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Humanism in Medicine

What Does It Mean and Why Is It More Important Than Ever?

Thibault, George E. MD

doi: 10.1097/ACM.0000000000002796
Invited Commentaries
Free

Humanism has been at the core of the medical profession since its inception, and it has been a foundation throughout modern history for political and community values. But today, countries and leaders are increasingly adopting antihumanistic policies and positions. In this Invited Commentary, the author probes whether humanism in medicine can survive in the current culture. The author defines humanism as any system or mode of thought or action in which human interests, values, and dignity predominate. He traces humanism as a philosophical and political movement from the Renaissance through the Enlightenment to the development of liberal democracies in the 20th century. He identifies the humanistic roots of the medical profession and describes efforts to revitalize humanism in medicine in recent decades. He then details antihumanistic behaviors and policies in the current political environment and makes the case that these behaviors and policies threaten humanism in medicine. He calls on the medical profession to renew its commitment to humanism and to oppose antihumanistic behaviors and policies. It will be hard, he concludes, to have humanism in medicine if there is no humanism in the world around us.

G.E. Thibault is immediate past president, Josiah Macy Jr. Foundation, New York, New York, and Daniel D. Federman Professor of Medicine and Medical Education Emeritus, Harvard Medical School, Boston, Massachusetts.

Funding/Support: G.E. Thibault received an honorarium from the Association of American Medical Colleges and the Gold Foundation for delivering the Jordan J. Cohen Lecture.

Other disclosures: None reported.

Ethical approval: Reported as not applicable.

Previous presentations: G.E. Thibault delivered the Jordan J. Cohen Humanism in Medicine Thought Leader Session at the 2018 Learn Serve Lead: AAMC Annual Meeting, a lecture cosponsored by the Association of American Medical Colleges and the Arnold P. Gold Foundation. This essay is adapted from that lecture, which was delivered on November 3, 2018, in Austin, Texas.

Correspondence should be addressed to George E. Thibault, 66 Sagamore Rd., Sagamore Beach, MA 02562; email: gthibaultmd@outlook.com.

What is humanism? Webster’s Dictionary1 defines humanism as “Any system or mode of thought or action in which human interests, values and dignity predominate.” Humanism as a philosophical movement began in the Renaissance. In emphasizing the centrality of humans and human experience it was a reaction to the theism of medieval scholasticism which placed God at the center of all things and emphasized supernatural rather than natural forces. This powerful and revolutionary premise that human interests, values, and dignity are dominant was the driving force of the art, literature, and creativity of the Renaissance. It celebrated the understanding of the natural environment and of the human experience. It stressed the essential goodness and perfectibility of human beings, and the importance of reason to solve human problems. The recent biography of Leonardo da Vinci by Walter Isaacson2 allows one to experience the creativity that was unleashed by this human-centered philosophy.

Two centuries later, humanism became the intellectual underpinning for the Enlightenment. Philosophers John Locke, David Hume, and others used humanistic principles to emphasize human liberty, human rights, and social justice as the elements of the social contract that is the legitimate basis for government. The U.S. Declaration of Independence (1776) is a product of the Enlightenment, and it is a humanistic treatise:

We hold these truths to be self-evident, that all men are created equal, that they are endowed by their creator with certain unalienable rights, that among these are life, liberty and the pursuit of happiness.

The Enlightenment belief in the power of reason unleashed the burgeoning of science in the 18th and 19th centuries that has continued into the 21st century. Steven Pinker’s recent book Enlightenment Now: The Case for Reason, Science, Humanism, and Progress3 documents with extensive data that the state of the human condition in the world is continuing to improve because of the continued application of the Enlightenment principles of reason, science, and humanism, which go hand in hand.

In the 20th century, the principles of humanism underlie the development of liberal democracies, which became the ascendant political order of the western world, defeating the rival philosophies of fascism and communism. However, Yuval Noah Harari,4 in his recent book 21 Lessons for the 21st Century, cautions us that we cannot take that continued ascendancy for granted.

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Humanism in Medicine

Given this background, what does “humanism in medicine” mean, and what are the implications of making a commitment to humanism in medicine? Medicine has always been regarded as a humanistic enterprise. The ethical principles of the Hippocratic Oath dating from the 5th century B.C. are humanistic (though the oath begins as a prayer to multiple Greek gods), in that they call for putting patients’ interests first. The great medieval physicians Avicenna and Maimonides were steeped in the humanities. From the Renaissance on, there has been the ideal of the physician who was learned in the humanities as well as the sciences.

The explicit attempt to renew the link between humanism and medicine became a phenomenon in the latter decades of the 20th century. This was motivated by the desire to “humanize” medicine in the face of “dehumanizing” forces that were taking medicine away from its historical roots. These forces included the corporatization of the practice of medicine, the increasing role of business and finance in medicine, the fragmentation of patient experiences, the reduced time for clinical encounters, the increasing reliance on technology as a substitute for human interaction, and a de-emphasis on the humanities in the education of physicians. All of these dehumanizing forces were leading to a general decline in both patient and professional satisfaction. The need to create programs and incentives to counter these dehumanizing forces led Arnold and Sandra Gold to create the Arnold P. Gold Foundation 30 years ago—a brilliant and prescient move. If it had not been created then, we would need to create it now. But in spite of the Gold Foundation’s positive impact on the education and attitudes of health professionals, the dehumanizing forces affecting our professions are stronger than ever.

