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“How Then Shall We Live?”

2001; Lippincott Williams & Wilkins; Volume: 51; Issue: 6 Linguagem: Inglês

10.1097/00005373-200112000-00001

1529-8809

Steven R. Shackford,

Empathy and Medical Education

This address did not originate in my neocortex, but in a deeper region of my brain, the one responsible for signaling a sense of warning. The sense I have is that a subtle, distinct change is occurring around me that is not quite right. This sense eventually grew into the perception that society, in general, and medicine, in particular, are devaluing the ideals of service and sacrifice. I did not intend to share this perception, however, until three seemingly unrelated events occurred. The first event occurred when I saw Saving Private Ryan for the first time. To me the most memorable part occurred when Tom Hanks, playing the dying Lieutenant Miller, whispers, “earn this” to Private Ryan. “This,” of course, is the ultimate and supreme sacrifice that he and others have made for Ryan. Over the ensuing weeks as I reflected more on the “earn this” phrase, it occurred to me that all physicians have been given an incredible gift, the science and the art of healing. No matter how many personal sacrifices the individual physician made in preparing to become a doctor, those sacrifices pale in comparison to those made by the thousands of physicians, nurses, patients, and scientists who have made medicine and surgery what it is today. In addition to the numerous diagnostic and therapeutic tools that have been given to us, we have been given trust, admiration, and respect simply because we are physicians and not because we specifically earned it. It also occurred to me that physicians of the future will rely on each of us to maintain and increase that respect and admiration by the way we practice and by the way we live. The Saving Private Ryan epiphany would probably have come to naught were it not for the second, more profound, event. This occurred in August of 1999, when our family took my oldest daughter Kate to college. She had chosen to attend the College of the Holy Cross in Worcester, Massachusetts. Holy Cross is a Jesuit school with a strong tradition of integrating service and spirituality with social issues. As part of that tradition, all freshmen are introduced to the first year program, 1 which poses the fundamental question, “How then shall we live?” This question, first proposed by Leo Tolstoy, 2 forces one to come to terms with his or her own role in society. The question exactly posed to Kate’s entering class was, “In the culture of the here and now, how then shall we live?” Like a thunderbolt, the question struck a chord in me and resonated. I realized this had relevance, not only for my daughter, a freshman at Holy Cross, but also for me, an academic surgeon in Vermont. FIGUREFigure: Steven R. Shackford, MD, FACS President, Western Trauma AssociationAt first, it seemed almost rhetorical to ask this question because conventional thought would suggest that how an individual lives has no real consequence in terms of societal or cultural change. Then the third event occurred. I read Albert Schweitzer’s autobiography. 3 Schweitzer, a philosopher, theologian, musician, teacher, author, husband, father, and physician wrote: It’s not enough merely to exist. It’s not enough to say, “I’m earning enough to live and support my family. I do my work well. I’m a good father. I’m a good husband. I’m a good churchgoer.” That is all very well, but you must do something more. Seek always to do some good somewhere. Every man has to seek his own way to make himself more noble. . .you must give something to your fellow man. Even if it’s a little thing, do something for those who have need, something for which you get no pay but the privilege of simply doing it. 4 I would like to share with you what I have learned about and from Albert Schweitzer. His life was his argument. He believed that how an individual lives is important, not only to the individual, but also to others. Albert Schweitzer was born in Kaysersberg, Upper Alsace, on January 14, 1875, the second child of Louis Schweitzer, a Protestant minister. Albert was a child of privilege, advantage, and opportunity. He grew up in a family that valued education. He was stimulated to pursue knowledge, music, art and, above all, truth. He began to play the organ at the age of 8 years and developed a passion for the instrument. He quickly became so proficient that by the age of 9 he was the substitute organist in his father’s church and by the age of 18 he was sent to Paris for organ instruction with Charles-Marie Widor, an acclaimed musician. In 1893, he entered the University of Strasbourg, where he studied musical theory, philosophy, and theology. He completed his studies in 1900 and was awarded a PhD in philosophy and an advanced degree in theology. He subsequently joined the faculty of the University and was appointed curate