By Bill Ventres, M.D., M.A.
For all of my over 30 years in medicine, and not unlike many other clinicians in the United States, the four principles of autonomy, beneficence, nonmaleficence and justice have been the dominant ethical tenets by which I have conducted my practice while attending to my patients’ physical and emotional needs. Into this decision-making mix of ethical practice and clinical medicine, at the interface of biology, psychology, anthropology and spirituality, I have recently also added important perspectives from narrative, feminist, virtue and Latin American ethics as well as points of view on social justice and professionalism. As I am able, I strive to be informed about weighty matters that influence my daily interactions with patients.
Over the years, I have tried to listen to my patients’ concerns with an ear for hearing not only their stories, but also the metaphorical voices by which they communicate these stories, voices that routinely blend sincerely held beliefs with all-too-human emotions. In doing the ethical work of being a medical practitioner, I have sought to help patients and their families manage the challenges of making tough decisions when moral concerns are paramount and personal values differ among stakeholders. I have endeavored to understand how people make sense of modern medical care in light of contemporary ethical standards and such timeless concerns such as confusion, anxiousness and fear.
I am proud of my work—not because I have been universally successful in guiding my patients and their families through the maze of medical decision-making with alacrity, and certainly not because I have managed to avoid those dreaded situations when clinicians and their patients are in direct ethical conflict and resolution seems impossible. Some of my most cherished professional memories have arisen out of my labors to bridge such deep divides. Some of my most painful ones have resulted from my inability to realize that same accomplishment.
I am proud because I have worked very hard over the years to grow a sense of trust in myself vis-à-vis my patients, their loved ones and the communities in which they live. I have learned to present my genuine self in encounters with those in my care, relatively free of the emotional reactivity and professional anxieties that often intruded upon my early work as a family physician. I have developed an accurate evaluation of my knowledge, an honest appreciation of my attitudes (including my biases), and a fair assessment of my clinical skills. I have also come to acknowledge the intentions with which I approach my professional endeavors and nurture the therapeutic relationships that I have cultivated with those who have sought my care.
Simply put, I have worked hard to use self-reflection and self-awareness as tools to bring my authentic, fully human self to my interactions with patients, especially in circumstances involving ethics and ethical decision-making.
Five process-oriented attributes have helped me cultivate my own authenticity in my medical practice:
- Genuine Curiosity. An inquisitiveness reciprocally derived from and supportive of an anthropological gaze, inquiry is what guides much of my work with patients. It supports the use of open-ended questions to explore both everyday clinical presentations and complex ethical dilemmas, whether of technological, informational or epistemological origin. By inviting open reflection on both sides of the stethoscope, this questioning approach helps to relieve me of the emotional burdens I face when challenged by interpersonally “difficult” patients or attempting to navigate conflictual circumstances when the means to moving forward seem unclear.
- Situational Awareness. Being ethically aware means that I systematically attend to the situational milieus that surround these conflictual circumstances in medical practice. Enhancing my ethical awareness means developing my ability to examine the intricate social, psychological and moral dynamics that influence decision-making, including issues not usually considered pertinent to medical ethics such as poverty, classism, racism and other social determinants that adversely affect health. I have forged this awareness through a process of bringing into my conscious mind both other people’s personal histories and my own lived experience; I continue to shape it now, reflecting, ruminating and writing at this very moment.
- Deep Understanding. The willingness to open my mind is a crucial step toward honestly understanding the root causes of ethical conflict. Such an understanding, even a semblance thereof, comes from being able to gain insight into the lives of others and the environments in which they live, as well as acknowledging that this ability is bidirectional. Gaining insight into the creation and manifestation of my own socialization as a clinician is equally as important. As played out in the world of medical ethics, understanding means discerning how suffering and resiliency affect the cognitive, emotional, relational and transcendent qualities on both sides of the decision-making equation.
