany her at the event…an event formerly considered far more private than one in which fifteen or so friends might attend (it was a large delivery room). And speaking of private, the wording and location of her tattoo demonstrated further that private areas had lost their former distinction.

The only practical option at that time was to ignore the crowd and attend to the imminent delivery, and ensure the newborn’s and mother’s safety. I could only hope that everyone had the sense to stay out of the way if an emergency arose. There was no time for instructions, explanations, or crowd control.

All turned out well. The teenager delivered a healthy baby, and I stayed on duty on labor and delivery. Our paths never crossed again, but I have thought of that brief encounter many times over the ensuing years.

When I think of the struggle to protect human dignity from innumerable external onslaughts, I think of battles such as those over public policy, technology, and cultural trends. But what I have not seen well is how the struggle extends to the hospital bedside, when the most pressing threat is from the patient herself. How much ought we, as physicians, while comforting and testing and treating and advising, take a firm stand and square off with patients, to explain why they themselves are the biggest threat to their own dignity?

Such a stance doesn’t reconcile easily with the current notions of patient autonomy. A sense of patriarchy within the medical profession comes rushing back, and it would be foolish to claim that patriarchy was always done well.

I am hard pressed to think of examples of seeing a physician address such concerns, unless couched in biomedical terms. It is difficult to know which of the numerous behaviors a patient exhibits falls, ethically and practically, within the realm of the practice of medicine. What I can say, with the advantage of some years, is that with the transformation of medicine to an autonomy-centered realm, we have lost sight of the most important defender of each person’s human dignity: the person herself. If we are to claim our dedication to a patient’s dignity, then should we not be more willing to speak the truth about it—even if it shines a light on an area the patient would rather not be seen?

“Grace” as a principle for the medical profession

The other day I was speaking to another physician about grace. This was at church, not surprisingly, but later I wondered why such discussions don’t occur in the hospital. When I recall the more remarkable physician-patient encounters I have seen, the word that comes to mind as the common theme is grace.

We can see it in the physician calmly and pleasantly treating the irascible and demanding patient in the darkest, bone-wearying moments of a long shift. We can see it in the compassionate but direct explanation of the direst of news to a frightened patient. We can see it in the happy celebration of a beautiful newborn to a relieved and exhausted mother. And we can see it in the bedside comfort given to a dying patient in those quiet moments when time slows down.

If one agrees that grace exists, then he ought to ponder from where we get it. For me it is clear: grace is God’s gift of Himself to us. We can speak theologically about godliness, but grace is a more specific and tangible manifestation of what that is. In medical ethics we have the well-known and practical principles of beneficence, non-maleficence, justice, and autonomy. But these describe the nature of what we should do. It is time, I propose, to speak of what we should be.

If we don’t speak of such things, then we ought to hope that they are at least manifest in our comportment, words, and deeds. Yet in our postmodern age, when society has abandoned such discussions, the mere mention of grace, something deeply profound, might strike that raw nerve in every man that fires the memory of something far greater than we’ve actually become. Or for many, want to become. And if the field of medical ethics is to move beyond an artful sophistry that produces philosophical justifications for our basest needs; if the profession of medicine is going to regain the moral standing in society for which it was created, then our medical schools must teach the highest principles. Like the magnificent blessing of grace we have received, that speaks to more than the nature of our acts, but to the nature of our being.

A different type of virtue

Last August while I was leading a faculty discussion of how emerging adults (a sociological term for those in the 18-29 age group) had been found to think about morality in a sociological study and how to respond as we interact with students, I had supported that proposal by David Setran and Chris Kiesling in their book Spiritual Formation in Emerging Adults that using a virtue ethics approach can be very effective. One of the faculty members in the discussion countered that virtue ethics was based on a Greek way of thinking that was not in line with biblical thought. I tried to explain that what I understood them to be saying and what I was supporting was not a complete acceptance of everything in Aristotelian virtue ethics, but that some of the ideas in that way of thinking did fit with a Christian view of spiritual and moral formation and could be a positive way to approach current students regarding ethics and morality. I’m not sure he was convinced.

Recently I have been reading N.T. Wright’s book After You Believe: Why Christian Character Matters that was recommended to me by fellow Trinity Masters in Bioethics grad Luann Van Campen. Wright expresses what I was trying to say much better than I did and in much more depth. Regarding the relationship of Christian virtue ethics to Aristotelian virtue ethics he sees that both embrace the truth that virtue has to do with the qualities that led to fulfillment of the telos or end which is intended for us as human beings and involves a process of practicing virtues in our lives so that they become second nature to us. The difference is that the telos is seen differently and for Christians the process is one that is not one of purely individual effort, but is part of a transformation empowered by God and done within the Christian community.