of the Church of St. Nicholai. While in the College of Theology, he researched primitive Christianity. This research was used in his University lectures and his church sermons and ultimately resulted in a book, The Quest for the Historical Jesus. The discipline of his youth and his commitment to knowledge, truth, and integrity are apparent in this work. Schweitzer demonstrated through exhaustive research and flawless logic that the gospel accounts of the last supper of Christ were historically inaccurate. His inaugural lectures on this topic were received with protests from established faculty, who considered his work unorthodox. Schweitzer was sustained in his argument by senior faculty because of the thoroughness and precision of his work. Nevertheless, he found the criticism unsettling. He also completed two additional, highly successful books: a comprehensive work about the contributions of Johan Sebastian Bach published in 1908, and a definitive work on organ building and playing, published in 1909. As early as 1896, Schweitzer, then 21 years old, began to sense that he should do something to pay back life for all of its goodness to him. In Schweitzer’s words: It struck me as inconceivable that I should be allowed to lead such a happy life while I saw so many people around me struggling with sorrow and suffering. The thought came to me that I must not accept this good fortune as a matter of course, but must give something in return. What the character of my future activities would be was not yet clear to me. I left it to chance to guide me. Only one thing was certain, that it must be direct human service, however inconspicuous its sphere. 3 In 1904, chance led him to an article about the need for workers in Gabon, the northern province of the Congo, in French Equatorial Africa. Schweitzer recalled, “I finished the article and quietly began my work. My search was over.”3 This decision presented Schweitzer with a dilemma. Was it better to teach theology than to put his theology into action? Was it better to preach the mission than to live the mission? “I decided,” he later told Norman Cousins, “that I would make my life my argument. I would advocate the things I believed in terms of the life I lived and what I did.”5 At this time, Schweitzer was rapidly approaching wide scale respectability throughout Europe as a scholar, an academic theologian, and a musician. Yet, he was willing to cast all of these attainments aside to serve others. In 1905, he wrote to friends telling them that at the beginning of the winter term he intended to enroll as a medical student and formally study medicine with the idea of eventually going to equatorial Africa as a doctor. He began his medical studies at the University of Strasbourg in 1905. He did not resign his post on the faculty nor did he give up his work preaching. He also continued to play the organ at concerts for the Paris Bach Society and frequently had to commute between Strasbourg and Paris. During this time of intense study and commitment, Schweitzer developed his boundless energy and his habit of being able to work 18 hours at a stretch and to require little rest or sleep to be effective. He completed his medical studies in 1911. In the spring of 1912, he took up the study of tropical medicine in Paris and began formal preparations for Africa. There was more to Schweitzer’s decision to leave Europe than motivation to do service for others. Schweitzer sensed the general decay of a society that he saw as willing to gloss over its injustice and discrimination, to condone its glaring inequities and shortcomings. The churches, the universities, the professions, the leadership of business and commerce had finally been content, he felt, to press only so far in their criticism of Western civilization. They completed the compromise of their integrity in his view by feeding the rise of nationalism, an attitude that was accepted by every nation in Europe. 6 Schweitzer simply did not want to be a part of a culture for which he had no respect and would not settle for, what he believed, was a morally mediocre world. He believed that the combination of moral mediocrity and nationalism could only lead to war. Subsequent events in Europe would confirm Schweitzer’s belief that war was imminent. During the later part of his medical studies, he courted Helene Breslau, the daughter of one of his professors. Schweitzer shared with Helene his ideas, hopes, and dreams of Africa, and she became enamored with him and with his project. On June 18, 1912, they were married. When he considered himself completely prepared for the trip, he met with the governing board of the Paris Missionary Society assuming that a man of his motivation, background, and training would be welcomed. Unfortunately, his assumption was incorrect. The committee that interviewed him was concerned that he might confuse the local missionaries with his great learning and that he might be active again as a preacher. It is important