The WEIRD Trio: The Cultural Gap between Physicians, Learners, and Patients in Pluralistic Societies

Abstract

Physicians are shaped by sociological and philosophical factors that often differ from those of their patients. This is of particular concern in pluralistic societies when navigating ethical disagreements because physicians often misunderstand or even dismiss patient perspectives as being irrational. This paper examines these factors and why many physicians approach ethics as they do while elucidating various patient perspectives and demonstrating how they make sense when considered from a different cultural worldview. Many physicians are trained in contexts that are WEIRD: Western, educated, industrialized, rich, and democratic. These sociological characteristics tend to go hand in hand with the trio of individualism, secularism, and existentialism. These then shape an approach to ethics that focuses on the individual patient, makes no reference to the divine, and focuses on a patient’s personal desires. This contrasts significantly with many patients who are collectivistic or religious, and then make rational decisions based on other values. The social fact of pluralism implores physicians to temper confidence in their own cultures while considering others to promote mutual understanding and improved care. This paper concludes with a discussion of how bridges can be built across cultures without sliding into relativism, beginning with recognizing and communicating our shared moral intuitions.

I. INTRODUCTION

A people’s ethics reflects its culture. This is no less true of medicine. While it may seem that medicine constitutes its own world, it is, in fact, part of a larger ecosystem. Medical students are already socially formed before they don their white coats. For most, they come from a subset of society that is often quite different from that of their patients. This creates a cavernous division in clinical medicine, one where physicians and patients misunderstand each other, particularly as it pertains to culture (Schouten and Meeuwesen, 2006; Rocque and Leanza, 2015). This paper elucidates this chasm through the sociological and philosophical factors that tend to be shared by those in medicine. This investigation is a form of cultural reflection targeted at one’s own culture, a form that is not about gaining a technical skill but engaging in deep reflection (Kleinman and Benson, 2006). In understanding the peculiar nature of our view of the world, we begin to see other viewpoints with openness and understanding.

Much of how we understand the world is socially created. In his seminal work The Social Construction of Reality, the late sociologist Peter Berger argued that our conception of reality is an interplay between ourselves and the institutions in our society, as we create them and they subsequently shape us (Berger and Luckmann, 1991). When we grow up in our societies, we imbibe a set of ideas that comprises the cultural air. Many of these are taken for granted. Different cultures foster disparate modes of thought (Shweder, 1991). For a relatively affluent Westerner, the idea of attending medical school is both plausible and desirable. For a recent refugee from Syria, life’s aspirations may consist of basic survival. Children that grow up in these two contexts live in entirely different worlds down to their neighborhoods and dinner conversations (Putnam, 2015). In a world of inequalities, these children may never meet, and their ideas of how to live diverge. Some of those children become our medical students.

The reality of this predicament is often overlooked by learners. Most trainees are relatively unaware of the sociohistorical currents that shape their understanding of medicine. This is not an insult. It reflects the present educational system and the explosion of knowledge that has splintered our universities into multiversities. Students break off into their respective disciplines to study their own worlds of anatomy or psychology or English literature. Our universities, dating through the turn of the twentieth century, have moved from a unity of truth to a fragmentation of knowledge (Reuben, 1996). Yet, this compartmentalization provides a pallid view of the world. José Ortega y Gasset reminds us that we must live in “full view of the entire scene of life, which is always total”(1941, 103). We miss much of the wider picture.

Most learners come from these narrow settings, and insofar as their premedical studies have been concentrated on life sciences, they tend to be unacquainted with the relevance of history or philosophy on medicine (Liao, 2017). Perhaps more unfortunately, any appeal to other disciplines besides science is met with a begrudging groan. The educational process shapes learners to believe that the humanities are “fluff” or only to be studied as obligatory courses in order to reach the golden goal of medical school. It is no surprise, then, that even within medical schools, the humanities are ancillary. They were relegated to the dustbin before medical school even began.

This is, in part, very understandable. There is much to know. The information explosion has left us scrambling to keep abreast of the latest medical developments. Yet, our brains are still finite. As we roll out the latest sub-sub-subspecialty fellowship program, it is not surprising that we have sidelined some of the humanities to focus on scientific knowledge. Consequently, many of us have forgotten that medicine is primarily a human discipline steeped in history, a sociocultural context, and a philosophical paradigm. Medicine is first and foremost practiced by people for people. There are certainly learners who are familiar with this broader vision of humanity, but they are the exceptions. It has only been in relatively recent years that we have seen a renewed emphasis on narrative medicine, palliative care, and spiritual health.