- Heartfelt Compassion. Compassion is the cognitive, emotional and relational experience that moves me to both recognize and work to reduce other people’s suffering. Compassion is more than just a virtuous precept and much more than an empathetic response. In matters of ethical decision-making, it includes the co-creation of a shared presence among involved stakeholders, one in which uncomfortable thoughts and feelings can be explored, out of which a healing alliance can emerge and from which therapeutic actions can ensue. Compassion is the philosophical, affective and interpersonal touchstone to which I return, day in and day out, as moral concerns both big and small arise in my clinical work.
- Reasoned Humility. Lest I think that I have a lock on the truth, humility is what keeps me honest: my work is conditioned on the reality that in medicine, many factors influence the course and outcomes of the clinical encounters and ethical decision-making I share with patients. Humility offers me a nuanced view of my role in curing illness and promoting health, the capacity to learn from of those whose perspectives and behaviors challenge ideas and attitudes born of my particular professional background, and an openness to appreciate how people assign meaning to their lives.
I imagine that some might refer these attributes as “optimized” traits, virtues to honored and learned through study. I see them instead as ways of knowing and being, habits of thought and feeling that have as their source my day-to-day work, a practice that values person- and people-centeredness in the application of a biologically-based approach to clinical evaluation, diagnosis and management. I also submit such distinctions are beside the point. These attributes of authenticity have helped me attend to both straightforward and complex ethically informed decision-making along the course my own professional path. They have helped me hold my own ideas and emotions with equanimity such that I am better able to approach my patients and their concerns with a non-anxious presence. They have helped me come to terms with my imperfections, idiosyncrasies and professional failures so as to offer those in my care a chance to recognize the worth their own human nature, inclusive of both the frailties and resiliencies with which they present. They have helped me balance the delicate interplay between philosophy and practice, between the culture of medicine and the culture of patients, and between my own sense of self and an understanding of others’.
Are any or all of these attributes of authenticity relevant to other clinicians or clinicians-in-training? That they have so significantly enriched both my professional sense of self and my way with patients, their families and my colleagues, and have helped me develop my own professional identity as a competent, capable and caring family physician, I like to believe they also might be of aid to others as they walk their professional paths. More important, however, is the rituals of reflection to which they speak. I invite others, young and old, learning and learned, to pay attention to the thoughts and feelings that arise in their interactions with patients. I invite them, through a process of awareness, recognition and integration, over time, to build a personal repertoire of applied attributes to help them nurture their own abilities to be considerate and compassionate clinicians.
I strongly suspect that our current methods of teaching ethical and decision-making principles will continue to leave many clinicians and clinicians-in-training struggling as they try to use those principles in practice. I suspect that they will similarly have to find their own sense of authenticity despite, not because of, the standard curricula and models of instruction that are currently in vogue. For authenticity will not automatically appear as a consequence of studying or applying the biomedical sciences, even when combined with such informative and enlightening adjuncts as narrative studies, patient simulations or mindfulness. It will neither arise from having read any number of articles in the literature of philosophy or decision sciences directed at medical practice, nor materialize out of the four principles or other aforementioned theories of ethics when explored as preordained templates to employ rather than as habitually considered concepts from which to gain insight. It will also not result from the codes of conduct that currently define professionalism, absent the emotional intelligence to embrace them.
Authenticity will emerge from the hard work of being curious, growing one’s consciousness of and ability to recognize other peoples’ realities, acknowledging their suffering while simultaneously engaging in activities to ameliorate it and, along the way, being humble in the face of the knowledge that we are all, metaphorically, in the same boat in life. We are all human.
And when it comes time to take down our shingles, whether that be in the not-too-distant future (as in my case) or many years hence (as in the case of younger colleagues), may we all be better clinicians and better human beings for having done this work and, as we were able, brought authenticity to our daily work with patients.
Bill Ventres is the Ben Saltzman, M.D., Distinguished Chair in Rural Family Medicine in the Department of Family and Preventive Medicine at UAMS.