to recall that his books and lecturing had questioned the historical accuracy of some of the New Testament and this offended the orthodoxy of some fundamentalist Christians. The president of the Society, Alfred Boegner, the author of the magazine article that was the touchstone of Schweitzer’s mission, was strongly supportive of Albert’s proposal. Boegner acknowledged Schweitzer’s achievements and international recognition and believed that if someone like Schweitzer would give up everything to go to the Society’s Africa mission, it might draw the attention of others to do the same. 6 Boegner’s prediction was persuasive and the committee allowed Schweitzer to proceed with his project and locate at Lambarene. On March 26, 1913, Schweitzer and his wife, who had gone to nursing school in anticipation of their work, departed Bordeaux for French Equatorial Africa. Schweitzer was now 38 years old. They arrived at Libreville, the capital city of Gabon, located on the western coast 40 miles south of the equator, on April 13, 1913. The following day, they traveled up river to the station at Lambarene. Schweitzer was the first doctor to arrive in Africa for the sole purpose of treating the Africans. All previous physicians had treated the white colonialists. Schweitzer did not arrive in a truly pagan Africa. In areas south of the Sahara, tribalism with its “fetishmen” and Islam were firmly entrenched. It did not take long for him to realize that he had to adapt to the African culture rather than having the Africans adapt to the European culture. 6 Lambarene was totally unprepared for his arrival. There was no interpreter, no place to see patients, no place to operate, and his instruments and medicines had been delayed at the port city. To add to this frustration, there were scores of patients waiting to be seen. Schweitzer realized that initiating his work without proper instruments or medicines made him no better than the native fetishman. He found someone to interpret for him and imposed an immediate edict stating that there would be no treatment until his medicines arrived in 3 weeks. This edict was accepted and provided Schweitzer with valuable time to establish his base of operation. He personally converted a classroom to an examining area and record room. With the help of a few of the local workman, he and his wife created an operating room out of an old chicken coup. In 3 weeks they were ready, and he and his wife began treatment of patients with leprosy, malaria, dysentery, pneumonia, heart disease, sleeping sickness, strangulated hernia, and trauma. Trauma consisted of wounds inflicted by animals and those sustained on the job at the local lumber camps. Their success was immediate, despite the poor conditions. Word spread quickly and soon he was besieged with sick people. In addition to providing the medical care, Schweitzer himself did much of the manual labor to improve the hospital buildings and grounds. Their success, however, was short-lived. In August of 1914, word reached Lambarene that war had broken out in Europe. On August 5, Schweitzer and his wife were interned in their home as prisoners of war and were not permitted to render medical assistance to the Africans or to the whites. Despite the internment, he continued to write and completed two volumes on philosophy:The Decay and Restoration of Civilization and Civilization and Ethics. In September 1917, Albert and Helene were ordered to a prisoner-of-war camp in Europe, first at Bordeaux, then at Garaison and, finally, at St. Remy in the Pyrenees. Here it was cool and damp, and Helene became afflicted with fever and a debilitating illness, an illness from which she would never fully recover. After the armistice and their release, the Schweitzers had no home and no visible means of support. For Albert, the war had destroyed his beautiful home, killed his mother, devastated his homeland, and ruined his life’s work. In addition, he had compiled a substantial debt to the Paris Missionary Society because of his work in Africa. There was even a question of whether or not he would ever return to Africa. His wife’s illness progressed and she did not recover the strength and vitality that she had before the war. He returned to Strasbourg where he took up his old post as curate at St. Nicholai and began practice as a physician and surgeon at the municipal hospital. During this time, he wrote On the Edge of the Primeval Forest, which recounted his initial experiences in Africa and began work on a more prodigious literary work, The Philosophy of Civilization. In 1919, he received an invitation to lecture at the University of Uppsala in Sweden. He chose the individual’s affirmation in living as his topic and concluded that, “Each man must decide how he will live. . . .”3 It seems that the preparation for these lectures and their presentation in Sweden invigorated Schweitzer, who recalled: In Uppsala for the first time I found an echo of the thoughts I had been carrying