By Dr. Peter Browning
Professor of Philosophy and Religion
Years ago I received a rare opportunity for an academic. I got to share my ideas about medical ethics in “the real world” with a group of physicians, nurses and hospital administrators. I will confess I was intimidated. As a person who spends his time primarily with college students, I don’t interact regularly with medical professionals. I see their vocation from a distance. Every fall my course “Ethical Issues in Health Care” trots out exactly what the title promises: issues. We look at human experimentation; euthanasia and physician-assisted suicide; debates over sexual ethics such as birth control, sex education and abortion; and quandaries related to organ transplantation, genetic intervention, and the funding and distribution of healthcare.
My interaction with the group of people offering medical care demonstrated that the biggest moral challenge in hospitals isn’t primarily associated with the issues discussed in my class. It is much more about the character of individual medical professionals and the quality of community in the hospital system itself. When I told those gathered about the character ethics of Stanley Hauerwas, the leading Christian ethicist in America, they nodded in approval. In the 1970s Hauerwas came onto the scene with a simple message: the moral life is not primarily about quandaries. In spite of the way that most universities teach ethics today with survey courses featuring hot topics to be debated, Hauerwas was convinced that our deepest moral reflection isn’t about actions and decisions in the face of tough circumstances; rather, it is about our character or “the ethics of virtue.” What kind of persons are we on a daily basis? What are the character traits or virtues we embody? And what form of community is required to nurture us to become better people?
At one point in the conversation a medical professional remembered when a colleague was asked to leave the medical setting where they were working. At the time, the reason for that request was novel. This person was not failing to show up to work or stealing. There was nothing wrong with the person’s competence as a professional. This individual was simply rude, hurtful and insensitive to colleagues. The leadership finally put its foot down and said “enough!” But that act changed the culture of the organization. It sent a message: “We want to be a community. We want to treat not only our patients with compassion and respect, but one another as well.”
We so often think that the biggest issues in the moral life are occasional crises demanding an immediate answer (e.g. “Should we pull the plug?”). But it turns out that the most important moral issues are often mundane. They are the presence or absence of day-to-day habits such as caring, civility, honesty and a concern for the community.
As Dr. Marty Makary discusses in his book Unaccountable: What Hospitals Won’t Tell You and How Transparency Can Revolutionize Health Care, hospitals that have a rich sense of community and which nurture practices of teamwork, honesty, and mutual accountability and support actually do far better for their patients. When Makary and a team organized the “Hopkins Safety Culture Study” with 60 U.S. hospitals, they discovered a correlation between the level of teamwork in a given hospital and its infection rates and health results for the patients. When a culture of teamwork is pervasive, infection rates are low and positive patient outcomes are high.
Honesty also pays off. When the state of New York decided to require hospitals to post their hospital-based death rates for cardiac surgeries back in 1989, individual hospital death rates for heart surgery ranged from 1 to 18%. When hospitals had to be transparent about the results of their care, they got better. Poorly performing surgeons were removed and/or retrained. The patients won.
Finally, developing practices of mutual accountability and support matter. When Dr. Makary speaks at physician conferences, he regularly asks the audience members to indicate whether they know someone who should not be practicing medicine. Typically, every hand goes up. Dr. Makary cites a 2009 study, which found that “31% of doctors are burned out.” He points to another study of 8,000 physicians by Drs. Charles Balch and Julie Freischlag that reveals “no fewer than 40 percent were burned out, 30 percent screened positive for symptoms of depression, and 28 percent had mental-quality-of-life scores below the general population norm.” When physicians feel more support, get help for their addictions or personal challenges and are given work schedules more conducive to a healthy lifestyle, they are more effective.
There are complex ethical issues in medicine. They require sophisticated analysis and interdisciplinary dialogue often over many years. But culture makes a difference and the “ethics of virtue” counts. When hospitals are communities of character, patients thrive—and so do the medical professionals. Indeed, the ethical tradition, which asks about our character, a tradition deeply expressed within the disciplines of the humanities, may be nothing short of life-saving.