Medicine as the Moral Imperative of Wholeness
In a June 12th, 2020 article in the online Journal of the American Medical Association (JAMA), Dr. Donald Berwick contends that members of the healing professions are compelled by their “moral law within” to act for social justice reform. He notes that:
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“Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it. The moral law within insists so.”
This is a bold and visionary understanding of the moral contract between frontline workers and the communities and individuals they are called to serve and care for. A moral stance that often conflicts with more institutional metaphors of effectiveness and efficiency in modern medicine.
Dr. Berwick’s article provides data, rationale, and guidance for why and how the healing professions can and should act as agents of change; healers as protesters. Care givers who act to address the systemic and systematic “social determinants” that negatively impact the health, flourishing, and life expectancy of patients. I agree with his mission and at the same time I wonder about the internal resources required by frontline workers to be activists. What knowledge and skills will facilitate social change without overwhelming medical professionals? What might fuel the “moral law within” in a way that leads to wholeness instead of burnout?
Burnout for many frontline workers occurs when their identity is split by institutional demands, structures, and narrowly defined performance indicators. Their inner calling to heal separates from the outer requirements of the profession. As Dr. Berwick suggests, healers are increasingly practicing medicine in settings that are less concerned with their wellbeing (humanity) and more attentive to efficiency and productivity metrics. A (2018) article in STAT by Dr. Simon Talbot, and Dr. Wendy Dean, makes a similar argument that doctors are suffering less from overwork and more from burnout as a form of “moral injury”:
“Physicians on the front lines of health care today are sometimes described as going to battle. The moral injury of health care is not the offense of killing another human in the context of war. It is being unable to provide high-quality care and healing in the context of health care. Continually being caught between the Hippocratic Oath, a decade of training, and the realities of making a profit from people at their sickest and most vulnerable is an untenable and unreasonable demand.”
If the current emotional and psychological condition of frontline workers can be described as “moral injury” and their call to heal as their “moral law within” how might they move away from dividedness to wholeness? In the field of counseling the process of repairing the divided self is called “moral repair” or “soul repair”. Depending on the depth or nature of the moral injury the move from fractured identity to wholeness can include practices like mindfulness, meditation, or the modulation of emotions through training in social-emotional learning (SEL). These are everyday approaches to stress reduction and integration that any frontline worker can initiate during breaks in the day, gentle breathing before entering a patient’s room, or taking an extra moment to deeply listen to a patient.
Sometimes the moral violation, as suggested by Dr. Berwick, cuts deeply into the soul of the healer. In such cases the process of returning to wholeness—moral integrity—entails more extensive work and repair. It requires responding to and caring for the internal cry of the heart as it reaches out for support and acknowledgement. The Moral Injury Project at Syracuse University offers two touchstones relevant to the goal of integration and wholeness, 1) never approach the process of soul repair alone but rather seek out “community for a shared process of healing” and 2) the frequent use of “artistic and literary formats” for self-knowing, because aesthetic formats invite “listening and witnessing” to the divided heart.
In my experience of facilitating retreats designed to integrate moral imperatives (a calling to heal) with institutional imperatives (a drive toward effectiveness), poetry is a useful co-collaborator. Healing language for the frontline worker is metaphor, imagery, and analogy. In high school I learned to take poems apart and analyze for meaning and the poet’s words for meaning. In soul repair the goal is to let the poem speak to the individual’s wholeness. An invitation to be vulnerable enough to let the poem interpret you. This is as much an individual as it is a collective experience. A good poem invites the healer’s spirit to “engage” the material in a way consistent with the slow and deliberate approach the heart uses to construct knowing. The power of poetry, as Emily Dickinson, notes comes from its ability to “tell the truth but tell in slant”. And sharing one’s truth in the presence of others has a particular communal power to it.
As an example. I recently sent Galway Kinnell’s Saint Francis and Sow to a group because the images in his poem invite me to remember that an important element of professional effectiveness stems as much from “self-blessing” as it does from technique. My goal with this community of brokenhearted healers was not to increase effectiveness through the metrics of industrial medicine. Instead my aim was to offer a brief respite from their divided life. To frame their healing as self-forgiveness, spiritual awareness, restoration of self-worth, and the renewal of wholeness. As Kinnell writes in his poem: “for everything flowers, from within, of self-blessing;/ though sometimes it is necessary / to reteach a thing its loveliness…” Imagine if you will a vision of medicine where the inner-life is rich and robust enough to fuel the “moral law within”. The more whole and integrated the healer’s heart is with the healer’s hands and mind the more capable they will be of confronting social determinants without risking emotional, psychological, and spiritual diminishment.
Paul Michalec, PhD
Clinical Professor; Teaching and Learning Sciences
Morgridge College of Education | University of Denver