The difference in telos is significant. For Aristotle it was eudaimonia which can be translated happiness or human flourishing. His telos was very much centered in the self and was achieved by personal effort in pursuing the virtues. For Christians the telos is one that is determined by God and it has to do with becoming completed human beings who reflect the image of God as we were intended in the beginning before the fall and as we will carry out in the roles God created us for in the new earth after all things are restored. For us the process is one that is dependent on the grace of God who through Jesus death and resurrection has made our transformation into completed human bearers of God’s image possible and is empowered by the working of the Holy Spirit in our lives. It leads to humility before God as creatures serving our creator and not proud self-made Greek heroes.

This understanding of Christian virtue is worth pursuing and passing on to our students.

An Ethics of Complexity

As a long-time member of the military medical community, this article caught my eye: “1 in 5 Army hospital leaders suspended in 2 years: What’s behind the discipline?”

The reasons for these suspensions are known only at the highest level of command, and I suspect that there they will remain. But such a circumstance is significant, and we must ask for the reasons, to determine if they are relevant to all of us in the healthcare profession, and not just to our military medical leaders.

In my decades-long experience with dozens of hospital commanders I have found that they are professionals of the highest integrity, dedication, and ability. They achieved their roles after years of challenging jobs, most certainly in the trying times since 9/11. They have ample leadership experience before being selected as hospital commanders, and the scrutiny and accountability they faced to get there is testimony to their abilities. It doesn’t take much of a slip to put one out of the running for hospital command.

But this level of scrutiny has become magnified in our age of technology and instant communications. Within large organizations vast amounts of information flow up and down the chain of command at the speed of light through fiber optic cables. Data is tracked, analyzed, and reported, requirements are created, and information is sought, gathered, pushed, scrutinized, speculated on, and multiplied. One effect is to have leaders constantly under surveillance, not from any mal intent, but from the pressures to succeed and avoid failure. When formerly errors might have been overlooked, found late, or simply not seen as errors, they now can be seen instantly and broadcast far and wide. If “to err is human,” there is diminishing room to be human.

In a small example–a few years ago I became the physician representative for my hospital’s implementation of an organization-wide initiative. The program was sound in concept, useful in practice, and beneficial to medical staff and patients alike.

The problem came as we watched the organization inch its way toward implementation. Nobody objected to the concept and it’s utility. Leaders and staff were simply too preoccupied with other demands. I as well did not pursue all the potential uses of the system simply because I already had my hands, and mind, fully occupied with everything else I had to know to practice medicine and use the existing computer systems.

I realized that if I, who am sought out as someone who can work through the complexities of technology, is at his limits in what he can attend to, then the organization is unlikely to get much more from either its busy leaders, or from physicians who have less patience or facility with the demands of technology.

I doubt that anyone can escape this phenomenon, for the complexity and scrutiny exist at any level, albeit in varying forms. We cannot afford to ignore it or simply acquiesce, for if the best among us fall, then the rest of are less likely to even try.

This steadily increasing complexity contrasts with a passage I recently re-read in Richard Swenson’s book, Letters to a Young Doctor: “There is no more beautiful sight in the world than that of a kindly, efficient doctor engaged in the examination of the body of a fellow human being.”

I wonder if such a passage makes sense to many people today. But what struck me is that part of the beauty was a simplicity unencumbered by the distractions of modernity. We decry “technology” but can’t separate ourselves from it. It’s not the technology itself from which we wish to be liberated, but the complexity that it brings.

What we need, then, is an “ethics of complexity” within the healthcare profession. This would measure the modern trends and pressures on and within healthcare by their tendency to create complexity, and thereby overburden and distract both healthcare professional and patient from the pure and ultimate goal of establishing a lasting therapeutic relationship, or covenant, as described by William May. The goal, then, of organizations, leaders, staff, and even patients, would be to identify complexity when it arises, and modify systems to mitigate it. I only hope that this one additional consideration doesn’t just add to the problem of managing healthcare.

An “ethics of complexity” would be grounded in the idea that mankind, in all his abilities to create and adapt, still has a limit…and that to push this limit is to begin to sacrifice something critical to our humanity. For those physicians who still sense the beauty of the doctor-patient relationship, such a recognition is overdue.

On our increasingly medicated children

A shocking (to me) report from the National Center for Health Statistics: 7.5% of children between the ages of six and seventeen used prescription medications for emotional and behavioral problems in the last six months. The numbers are even higher among certain subgroups, such as children with Medicaid insurance, children from families whose income is below 100% of the federal poverty level, and males (10% of males aged 12-17!!). The report states that, “Over the past 2 decades, the use of medication to treat mental health problems has increased substantially among all school-aged children and in most subgroups of children.”

Why? 