Gold Foundation initiatives have created humanizing communities and rituals that connect health professionals with their roots and their values to be compassionate, caring, and collaborative clinicians. They have created rewards and recognition for these humanistic behaviors. They have stimulated reflective writing and research on humanistic topics. The medical education world has, in fact, been humanized by these initiatives. But there is much more to do to increase the penetration of these initiatives in medicine and to reach more deeply into nursing and the other health professions. This is the exciting work ahead for the Gold Foundation, and I am proud to be part of that journey.

This work to humanize medicine follows the principles of humanism—putting patients (human beings) at the center of focus; promoting better understanding of the human experiences of both patients and clinicians; deriving professional goals and actions from the real needs of patients; applying reason to better solve the problems in health care; and using science to devise ways to better help patients maintain health. It is important to re-emphasize the point that, consistent with its historical roots, humanism never has been nor should be seen as antiscience.

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Humanism in Society

In accordance with these humanistic principles, we strive to make the health professions the model for humanism in our society. This is absolutely essential work that is more important than ever. But we as professionals and as members of our society have an even larger challenge that goes well beyond the mandate and charge to humanize medicine. It is not just medicine that is threatened by being dehumanized; our society at large is turning against the principles of humanism that have been its underpinning since its founding. Political events in the United States and abroad threaten the principles of humanism and of democratic liberalism which has been the predominant form of government in the Western world, regardless of which political party is in power. The election of Donald Trump was both a symptom of and accelerant to this antihumanism trend in the United States.

This trend toward more autocratic and nationalistic philosophies that are not in line with the principles of humanism has been documented in the rise to power of autocratic leaders in Russia, Turkey, Hungary, Poland, and Brazil, and in the emergence of strong nationalist parties in many Western European countries. These trends antedated the 2016 U.S. presidential election. There clearly are differences across these various examples, but there is much commonality in the antihumanistic rhetoric and behaviors and in resulting policies that are not consistent with humanistic principles. In applying a humanistic lens to these political issues, I do not want to suggest that there are not legitimate areas for policy debate, nor am I attempting to divide the world into humanists and antihumanists. But I believe we cannot legitimately address the issue of humanism in medicine today without exploring the state of humanism in our larger society.

Many antihumanistic behaviors are becoming more prevalent today and are being legitimized by some leaders. Prejudice against individual groups based on race, ethnicity, or religion is antihumanistic because it denies the value of each human being. Threats to restrict freedom of speech and other individual liberties are antihumanistic because they deny individual rights that are the underpinning of humanism. An absence of truthfulness is antihumanistic because humanism is based on rational thought and speech. The denial of scientific facts is antihumanistic because humanism celebrates science to improve the human condition. Bullying and insulting behaviors are antihumanistic because they demean the value of each individual and threaten the ideal of the full development of each human.

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The Threat of Antihumanism

As leaders and professionals in our society and as defenders of humanism, we must call out these behaviors when we see them—in our leaders, in our social interactions, and in our profession. Sadly, these behaviors are now linked to policies and positions that are antihumanistic and that are a direct threat to our patients and to our values. There are many examples of these policies and positions, and the list appears to grow almost daily.

Rolling back the expanded access to care of the Affordable Care Act is antihumanistic and is a denial of equal rights. Unreasonable restrictions on immigration are antihumanistic because they deny the value of all humans and deny society the benefit of diversity, talent, and innovation. Separation of children from their families is antihumanistic because it is a denial of a basic human need. Failure to enact reasonable gun safety legislation is antihumanistic because it leads to preventable human harm and suffering.

Denial of the safety and efficacy of vaccines is antihumanistic because it is antiscience and leads to human harm and suffering. Denial of climate change is antihumanistic because it denies scientific fact with direct negative consequences for optimal human health and development now and in the future. Denial of science in general is antihumanistic and undermines the public’s confidence in our institutions and their ability to do good on their behalf.

Others could add to this list of antihumanistic policies and positions that directly threaten our patients and our values. If we are to have humanism in medicine, we must play a role in addressing, mitigating, and reversing these policies which threaten to dehumanize our society and run counter to our greater-than-200-year tradition of humanistic values.

This, of course, is not the first time in our country’s history when humanistic values have been threatened. Slavery, the Civil War, Reconstruction, the Ku Klux Klan, the Know Nothing Party, the Depression, McCarthyism, and the Vietnam War challenged our commitment to humanism. Jon Meacham,5 in his recent book The Soul of America, speaks to these unsettling moments in our history and how the people of the nation and its leaders responded to them by ultimately reaffirming our values. How are we going to respond to the current threats?

