Oh Henry
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It is a moral imperative that EPs become philosophers, asking the critical questions of why we do what we do.

In his 1981 magnum opus After Virtue, Alasdair MacIntyre – who may be our greatest living philosopher – challenges us to look for a new paradigm to examine our life’s work and accomplishments. He argues that sustainable understanding of morality is based neither on Kant’s deontology (rule-based ethics) nor on Mill’s utilitarianism (the greatest good for the greatest number) nor on a social contract (“go along to get along”). Instead, MacIntyre states that a “correct understanding” of morality and ethics should be based on the Aristotelian concept of a telos, the principle that there exists a final cause or meaning. This telos, whatever it may be, should frame our discussion and drive the analysis of our actions. Moral right and wrongness can only be judged by having the desired end in mind. This understanding of moral foundation has been lost as the “modern era” has advanced; there seems no room in science for a telos.

The four causes in Aristotelian analysis – material, formal, efficient and final – have given way to the two principles of modern science: “what is it made of” and “what does it do”. By losing Aristotle’s “final cause,” – understanding the purpose or end that a thing is supposed to serve – we have built for ourselves a secular societal prison. Living a good life nevertheless depends on a recognizable or understandable meaning. This cannot be escaped.

We cannot turn to either simple secular humanism or Mr. MacIntyre to direct the moral basis of the current healthcare debate we deserve to have. Science alone will not save us either, for science is not moral or immoral; it is amoral. The engineers of the gas chambers at Dachau were perfectly good engineers. Their science was fine. They just lacked moral telos to ask the final analysis of their work or product. We cannot escape the comparison: blood gas results don’t tell you why you got a blood gas on a demented 92-year-old in whom pneumonia was probably not a bad thing.

With the majority of our healthcare funds now going to marginal benefit drugs/testing and hospitalization dollars going to end-of-life patients, we cannot go another generation without waging this philosophical debate. As we sit looking into the abyss of a $14.5 trillion deficit from which our children and grandchildren will never recover, we need to insist that our leaders start to lead on this, the largest moral issue of our time. Real intellectual life can be sustained through these new dark ages, which are already upon us. But, as St. Benedict observed at the fall of the Roman empire, it will take men and women with a moral compass, with a true north.

We speak of this topic (when we bother to have any intellectual speech at all) as if healthcare was a national question. I reject this categorically. Former U.S. Speaker of the House Tip O’Neill once said that “All politics is local.” I believe that all healthcare is local as well; one person, one death. There are so many ways we could distribute healthcare resources and provide multiple national laboratories to test results. Miami spends about 2.5 times per person in the Medicare program than is spent in Minneapolis. Why? Maybe there are cultural differences that need to be overcome. The Canadians administer their healthcare at the provincial level; doctors in British Columbia and Nova Scotia do not get paid the same. Testing and therapeutic decisions may differ from province to province. Let’s start thinking outside the box we’ve built for ourselves.

My final appeal is to change the rhetoric in the healthcare forum. I have taught in 14 countries. News flash: there are no “death panels” in Singapore or Britain. What they have is more of a shared concept of the cycle of life. We are born, we live, we die. If someone has a different analysis of this, let me know. J. G. Hamann, the famous critic of the enlightenment, once wrote “Language is the mother of reason and its revelation, its alpha and omega.” Amen. We have allowed pundits on both the right and the left – most of whom wouldn’t know science from their butt – to hijack this needed discussion for their own purposes. We have allowed people who have never cared for, let alone ministered to the dying, to tell us what to do.

Lexicography and grammar are the instruments of the culture. I propose we take them back. Neither the pin-head academics or the news pundits have any more right to lead this debate than we. We need to be guided by Aristotle, who asked us not just how, but heaven forbid, why. Momento mori.

Post Script – We have now entered into the second major area of debate. The last two months covered the question of maturing the career. This debate, which I hope catches the interest of our readers, will ask what career that will be and how it will fit into the larger picture of improving societal life in this country. 

 

Comments   

# Thank youWithheld 2011-03-24 02:29
Dr. Henry is right about the imperative of each physician to closely examine the reasons for testing the patient in front of them. I, for one, am sick from testing and treating terminal or near-terminal patients because they are "full code" or there is no designated decision-maker. We need to look at what we do and make the hard decisions to provide comfort and care for the dying, and not more MRI's.
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# GruntIatros 2011-03-24 04:08
Once again, I am stunned by the depth of Dr. Henry's knowledge and logic. He is absolutely right in this argument. We must remember that we are all mortal, that we too will pass on in our time. No one is going to live forever, and who wants to, when confined to bed, unable to know night from day, sustained only by a small plastic tube?

But there is one proposition of great import: how to get a public that feels entitled to everything for nothing to realize that there are limits, both monetary and moral, to what the house of medicine can do to prolong life. The telos is indeed what is missing in all of the arguments that I have heard, with the exception of some recognizing the lack of that principle in end-of-life arguments.

O mores! O tempora!
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# BostonERdoc 2011-03-25 06:56
Part of the problem is the lack of the PMD or oncologist discussing hospice and/or end of life care. I would be a well off man had I $100 for every individual presenting in extremis to the ER without any one-any one--having any meaningful discussion on advanced directives. That leaves me the breaker of bad news and family members dont want to hear this news at the time of emergency so tube I do or crunch the cage we do.
I also blame the fact that most americans never see a dead body until middle age so death is completely foreign to them. Used to be most people buried a wife or husband or two and a couple of kids and death was well part of the grind of life.
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# drug abuseTom Faulhaber 2011-04-04 08:48
Hi Greg,
Since you are tackling difficult subjects how about the #1 most commonly abused drug (prescription). I have seen a disturbing trend coming from the larger hospitals with constant Press Ganey or other scores of using opiates for the masses for any minor problem. We are a smaller hospital with our docs living and interacting in the community. We have had several big city docs come to our ER and have noticed opiates for all seems to be their mantra. When did the ER become the dealer of choice to get vicodin or similar?
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# ** 2011-04-05 23:26
I plan on becoming a ripe centenarian. Why wouldn't you?
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# EDL 2011-04-06 19:40
With the increase in life expectancy continuing to climb, I am preparing to seek the world record of 200 years. I hope medical advances will enable me to enjoy it to the fullest.
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# Mario C. Villegas, MD 2011-04-07 08:46
Didn't we already see, at the turn of the 19th century, that training doctors on the job with little or no formal training, did not work? Even the "bare foot physician" program in China, I believe, was a failure; and they didn't even have lawyers, let alone malpractice legistration. Why should I be mandated to train, supervice, and activly participate in dumbing down and ultimately destroying our profession. Why? To injure that everyone has "access to care". Really? This is the ticket? Please you have the ear and respect of many in . Please clarify this issue, only the way you can.
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