Bernat, James L. MD
The psychiatrist Ralph Crawshaw is best known to medical audiences as an essayist, movie reviewer for Pharos, and a leader of innovative health policy in his home state of Oregon. Compassion's Way: A Doctor's Quest into the Soul of Medicine is an anthology of his writings published over the past three decades. It offers a sampler of Crawshaw's commentaries, stories, travelogs, observations, criticisms, and recommendations stemming from his rich half-century as a practicing psychiatrist, educator, and humanist.
Crawshaw's unifying theme is compassion but his 83 essays encompass a diverse group of topics all related to improving physicians' care of their patients. In addition to discussing the dimensions of compassion, he considers mercy, suffering, courage, the patient-physician relationship, truth-telling, communication, the humanities, professional conduct, the Hippocratic Oath, problems of technology, duties of physicians, and health care reform. Crawshaw suggests that the reader sample the essays at random and advises against reading them in order. But I did so anyway and found it quite enjoyable.
Throughout the book, Crawshaw's wisdom, humanity, and love of medicine are clearly visible. He admonishes physicians to strive to be better doctors and to work to improve systems of medical care. His message, though critical, is uplifting and heartwarming. In a particularly concise and important ethical statement, Crawshaw and coauthors unambiguously assert the moral purpose of medicine, identify the internal and external stresses on contemporary physicians, and explain how unwary doctors and the medical profession can go wrong.
‘A COVENANT OF TRUST’
“Medicine is, at its center, a moral enterprise grounded in a covenant of trust,” he writes. “This covenant obliges physicians to be competent and to use their competence in the patient's best interests. Physicians, therefore, are both intellectually and morally obliged to act as advocates for the sick wherever their welfare is threatened and for their health at all times. Today, this covenant of trust is seriously threatened. From within, there is a growing legitimization of the physician's materialistic self-interest; from without, for-profit forces press the physician into the role of commercial agent to enhance the profitability of health care organizations. Such distortions of the physician's responsibility degrade the patient-physician relationship that is the central element and structure of clinical care. To capitulate to these alterations of the trust relationship is to significantly alter the physician's role as healer, carer, helper, and advocate for the sick and for the health of all.”
Crawshaw devotes several essays to topics of medical ethics. He strongly endorses continuing the traditional role of beneficence in medicine and the duty of physicians to prevent harms to patients. He acknowledges several important ethical questions that demand public examination and solution, but then charmingly and humbly delineates his own more minor concerns.
Figure. Compassions ...Image Tools
“Perhaps perversely my ethical interests stray from the ‘great issues’ of medical technology that make headlines,” he writes. “… My wonderment is restricted to those smaller, more mundane, though every bit as human, ethical problems of the profession, such as, should a doctor keep a patient waiting and if so why.”
SOCIALIZATION DURING TRAINING
Crawshaw understands that the medical profession exists to serve patients. He explains why students need to be socialized during medical education always to maintain the primacy of their patient's health interests. Emphasizing the importance of students publicly pledging the Hippocratic Oath, in light of recent attacks that it is antiquated or quaint, he reminds readers that “[the Hippocratic Oath] is a sacred agreement between the student who stands with hand uplifted and the future physician he or she will be, to protect, not self, nor the profession, but the patient.”
Crawshaw explores facets of the patient-physician relationship in a series of essays. He asserts the requirement of physicians to have the courage to do the right thing even at personal cost. On the relationship between compassion and courage he observes: “If a physician strives for a noble life, there are two virtues that must be in his cells … beyond intelligence, the two necessary virtues that divide his world into feeling and action are compassion and courage.”
In a few highly personal essays, Crawshaw relates his own experience as a patient and how those experiences illuminated the emotional needs of patients and the essential elements of the patient-physician relationship. Recounting his own emotionally and physically painful experience as a patient requiring a Foley catheter when his physician seemingly abandoned him in the hospital all day, he comments: “The most immoral of omissions in the patient-doctor relationship is the physician's failure to let the patient know where the doctor is, to leave the patient waiting and not explain why.”
LIMITATIONS OF TECHNOLOGY
Crawshaw warns that although technological advances are wonderful for patient treatment, they are not unbridled goods. He detects an over-reliance by contemporary physicians on technology. He charges that some physicians hide behind the screen of technology, and allow their clinical decisions to be controlled by a technological imperative that mandates the use of technology irrespective of its value in an individual case. He points out: “Medical technology, lacking values of good and evil, does not generate moral values. Quite the contrary, machines can erode the user's values to the point where the technician is a valueless person.”
He recounts examples of physicians who have been ruled by the technological imperative, such as the physician who refused to cease life-sustaining treatment on an obviously and hopelessly dying patient. He regards these examples as tragic failures of physicians' professional duties to their patients. As a corrective action, he recommends that physicians abandon the technological imperative and replace it with the humanitarian imperative.
“We need an expanded Hippocratic tradition in all hospitals that deals constructively with the implicit counterproductive cost, pain, and arrogance of medical technology,” he writes. “To begin with, every hospital in the nation should treat such ‘ethical’ problems as medical emergencies.”
MEDICINE AND THE HUMANITIES
Several of Crawshaw's essays are reviews of medically relevant movies and books, or interesting travelogs. His writing shows the value to physicians of nurturing a full appreciation of the humanities. I was especially moved by his poignant essays describing his heartbreaking experience at a leper colony in India and his visits to the graves of Maimonides and Chekhov. In his analysis of physicians' interests in art, music, and literature, he insightfully identifies the reason: “There is an arrogant perversity in all caring physicians, an unrelenting search for beauty in the ugliness of pain, human suffering, and death.”
Many of Crawshaw's essays discuss how physicians should best care for their patients. Like Francis Weld Peabody's famous 1927 aphorism on the secret of the care of the patient, Crawshaw explains how care and caring are related: “To nurture the humanitarian imperative, the physician seeks contact with human beings, not organs of human beings or representatives of human beings. The physician engages with the patient in a discourse that does not deny science but affirms humanness.… Caring physicians find meaning in human beings, not in things. It is then that genuine caring takes place.”
Additional topics Crawshaw considers include the identification and rehabilitation of impaired physicians, the development of the model of Medicaid diagnosis priorities in Oregon, and the health care systems in several countries. He reserves particular scorn for the former Soviet Union because of their institutionalized coercion and manipulation of physicians for the alleged good of the state.
Compassion's Way is the product of Crawshaw's lifetime of thinking, acting, and writing on how physicians can restore humanity to medical practice. It is brimming with wisdom and well worth sampling by physicians. As Dr. C. Everett Koop noted on the book's dust jacket, it was written by a physician who never gave up the struggle to keep our profession humane.