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The Role of Medicine in Restoring Humanism

More than two decades ago, we began the discussion in the health professions that our responsibility is not only to our patients but also to improving the systems in which we work—making care more reliable, accessible, equitable, and affordable for all the humans we serve. This humanistic professional value was beautifully articulated by Don Berwick, Paul Batalden, and others and was embodied in the now classic Institute of Medicine report “To Err Is Human.”6

Although the task of improving our systems of care is by no means done, we now must add to it another task, and that is to help make our society at large more humanistic. We will do this by the example of how we conduct ourselves as compassionate professionals in our individual patient encounters. And we will do this by continuing to reform our systems of care to make them more humanistic. But we must also bear witness to the threats to humanism that are all around us that are having a negative impact on the lives of our patients and the values of the society in which we function as professionals. We cannot achieve our goals for humanism in medicine within an antihumanistic society.

This may seem like too much to expect of us—we are already overburdened, sometimes overwhelmed with our professional tasks. And it is certainly true that we cannot take on every issue or devote all our time and energy to a national political campaign to restore humanism. But I do believe that by speaking to these issues in the appropriate fora, we will reaffirm our professional identities and avoid victimization or complicity by our silence. President Kennedy frequently quoted Dante that the hottest places in hell are reserved for those that in the time of moral crisis maintain their neutrality. We will be aided by creating communities of like-minded health professionals and by finding partners in other societal sectors. Such a renewed sense of purpose in defense of humanism can be an antidote to professional ennui and disillusionment.

And there is an important role for educators in providing the substrate and tools for this expanded vision of humanism in medicine. We must see that our educational processes afford more opportunities to express and develop humanism. These opportunities include caring for underserved populations in the United States and abroad, more focus on the social determinants of health, and a strengthening of the social contract between our academic medical centers and the society we serve. I commend the Beyond Flexner Alliance (http://beyondflexner.org) for its important work in this area. We also must support the study of the humanities to better understand the human condition and the human experience. Many such programs are now in place in medical schools across the country, and I applaud the new initiative of the Association of American Medical Colleges to codify and expand these efforts.7 And we also must create opportunities for the discussion of policy, philosophy, and advocacy so that our graduates are equipped to be fully engaged, humanistic citizens. And of course, we must continue to work hard to ensure that all our learning environments are examples of humanistic behavior.

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Finding Our Touchstones for Humanism

I will end with a story. There was a general practitioner (GP) in a small rural town. He cared for the residents of the town and of the farms and hamlets in the surrounding 10 to 15 miles. He made house calls; delivered babies; performed minor surgery; dispensed medicine; and tended to the physical, emotional, and social needs of his patients. His office was in his home. No patient was ever turned away. Patients were charged on a sliding scale, and some paid with produce or by performing home repairs. In this small town, he was also the public health officer and school doctor and served as chairman of the school board. Unfortunately, he died at the age of 49 of a myocardial infarction. His patients lined the streets for two days to say goodbye and thank you as he was laid out in his home. This GP was my father; the town was Chittenango, New York; the year of his death was 1962. I had just finished my freshman year in college, studying philosophy. Chittenango was where I first learned about humanism in medicine, and I have carried it with me throughout my whole career.

Each of us has our own touchstone for humanism—an experience, a role model, an inspirational writing. It is time for each of us to draw on that touchstone and make it more real in our daily lives. Let it inform every encounter with a patient, let it inform the work within each health system to make it more humanistic, and let it inform how each of us expresses our citizenship. Let us use our expertise and professional standing to speak out on issues that are important to our values and our patients’. Let us be more politically active, supporting candidates with humanistic values. We can make a difference and we can help to have our society be more aligned with the principles of humanism. But we must be intentional in doing this and make our case on these principles, not on personality. And we must vote and urge others to vote in order to have a truly representative democracy. Voter apathy and voter suppression are great threats to our ability to restore our values. We are citizens of our society, and we must play a role in addressing the antihumanistic forces that are gaining in strength.

Let me conclude by reasserting this central observation. It will be hard to have humanism in medicine if there is no humanism in the world around us. Human interest, values, and dignity must predominate.

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Acknowledgments:

The author thanks Ellen Witzkin and Brianne Alcala for invaluable assistance in preparing the Jordan J. Cohen Lecture and the manuscript.

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References

1. Webster’s New Universal Unabridged Dictionary. 2003.New York, NY: Barnes & Noble Publishing, Inc..
2. Isaacson W. Leonardo da Vinci. 2017.New York, NY: Simon & Schuster.
3. Pinker S. Enlightenment Now: The Case for Reason, Science, Humanism, and Progress. 2018.New York, NY: Viking.
4. Harari YN. 21 Lessons for the 21st Century. 2018.New York, NY: Spiegel & Grau.
5. Meacham J. The Soul of America: The Battle for Our Better Angels. 2018.New York, NY: Random House.
6. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. 2000.Washington, DC: National Academies Press, Institute of Medicine.
7. Association of American Medical Colleges. The Role of Arts and Humanities in Physician Development: From Fun to Fundamental. https://www.aamc.org/initiatives/meded/494588/roleofartsandhumanitiesinphysiciandevelopment.html. Accessed April 11, 2019.
© 2019 by the Association of American Medical Colleges