about me for five years. In the last lecture, in which I developed the fundamental ideas of the principle of Reverence for Life, I was so moved that I found it difficult to speak. I recovered my health and once more found joy in my work. 3 Helene also found new purpose. A daughter, Rhena, was born to the Schweitzers on January 14, 1919. To pay the debts that he still owed the Paris Missionary Society, he gave lectures and organ recitals. Because of his immense popularity on the continent, the lectures and concerts were well attended, and within weeks he had earned sufficient money to relieve his financial obligations to the Society. This financial independence unfettered his active mind and on great reflection he made the decision as to how he would live—he would live as a jungle doctor. Helene supported the decision, but lacked the constitution to return. She would remain in Europe with Rhena. Schweitzer was now 47 years old. He returned to Lambarene in April 1924, but the scene that greeted him was not familiar. The buildings had collapsed and the grounds were overgrown. His first job was to reconstruct the hospital, which he did while seeing patients. Schweitzer recalled, “My life during those months was lived as a doctor in the mornings and as a master builder in the afternoons.”3 During 1924 and 1925, the number of patients increased substantially compared with the number he treated during his first sojourn. The hospital was completely renovated by the end of 1925, but was already too small. It had been built for 50 inpatients per day, but was treating three times that many. In addition, there was an epidemic of dysentery, which had been made worse by the inability to isolate infected patients. There was also a need for special facilities to care for the mentally ill. A decision was made to relocate and enlarge the facility. It was to be moved upstream and closer to the river. As he had before, Schweitzer participated in the actual clearing of the land and the building of the new hospital. It was completed in 1927 and provided sufficient capacity for 200 inpatients, as well as isolation wards and an entire building for mental patients. The staff had increased as well. He now had three additional physicians and three nurses. With the additional staff, a research program in tropical medicine was begun. For the first time Schweitzer’s presence, although desirable, was not essential. In July 1927, he returned to Europe to be with his family and to give lectures and organ recitals to raise additional funds for the hospital. During his lectures and recital tours, he received numerous prizes for his humanitarianism and for his scholarship. Between 1927 and 1939, he would repeat this cycle between Europe and Africa six more times. During the Second World War, he remained at Lambarene. In Africa, the Vichy French were fighting the Free French under General Charles DeGaulle. Both sides agreed to the sanctity of the hospital and, in return, Schweitzer treated the wounded combatants, regardless of their affiliation. He toured the United States for the first time in 1949 and returned to Lambarene the following year. In 1952, he received the Nobel Peace Prize. Between 1952 and 1957, he returned to Europe two additional times to visit Helene. Her health was failing, as it had been for some time, and she died during his visit on June 1, 1957. Subsequently, he located permanently in Lambarene, only to take seven more brief trips to give lectures or to receive awards, of which there were many. With Schweitzer now permanently at Lambarene, the work at the hospital grew logarithmically. Schweitzer continued to see and treat patients through the early 1960s. Despite the workload, he took on additional challenges. Along with Albert Einstein, he became a vocal advocate for a nuclear weapons ban. Because of his celebrity he was encouraged to leave Lambarene and to become a citizen of the world. He declined because he felt he was too old. In fact, his vigor was waning. He could no longer maintain the pace that marked his younger years. In late August of 1965, he was confined to his quarters, and on September 4, he died quietly in his sleep. There were many tributes written to Albert Schweitzer during his life and after his death. Einstein’s tribute I found to be the most appropriate: I have scarcely ever known personally a single individual in whom goodness and the need for beauty are merged to such a degree as Albert Schweitzer. He did not preach, did not warn, and did not dream that his example would be an ideal and a comfort to innumerable people. He simply acted out of inner necessity. There, thus, lies hidden, everywhere in many people, an indestructibly good core. Otherwise they would not have recognized him and his simple greatness. 