The dangers of having so few of our learners versed in the humanities are myriad. Here, I am most concerned with the cultural currents that have produced what I call a weird trio of ethics. This trio refers to three ideological pillars that shape our very understanding of the world: secularism, individualism, and existentialism. These are not necessarily ethical principles in themselves, but they lend to an orientation of the world that produces a certain kind of ethical reasoning. Thus, the present state of ethics can be understood on an ideological level and through various demographic factors on a sociological level. I explore both in turn.

The project of tracing a brief genealogy of this weird trio can be beneficial for at least three reasons. First, a historical genealogy will make us conscious of some of the factors that have shaped the contemporary mindset. Second, tracing our intellectual history will help us to understand our own positions with new clarity. Third, and most importantly, I want to show that the weird trio is a very particular way of understanding the world. It is not a default position, and it is not shared by many cultures. This is crucial to recognize in a multicultural world where many patients do not subscribe to the intellectual history of the West. The inability to see how our positions are not immediately evident to those around us is a serious defect. To even aspire toward reconciliation or at least mutual understanding in our globalized society, we must first understand what has shaped us. All these three tasks are important, but I focus on the third.

First, I must highlight a few points. When I discuss this weird trio, I am concerned with the average medical learner and physician who has never read Tolstoy’s Death of Ivan Ilyich or Sartre’s Existentialism is a Humanism. These learners are intent on completing training, and the thought of reflecting on philosophy or literature is met mostly with apathy. Yet, these are also the very learners who live this weird trio unconsciously. To many, existentialism is an otherworldly, technical sort of term. Yet, it is in the air we breathe. I am not here concerned with professional ethicists or philosophers. This bolsters my purpose of being more descriptive than normative. I am not trying to argue that this trio is a positive or negative trend in itself (although inevitably I make such remarks here and there) but to note that this is something of which most learners are unaware and that recognizing it is critical in our multicultural context.

II. THE WEIRD TRIO IS WEIRD

Turning first to the social context, most medical students in North America are WEIRD—Western, educated, industrialized, rich, and democratic (Henrich, Heine, and Norenzayan, 2010). Henrich et al. have shown that people who come from a WEIRD background are weird, insofar as they are frequent outliers compared to the global population when discussing fairness, moral reasoning, and self-concepts. Specific to my argument, those who are WEIRD also tend to adopt the weird trio toward ethics. Two points are important to consider.

First, this is a minority population. The status of being a majority or a minority matters little for the logical soundness of a proposition, but it is practically significant. WEIRD people tend to cluster in contexts where they are not a minority group. Medical schools would be one such example. Even for students who are not born into a WEIRD world, many become integrated into the culture when they arrive in WEIRD countries. Furthermore, the very medical school admissions process favors social and ethical stances that are in keeping with the predominant institutional culture, which likely reflects WEIRD culture. Thus, medical schools tend to congregate WEIRD people. In contrast, many patients simply are not WEIRD. The second point grows from this sociological disparity. The WEIRD environment fosters a set of ideas that constitutes the weird trio, which subsequently creates what many patients view as a peculiar approach to ethics. These ideas simply are not fostered in other sociocultural settings.

Briefly considered, each element of being WEIRD tends to homogeneity of thought. This does not imply that opposites of the WEIRD attributes tend to diversity; it simply underscores that being WEIRD is one configuration. Beginning with the Western tradition, a predominant ideological and cultural influence has been the Judeo-Christian worldview and its critical text, the Bible (Ferry, 2011; Ryrie, 2017). Philosophers and scholars in the East have noted the dissimilarities in cultural ideologies that have shaped their respective countries and have seen the Bible as a cultural guide of the philosophy of the West (Tiedemann, 2010). In China, “Centres of Christian Studies” exist at universities to consider the Bible as a philosophical text and compare it to Chinese philosophy (Tiedemann, 2010, 907–908). Such scholars appreciate the insights of Christian thought without engaging in any of its religious content. This separates the West from other non-biblical cultures, including my own Taiwanese heritage, which is relevant for the ethics that grow out of being WEIRD.