Of course there is no way to answer that question from these data, but the report set me to wondering at the cause. Why so many, and why is it increasing? Is the prevalence of children with emotional and behavioral problems actually that high? Are there more kids with these problems now than previously? Or have we just gotten better at diagnosing them? Or is there a chance that we are overdiagnosing? Is this a case of pharmaceutical companies successfully creating ever-larger markets for their wares?

Or is our society becoming so maladjusted to the normal rhythms of childhood life, so out-of-sync with normal patterns of human flourishing, that we increasingly need to medicate our children (and ourselves) so that they can function and fit in to the environment in which they find themselves?

Human Flourishing: It’s in the Eye of the Beholder


In my last blog, on the eve of presenting the fruit of a year and a half study on human flourishing from a biblical perspective at CBHD’s conference “Health and Human Flourishing,” I shared some insights gained from that study into the role of suffering in human flourishing. This week I would like to share one other insight gleaned from the biblical perspectives on flourishing before moving on to other topics; and that is, how flourishing is to be defined or evaluated.

One approach to the definition of human flourishing was developed by Carol Ryff (1989) who systematized various views of optimal human functioning into six dimensions of psychological human well-being: purpose in life, environmental mastery, autonomy, personal growth, positive relations with others, and self-acceptance. To these six psychological dimensions of well-being Corey Keyes added five dimensions of social well-being–social coherence, social actualization, social integration, social acceptance, and social contribution—to yield a composite and complete measure of the flourishing life—a life that is filled with positive emotions and is functioning well psychologically and socially.

An examination of Scripture, however, yields an alternative insight: human flourishing is not by human definition or design, but is a manifestation of God’s divine purposes and plans for our lives. Human flourishing, like beauty, is in the eyes of the beholder, and the only proper beholder is God. As the source and telos of human flourishing, He is the only one with a proper perspective, who knows the end from the beginning, who can understand and anticipate all the consequences of our valiant, yet feeble attempts to flourish. Human flourishing, therefore, is to be evaluated and judged, not from an anthropocentric perspective, but from a theocentric or Kingdom perspective. As His creatures, and because human flourishing is an intentional act of God in blessing his human creatures, flourishing must be defined and understood from His perspective. From that theocentric vantage point flourishing is not measured by long-life, material prosperity, or even shalom as personal well-being, but by being set apart to accomplish the good deeds He has planned for us in this world. It is discovered in walking with God and is measured not by material possessions or visual analog scales, but by righteousness as a relational concept, the fruit of which is a harvest of gratitude and even greater righteousness, the resources for which are provided by God Himself. Such godly favor does not necessarily bring a life of prosperity and ease, as we discovered in my last post, but often of even greater challenges, as witnessed in the lives of those who were said to have found such favor (Noah: Gen 6: 8-9; Moses: Ex 33: 17; Mary: Lk 1: 30). Hence, flourishing from the perspective of God may not be consistent with what we would envision and may at times be incongruent with what we desire. For just as with the thoughts and ways of God are not ours, the plans and purposes of God for our flourishing transcend our objective and subjective limitations.

If true human flourishing is an intentional act of God, is contingent upon a relationship with God, and is defined by God’s purposes and plans for humankind, this raises the question: can humans flourish apart from God? This question can be answered affirmatively with qualifications: all human flourishing is by the gifts and grace of God who sends rain on the righteous and unrighteous alike, and who is kind to ungrateful and evil men, which can be all of us at times. Human flourishing apart from relationship with the source of that flourishing—human flourishing that is perceived to be by one’s own hand, and not the hand of God—is a testimony to the incredible grace and glory of our Creator. But flourishing without a proper heart orientation toward both God and material possessions is ultimately momentary and transient, bearing no lasting fruit. Flourishing that is enduring is oriented to God, His glory, and His Kingdom.

Human nature, health, and human flourishing

The past few days, I have been attending the Center for Bioethics and Human Dignity’s 20th annual conference, entitled “Health and Human Flourishing,” and the following ramblings are a result of some good speakers and good conversations with fellow attendees.

Two essential truths: First, there is a “given” or normative human nature, and Jesus Christ is the normative human; second, he is the paradigm for human flourishing. By following him (including into suffering), becoming like him, and taking on the fruits of the Spirit, we become more truly human and discover true satisfaction and human flourishing.

Denying these two essential truths leads directly away from human flourishing. The first truth is that Jesus provides the norm for human nature. But the human enhancement project does not acknowledge a normative human nature, instead seeing it as malleable, thus open to tinkering in attempts to improve it (“take control of our evolution”). This naturally leads to dissatisfaction with our current state because we seek endlessly for the next better thing — a dissatisfaction that is the opposite of flourishing.

