Handbook of Primary Care Ethics

Book Preface

Since 1978, when my first novel, The House of God, appeared1, I have been asked to speak all over the world, and from the start, in a less refined way, this concept has always been what I say, putting it in terms of ‘Staying Human in Medicine’. I’m delighted to use it here, in this remarkable scholarly and pragmatic volume put together by my dear and remarkable friends Andrew and John.2 Note that this guiding phrase is central not just to medicine but also to our lives. My attempt to write about American primary care is a novel, The Spirit of the Place, about a doctor going back to his home town to join the old doc who steered him into medicine when he was a lost teenager.3

Hints of this concept were present in The House, in rudimentary form. Over and over, there is the phrase, ‘Being with (x)’ – sometime ‘x’ is the patient, or a family member, or a colleague, or, even oneself. As The Fat Man, the hero of the novel who deftly conceals his deep care for patients, docs, and life itself: ‘I make them feel that they’re still part of life, part of some grand nutty scheme instead of alone with their diseases. With me, they still feel part of the human race’. And at the end of the novel, the African-American intern chuck sums up the main reason that the year in The House has been horrific: ‘How can we care for patients, if nobody cares for us?’.4 The tone of any institution comes from the top; the top of the House was unwise and abusive in the way that almost all big power-over systems are such. In my new institutionalisation, New York University Medical School, run by three of my generation who trained at ‘The House of God’ hospital, there is an aura of ‘We were treated badly, and now that we are in a position of power, we will not treat the ‘lower-downs’ badly’. The institution reflects this kindness from the top, all the way through.

What is a good connection? (See We have to talk: Healing Dialogues between Women and Men, the novel Mount Misery and the play Bill W. and Dr. Bob).5,6,7 Think of going to lunch with a friend. If the lunch goes well, by the end each of you feels an increase of ‘five good things’: more energy or zest, more sense of self-worth and worth of the other, more self-knowledge and knowledge of the other, more empowered to take action, and, last, a desire for more connection – ‘Hey let’s do this again soon!’ Note, especially the issue of  power’. This is not the traditional model of the dominant culture, where ‘power’ resides in a person. Rather, the power here arises in connecting. You may have felt burnt out, unable to act, disempowered, when you went to lunch, but in the mutual connecting there is an arising of power in both of you. (The gerund is as close as our language gets to describing this.) This is especially helpful for doctors: it means that good connection helps you to take action in your job and your life! It helps you to be a better clinician and person. Note that in this ‘relational model’, the measure of a person’s psychological health and growth does not reside in the ‘self’. Rather it resides in the quality of that person’s relationships.