A Vocation to Heal: On Medicine and Morality
A U. S. of modern A. where the State is not a team or a code, but a sort of sloppy intersection of desires and fears, where the only public consensus a boy must surrender to is the acknowledged primacy of straight-line pursuing this flat and short-sighted idea of personal happiness.
– David Foster Wallace, Infinite Jest
Théobald Chartran, Laennec Examines a Consumptive Patient with a Stethoscope in front of his Students at the Necker Hospital, 1816. Université de la Sorbonne, Paris
It’s hard to imagine a time when popular music spoke to us on any level deeper than the skin. But in the 1980s we were blessed with a precious few years when The Smiths, the famed English rock band, mixed dulcet tones with sharply perceptive lyrics and all sorts of oddities into a unique strain of hypnotic poetry. In one of my favorite tracks, lead vocalist Morrisey laments, “I was happy in the haze of a drunken hour / But heaven knows I’m miserable now / I was looking for a job and then I found a job / And heaven knows I’m miserable now.”
The writers of that song, Morrisey and Johnny Marr, reformulate a truth long understood but oft forgotten: the things we want, which may even make us momentarily happy, often really make us miserable. This truth is also central to St. Augustine’s fourth-century autobiography, Confessions. Augustine recognized that coming to understand the fallibility of our personal desires is an essential part of growing up. Letting our wants and whims chart the course of our life is not only egocentric, but it’s much more likely to lead us to despair than joy or self-actualization.
Of all walks of life, few ought to be more other-centered than medicine. Most people assume that healthcare workers act totally in the interest of their patients. Physicians, a profession with a strong group identity, expect the same of themselves and their peers. Perhaps the most important of all medical principles is that of beneficence, defined as the imperative to always act in the patient’s best interest. Medical schools uphold this virtue, listing it in their admissions criteria as part of their fifteen “Core Competencies.” There is room for all sorts of different people in medicine, but the profession is defined by a strong unifying ethic, an ethic that has existed at least since classical Greece. In the fifth century B.C., the Greek physician Hippocrates revolutionized the field by asserting that medicine is a moral practice, one that necessitates a covenant between physician and patient guaranteed by the transcending Divine. This heritage formed the foundation for the work of later physicians, such as the eighteenth-century Englishman Thomas Percival, who is credited by the American Medical Association as the primary influence on their own Code of Medical Ethics (1847).
In the fall of 2020, I interviewed around twenty medical students for an ongoing project I’m pursuing as part of the Humanities program at my medical college. The aim of this project was to better understand students’ goals for their careers and personal lives. The thought was that if medical professionals can understand what students want in life, then we might be able to better understand why so many feel they are not achieving those goals, as evidenced by the frightening rates of burnout and depression among medical students and doctors. When I asked students how they envisioned a successful life, their answers shocked me.
The responses were surprisingly focused not on desires for family or money or even career advancement, but rather on a desire to feel good. Responses concerning positive emotions and personal goals, words like “joy,” “fulfillment,” and “happiness,” dominated overall responses. This trend became even more prominent when looking at the first few responses for each participant (what I designated “high salience” responses). Amongst high salience responses, these words accounted for nearly half of the total. For comparison, responses concerning family and relationships accounted for about 20%, career-related responses made up less than 10%, only one student mentioned matters of faith, and not a single response focused on altruism.
The existentialist philosopher Søren Kierkegaard called a life oriented toward the pursuit of pleasures the “aesthetic sphere of existence.” This occupied the lowest of three spheres, one destined to dissatisfy and give way to the higher “ethical” and “religious” spheres. When happiness is the goal, one is more likely to experience depression. This may be partly why mental illness is such a colossal problem in medical schools, with more than one in four students experiencing depression and suicidal ideation topping 11%. If students prioritize happiness, then why are we failing so miserably to achieve it?
