A friend of mine and fellow doctor vented during dinner the other night. He was upset about how much time he had spent over the last week taking care of a particular pregnant patient. She was a person with several health conditions including diabetes and lupus, which were so poorly controlled, that if and when she became pregnant, it would become life threatening to her and a point of major medical concern to her doctors. She was at risk of losing her kidneys, sending catastrophic blood clots to various places in her body and having a baby compromised by the threats of her maternal disease. She was also young, poor and for whatever reason did not give a fuck about any of the aforementioned problems. In any case this was her THIRD pregnancy, despite the fact that she was warned after each of her two previous pregnancies that those should be her last. One may have argued that this is a free country, and that this woman should have been able to do whatever she wanted with her own body, but my friend’s frustration was that her care was far from free. It would be one thing if she just got pregnant, suffered a life-threatening complication and died. But instead, she came to see us irregularly and this obligated us. We were obligated to get her expensive medications that she took sporadically. We were obligated by medical algorithms to order expensive tests and labs almost every week, obligated to call her about missed appointments or squeeze her in when she came in late, obligated to have special multidisciplinary meetings with a room of doctors and nurses to plan her care, obligated to hospitalize her when she became too sick to be outside the hospital. She obligated us to worry about her health when she did not seem to care herself.
The nobility of taking care of the “poor and underserved” can be uncomely and unpleasantly raw in real life. This isn’t taking care of the poor, graceful, articulate single mother with three kids. These are often people with drug addictions, missing teeth, obese frames, tattoos, rude demeanors, frustrating cultural hang-ups, and poor hygiene. These are sometimes people who keep you late at work trying to arrange for their medications to be covered and then don’t pick them up. So it’s not surprising that most people in my program after residency work at a private practice in the suburbs. Intuitively, you might think this is some kind of a career sell-out. You can see these as doctors who have decided to take care of the rich in exchange for Medicaid-free practices and high salaries. You can see these doctors as people who have forsaken their medical school ideals of entering a profession predicated on helping others by not helping the people that need them the most. You might ask, “Are they even fulfilled anymore by their work?” But you’d be wrong. It’s the exact opposite.
Imagine teaching two kinds of classroom. In classroom one, students throw paper airplanes, text on their phones and audibly refer to you as “the bitch” in their whispers. In classroom two, everyone takes notes and faces forward. Actually, the most frustrating part of classroom two is that some of the kids ask way too many questions and ask you to explain things to a level of detail that pushes your own comfort level with the material. Everyone turns in their homework and everyone gets good grades on their tests. Which classroom do you think would be more enjoyable to teach? If you answer classroom one, it’s because you’ve never taught anything and watch too many movies like Dangerous Minds. Teaching classroom one doesn’t make you feel better about being a teacher. If anything, it makes you want to quit teaching and go to medical school.
This brings me to the question that I’ve been considering since my conversation with my friend and since Mitt Romney dropped his 47% sound bite. As doctors, we are beseeched to do our best to care for all patients equally, no matter how we feel about them as people. Some people resent this mandate, but I embrace it because it doesn’t force me to make ethical choices in this respect. At the same time it’s not necessarily personally comforting to do things you don’t believe in. Ultimately, we still have the choice to care for a patient because we want to, or to care for one only because we have to. So my question is this: Why should I want to care for all of my patients? Should there be a fundamental basis for generalized altruism even when there isn’t strong empathy?
The argument for automatic altruism has always been drawn so deeply and so fundamentally that when I try to consider it from a pure place, I feel somewhat ashamed. Generally speaking, the argument for being an altruistic person relies on appeals to the obvious — that helping someone less fortunate should be so obvious the argument for it doesn’t need to be argued (to some extent, I feel like this was the reaction to Romney’s 47% comments). Pushed further, the argument seems to hinge on obligation: that achieved success never occurs in a bubble, that it was either built on a foundation of privilege or that it occurred with aid from altruistic entities — generous people, publicly funded social programs, free school buses etc. In other words, universal altruism is a debt-payment to the benefits of synergism in humanity. I have no problem with this logic, which is also why I also had no problem enjoying the ensuing Facebook lynch mob of Romney post-47% comments. But I have to say this is more of a reasoned argument for altruism then something I innately feel.
Anyway, I’ve contemplated this question on and off over the last few weeks. I’ve gone on long runs with the sole intention of trying to answer this question. And the best I can come up with is that the altruistic sentiment isn’t actually motive-based at all. Perhaps someone decided to give to a cancer charity because of a personal family experience with breast cancer, but whether that person is a giver or not has nothing to do with that motive. I think it’s an internalized quality, formed gradually and amorphously like other aspects of our personalities — like our sense of humor and how loud our voices are in a conversation. Certainly it may be shaped through time by experience, and its application is always motive-based, but its extent is constitutional to the individual. Two different doctors may look at the same patient with feelings of disgust or deep feelings of sympathy. And truly you can declare the second person as more altruistic, more compassionate, but that feeling of altruism or lack thereof isn’t a quality that either doctor controls at that moment. It isn’t a choice, and because of that, no one is wrong.
In reality, all doctors will admit that their patient care is affected by their personal opinions of patients. That potentially leaves the door open for marginal care of marginalized people. And I think the profession itself recognizes this to some degree as we implement standardized procedures and evidenced-based responses for almost all of our medical treatments. Destroying subjectivity might be medicine’s most singular obsession of our time. Some people aren’t sold on this revolution and believe that “the art of medicine” will be lost and that doctors without free reign from insurance companies can’t use their judgment to out-perform statistics and algorithms. My view is a little more cynical. I think of this standardization as a naturally developing safety net for doctors from themselves. As insurance implores our clinics to become more demanding and physicians become more motivated toward work-life balance, our intrinsic altruistic capacity becomes smaller and because there is less potential in the partial to be transcendent and more temptation to be compromising. Because we are only human, our humanity is injected into the Hippocratic oath and the potency of it potentiates the swell of our output. These changes in medicine are much like a pacemaker for a pulse, a pulse that I believe is gradually weakening as we beat forward in time.