6 Schweitzer’s lectures and books helped to fulfill Boegner’s prediction that “his commitment might attract others.” For example, Schweitzer had a direct influence on William Larimer Mellon, whose family founded Alcoa and Gulf Oil. Larry Mellon, after serving as an intelligence officer with the Army in World War II, had retired to a ranch in Arizona where he had decided to do something physically invigorating and useful. He found, however, that he needed a greater challenge beyond that involved in ranching. Providentially, the October 6, 1947, copy of Life magazine arrived. In it was an article about Albert Schweitzer, calling him the greatest man in the world, and describing his medical mission in Africa. 7 Larry read it carefully and told his wife Gwen that he wanted to go to medical school. Mellon met with Schweitzer the following year. He subsequently enrolled in Tulane University Medical School, became a physician, and started a native hospital in Haiti. Mellon recalled, “Naturally, I called my hospital the ‘Albert Schweitzer Hospital’ because he was my inspiration and if it wasn’t for him, I would never have done this.”6 Larry Mellon presents an interesting contrast to his first cousin Paul, a known philanthropist. Both were raised in privileged families, both were educated in the best preparatory schools in the northeast, and both attended the best of the Ivy League universities. Paul became an international sportsman and art benefactor. He served as the President of the National Gallery of Art and eventually founded Rokeby Farms and built it into a powerful thoroughbred nursery. 8 In answering, “How then shall I live?” Larry Mellon chose a different course of action, a different road—one “less traveled by.”9 Others have made their life their argument. One was an Albanian woman who, like Schweitzer, would eventually win the Nobel Prize. Her name was Agnes Bojaxhui. At the age of 18 she joined the Catholic Irish Sisters of Loreto, a group performing missionary work in India. She was initially assigned to teach the children of the wealthy, but was uncomfortable in this role. She wanted to do more and could not rest knowing that the poorest of the poor were dying daily in the streets of Calcutta. She began her work by caring for just one poor dying man, and by this small personal action, by this choice of how she would live, she has affected millions around the world. Early in her work she was approached by an American socialite who encouraged her to stop working with the poor and to leave it to others, saying that she could be more influential if she lectured about her activities. The socialite remarked, “After all, Mother Theresa, your caring for one dying person will not change the world.” To this Mother Theresa responded, “I do not do this to change the world. I do this so that the world will not change me.”10 It has been my pleasure over the years to know many people who have emulated Schweitzer’s simple greatness. John McGill, a member of this association and, I am proud to say, a graduate of the University of Vermont College of Medicine, has repeatedly served with Doctors Without Borders. His medical assistance to the Afghan rebels and their families, at great personal risk and expense, is a selfless example of service and sacrifice. Sylvia Campbell, a busy general and trauma surgeon in Tampa, Florida, as well as being a very busy mother and wife, returns to Mombin Cochu in the mountains of Haiti each year to provide basic surgical care to the natives of the region. Geoff Tabin, an ophthalmologist from the University of Vermont, established the Himalayan Cataract Project. Each year he returns to mountainous Asia to train indigenous surgeons to perform modern cataract extractions. He is actively working to eradicate curable blindness in this region. David Leitner, a plastic surgeon from the University of Vermont returns to the Hospital Albert Schweitzer in Haiti each year, at times with a medical student or resident. There, he and his team perform facial reconstructions on children with cleft lip and cleft palate. They also treat the horrific burns of children sustained in the persisting ritual practices of voodoo. Peter Cataldo, a colon and rectal surgeon at the University of Vermont, established a free surgical clinic in Burlington to serve patients without medical insurance. The clinic is staffed by volunteer attending surgeons and medical students. These are a few examples of individuals doing more, of individuals giving back and, somehow, making us all more noble. Frequently and prominently, and for obvious reasons, the University of Vermont is mentioned because it is what I know. I am sure that the examples I mention exist in other places and I suspect that there could be many more, if people would simply consider the question, “How then shall we live?” The consequences of not addressing the question are potentially grave because the individual will continue to live in accordance with society’s metric rather than his or her own. In addition, the distinct importance of that individual as a role model is lost. Medicine and society are moving away from a culture that values service and sacrifice. The movement is insidious, but definitely present. It has been fueled by the almost constant attention paid by our culture to personal gratification and the avoidance of anything that resembles stress or overwork. 