The second truth is that Jesus is the paradigm for human flourishing. But in a culture with a materialist world view (i.e., matter is all that is and all that matters), it is natural that “human flourishing” will be identified with “physical health.” Add to this the WHO definition of health as “a complete state of physical, mental, and social well-being, and not merely the absence of disease or infirmity,” and the inevitable result of the pursuit of happiness and human flourishing will be the increasing medicalization of all spheres of life. But while health is an important contributor to human flourishing, it is not the same thing as human flourishing, and flourishing can even exist in its absence. In our culture’s rush to turn every event in life into a medical incident we keep pressing the health button in the hope that human flourishing will come out; but the only thing that comes out is more illness, more technology, more dissatisfaction — and less flourishing.

 

One Welfare, Part 2

Last week, I mentioned the framework of “One Welfare” that has been used to link the interconnected concepts of human and animal well-being within the ecology and societal contexts we share on this Earth. I generally find this to be a workable model for discussion, one that safely incorporates disparate groups under one large umbrella, and am cautiously optimistic that it will provide some success. I never seem to go past a level of guardedness when I talk about these issues because the train goes off the rails so often when it comes to animal welfare, or even human or societal welfare for that matter, but particularly when all of them are placed into the same arena, where they must, of necessity, often compete. Are we to assume we are all given an equal “voice” (particularly since animals cannot articulate theirs)?

And that IS the caution. It is well and good to speak of the strong relationship that welfare of animals shares with human flourishing; cruelty to animals and wanton misuse of the resources they provide damage our culture and our souls. My cardiologist friend and Trinity bioethics alumnus, Dr. Jay Hollman, has committed a lot of thought to (and written on) the impact on the general overall and (specifically) cardiovascular health of human beings, as well as the environment and climate, that comes from our consumption of meat. Our excesses don’t just negatively impact the welfare of animals and the planet but our own as well. But what can we do, in a tangible way, to change that? Are we to become vegetarians or vegans? A look at a great number of people in the world, who I consider to be excellent stewards of the livestock resources that the Lord provides, doesn’t seem to suggest that this is the only “moral” answer, and it certainly won’t convince the meat-hungry developing world to change their collective mind. Animals provide much of our food and clothing and our companionship and pleasure and (in times past) our transportation. We have vested interests in keeping them in good condition and spirits; our welfare really DOES depend upon theirs.

But sometimes there seems no way to make “One Welfare” possible. I remember a story (based on a real account) in a Vilhelm Moberg novel of Swedish immigrants that spoke of a father and daughter caught in a sudden Minnesota snowstorm as they traveled with their ox. Faced with death from hypothermia, the father slaughtered the ox, and the humans huddled within the warm carcass of the animal that had served them so fully over its life—and beyond, and they survived. Human welfare trumped that of the animal, and most would feel that the choice to kill the animal was an ethical one. But there was a winner and a loser, and human beings were the winners.

Dallas Willard, in the modern classic “Spirit of the Disciplines”, places the position of human beings into proper context. He describes the “nature of our conscious life that separates us from other creatures.” In the Genesis account of the appearance of human beings:
“…our creation process is strikingly different from all that preceded…Humans are made to govern—to rule over the zoological realm as God rules over all things. The imago Dei, the likeness to God, consists, accordingly, of all those powers and activities required for fulfilling this job description, this rule to which we were appointed. And of course it includes the very rule itself.”
Yes we are indeed rulers, and rulers always hold sway when interests are in conflict. But Willard goes on to say:
“But in light of the immensity of the task, God also gave humankind another very important ability—the ability to live in right relationships to God and to other human beings. Only in those relationships, in the communication needed to keep those relationships healthy and thriving, could everything be found that was required to succeed at the work assigned.
It is still true today that the greatest and most admirable power of humans over animals is not found in those who slaughter or abuse them, but in those who can govern their behavior by speaking to them—by communicating with them…Anyone with a gun can blow the head off a cobra, but to charm it into quiescence with a flute is quite another thing.”

So the notion of “One Welfare” reminds us that this dominion, this “trump” status, is a nuanced position. We have power, but that power in endowed with the mark of our Creator. It is our very difference in essence from the rest of God’s creation that lets us seek out “right relationships” with God and other human beings (and, if I may add to Willard, to God’s very creation). Seeking to meet all the wants and desires of human beings is not in the best interest of human and societal welfare and flourishing, as the excesses of the modern world reveal with increasing clarity. There are consequences, tangible, psychic and spiritual, when we ignore the welfare of animals in domestication and throughout the ecosystem. “One Welfare” cannot exist apart from right anthropology and an understanding that the fearsome, wonderful role we have to communicate the love and justice of God over all His creation is ours alone, and that our welfare is never tangential to the welfare of anything else within it.