Perhaps it is because happiness is an unrealistic goal. Drawing on the work of prominent psychologists like Viktor Frankl and Martin Seligman, Emily Esfahani Smith wrote in The Atlantic that happiness “is about feeling good . . . [it is] defined by lack of stress or worry . . . [and] associated with selfish behavior.” Happiness, in an evolutionary sense, is all about “drive reduction.” But happiness is unsustainable, as “positive affect and feelings of pleasure are fleeting.”
There is little that is similar between Smith’s image of happiness and the realities of the medical profession. Life in medicine is full of both great worries and great meaning, requires the subduing of present desires for the long term good, and is relational, not egocentric. We seem to have forgotten not only that ancient truth about temporary desires leading to misery, but also our very identity as physicians. To a certain extent, this phenomenon is hardly surprising. In their pursuit of happiness, Americans have long prioritized individualism, in the form of self-reliance and self-determination. No matter the apparent cohesiveness in medicine’s subculture, no code or oath can stand against it, at least not while the problem remains insidious and unnamed.
However, over sixty years ago, Walker Percy, M.D (1916-1990) diagnosed this very disorder. While Percy is best-known as a novelist, he began as a student of science, eventually earning his medical degree from the prestigious College of Physicians and Surgeons at Columbia University. After contracting tuberculosis during his residency at New York’s Bellevue Hospital, Percy spent an extended period of recuperation in the Adirondack Mountains, where he read widely, began attending Mass, and decided to quit medicine. Though he never completed his medical training, he proved his diagnostic excellence in his subsequent career as a writer and observer of the human condition.
His most famous novel, The Moviegoer (1961), was almost entirely concerned with man’s quest for happiness. His protagonist, Binx Bolling, by all accounts is living the American dream in one of the most prosperous periods of American, if not human, history. He has a good job, a house in the suburbs, plenty of money, time to enjoy himself, and lots of romantic company. However, Binx is in deep despair, stuck in the “malaise” of his life. His life is so empty of meaning that he feels most real when watching films at the local cinema, which has a marquee that reads “Where Happiness Costs So Little.” In Lost in the Cosmos (1983), Percy describes this condition of malaise in the midst of material prosperity as a loss of identity, that “despite great scientific and technological advances, man has not the faintest idea of who he is or what he is doing.” These writings dismantle the ubiquitous American belief that material success and the eternal march of progress necessarily bring with them better days and better people, a toxic ideology that has permeated much more of our culture beyond that of medicine. In fact, as Percy argues in Lost in the Cosmos, progress only further distances men from themselves, as increasing knowledge of the universe reveals nothing about man’s purpose. As progress marches onward, the self increasingly becomes isolated from the world it inhabits, “a space-bound ghost which roams the very Cosmos it understands perfectly.”
Walker Percy’s writings convey, above all, a sense of loss. Just as one purchases tickets at a theater marquee, Americans have bought pleasure, but at the steep price of reality itself. That reality is our authentic identity, our place in our communities, our heritage. What is worse is that we are mostly unaware of this deracination, like Binx, who spends much of The Moviegoer struggling to understand what his existential “search” is even for. Paradoxically, the object of that search is not some personal mountain of spiritual actualization, but instead a pivoting of the gaze away from the subjective self and toward the rooted reality outside the self. Only then can Binx, similarly to Percy in his own painful search for meaning and struggles with despair, begin to heal.
We in medicine must also remember our heritage, our almost sacred role as benevolent healers, guardians of human dignity, and co-bearers of society’s suffering. This does not mean that we cannot care for our own wellness. Rather, we as physicians must acknowledge that our wellness comes from embracing our authentic identity, not from a pursuit of individual happiness. Recent years have laid bare the failure of that deal with the devil, both in society at large but even more sharply in our field. The great challenge that lies before us is not so much to heal humanity or to heal ourselves, but rather a renewal of the search for our lost communion.
Michael Eamonn McCarthy is a native of Delaware County, Pennsylvania and a recent graduate of the University of Pennsylvania. He currently studies medicine at Sidney Kimmel Medical College in Philadelphia.