11 It has been assisted by the political correctness phenomenon and the reticence of people who should know better to criticize it. Medical schools led by well-meaning deans have deplored the disappearance of the physician scientist and have made research and grant funding a priority while deemphasizing service and patient care. 12 This has led to the appearance of chairs of academic departments of surgery and medicine who perform absolutely no clinical service, but busy themselves with research and administrative duties. The loss of service and sacrifice in medical education also has been marked by the appearance of the entitled medical student. 13 The entitled student is one who expects “attention, care taking, love, success, income, and the other benefits” associated with being a doctor “without having to give anything in return.”13 Recent studies have also shown that medical students become less altruistic as they progress through the 4 years of medical school. 14,15 This loss of altruism may be because of the societal impact of self-gratification. More likely, it is because of the influence of the chairs, faculty, and residents who are less altruistic and less service oriented and, thus, can no longer model it. The loss of service and sacrifice as ideals is also being forced on medicine from the outside. Legislators without credible data have proposed limitations on resident work hours, and in some states these proposals have been enacted. 16 Outside of medicine, service and sacrifice are undervalued compared with our current culture’s metric of achievement, which is media stardom. Mr. Michael Pearo has been teaching history at Rice High School in South Burlington, Vermont, for over 30 years. During that time he has coached the varsity baseball team, taken scores of students on summer excursions to other countries as part of a comparative cultures course, and has been an exemplary role model for young men and women because of his commitment and service. Alex Rodriguez, who this year signed a baseball contract for $250 million, will make more money in one time at bat than Mike Pearo will make in an entire year. I am not an activist and my presentation to you today is not a call to action; it is a simple call to reflection. I am asking that you consider, “In a culture of the here and now, how then shall we live?” To help in this reflection, I would like to share with you a few aphorisms and a few recommendations that have helped me prioritize my life over the years: Service and sacrifice apply to one’s own family. Success in academic surgery does not justify failure as a spouse and parent. Your children will never read your curriculum vitae. They do not care if you are President of this or Chairman of that. They have specific needs and expectations that must be fulfilled if you are to earn this, the true respectability of being a parent. Your children will grow up at light speed and, with your spouse, will make more sacrifices for your patients than you ever will. The sooner you realize this, the better for you and the better for them. Commit to make up for the missed dinners, piano recitals, and soccer games. Volunteer your services—if the opportunity does not exist, create the opportunity. If your current situation prohibits volunteering, spend time learning health care policy. 17 Educate policy makers about the need for service and about the profession of health care before they legislate, regulate, and propagate policies that constrain your ability to serve your patients. If you are an academic surgeon, educate your Dean about the value of clinical service. Emphasize how serving others is what medicine is all about. Ask yourself and the Dean if Albert Schweitzer would have received tenure at your institution. Don’t whine. Don’t whine about reimbursement and don’t whine about the long hours. If you do, then you can thank yourself for creating a role model for the entitled medical student. Remember that you wanted to be a doctor, and the long hours and hard work come with the territory. Above all, be a good doctor—remember why you chose this profession. You answered the question, “How then shall I live?” by choosing to live your life in the service of others. Do it well and you will not only earn the respect of your patients, but you will also be a role model for others and in so doing will maintain and increase the integrity of the profession. Equally important you will have earned this—the privilege of being a physician and surgeon. In closing, let Albert Schweitzer’s story influence you. Do not accept your good fortune as a matter of course. Give something in return and decide how you will live. ACKNOWLEDGMENT I am indebted to Jody Ciano for editorial assistance and preparation of this manuscript.