Contemporary education also fosters uniformity of thought in two ways. First, universities have largely abandoned the quest for truth and the meaning of life in place of more pragmatic goals of securing their students a job (Kronman, 2007). The university has become a place of being herded through a set of hoops as “excellent sheep” (Deresiewicz, 2014). While such a homogenizing tendency is not new, the loss of liberal education, which aims at engaging a wide range of ideas, minimizes alternate perspectives. Second, as liberal education has waned, many of the liberal democratic ideals have also diminished. For example, John Locke, who is in many ways the father of present-day liberalism, heavily emphasized the importance of proper etiquette of discourse, because it would be crucial for debating ideas in a democratic society (Locke, 1889). These concerns are warranted because the general degree of respect for free speech as an independent, valued entity has declined (Lukianoff and Haidt, 2018). This is significant because it creates a milieu in which only certain ideas are accepted as orthodox. John Stuart Mill argued that the refusal to hear alternate opinions was to conflate an individual’s certainty with absolute certainty: “All silencing of discussion is an assumption of infallibility” (2003, 88). Thus, the importance of academic freedom to explore ideas has received renewed attention and support (Lackey, 2018). Together, these two factors shape learners in ways that may not be shared by those who never enter such institutions.

In terms of industrialization, I mostly want to highlight the relevance of the Industrial Revolution to the scientific one that led to the rise of instrumental reason and preoccupation with the means for our ends (Taylor, 1992). The scientific revolution brought stunning innovations, but over time it developed into an aspiration that science would lead to salvation (Midgley, 2002). In his famous lecture Science as a Vocation, Max Weber described this as the tendency to “glorify science, or rather the techniques of mastering the problems of life based on science, as the road to happiness” (Weber, 2004, 17). Others have described this mentality in critique of the Enlightenment: “Knowledge, which is power, knows no limits… Technology is the essence of this knowledge” (Horkheimer and Adorno, 2002, 2). Scientific knowledge became control, and through it we would become masters of our destinies. This idea characterized a tremendous shift in thought. In the Greco-Roman worldview, the Cosmos was divine, and the good life entailed conforming oneself to the good patterns of the world. In the scientific worldview, the conformity works in the opposite direction. The goal of knowledge shifted from virtue to power. Industrialized nations tasted instrumental reason first. The rise in the authority of science led to the philosophical school of positivism and the idea that unless something was empirically verifiable, it was essentially meaningless. While this idea is self-refuting (the idea that something must be empirically verified to be true cannot itself be empirically verified), forms of it continue to enjoy adherents in the medical world. The role of empirical data and the confidence in the scientific process may not be shared by others. Others may appeal to different standards to assess therapies. The point to emphasize here is not cogency, but simply that this disparity exists.

Industrialization also led to wealth and consumerism, which has been identified as a key element in the success of Western civilizations (Ferguson, 2011). On one hand, these riches created new lifestyles, which in their extremer forms were characterized by what Veblen memorably called conspicuous consumption. On the other hand, consumerism also developed a negative reaction by those who realized that the production system was depersonalizing and turned people into means rather than ends (Ellul, 1964), whether as factory workers subservient to manufacturing goals or as advertising targets. While consumerism is not a distinctly Western phenomenon, it did first develop here before being exported globally and manifesting differently according to local cultures (Stearns, 2006). Presently, being rich also shapes the ideological milieu because it grants access to particular social circles that are otherwise inaccessible, such as certain schools. Furthermore, as alluded to earlier, the concerns of the rich simply do not mirror the concerns of the poor. The differences in the ideas and exposures of these groups are stark.

Finally, many of the above attributes are also found in cultures that are democratic. This returns to Locke and the general idea of the role of public education in fostering certain virtues that will be necessary for a flourishing democracy. The ideas necessary to sustain a democracy are not the same as those necessary for a communist state. Furthermore, democratic states, in theory, presuppose citizenry and the role of individuals to choose their governors for the collective good. As the historian Alec Ryrie (2017) has highlighted, this democratic tradition was one of the major outgrowths of the Protestant tradition. This ties back in with the Western Judeo-Christian heritage. These political and religious traditions are not universal. The roles of the individual and governing structures depend on the political theories that undergird a culture.

The WEIRD attributes can further be nuanced insofar as they are interrelated. Those who are Western are more likely to come from a Judeo-Christian heritage, an earlier industrialized nation, and so forth. Furthermore, each element must be intermingled with the others to guide the ethical thought process in a certain direction. Christianity in the Global South manifests differently from how Christianity historically manifested in North America (Jenkins, 2006). This highlights the particularity of being not only democratic or rich but fully WEIRD.

It should come as no surprise that those who are WEIRD have a different approach to ethics than those who are not. For those who are WEIRD, morality is defined almost exclusively in terms of harm. This harkens back to Mill’s famous statement that “The only purpose for which power can be rightfully exercised over any member of a civilized community, against his will, is to prevent harm to others” (2003, 80). If nobody is being harmed by a certain act, it should not be considered immoral. Yet, in his work on moral foundations, the social psychologist Jonathan Haidt has shown that intuitively people have a much broader range of moral intuitions. WEIRD people, however, have to some degree rationalized these intuitions as being outside the domain of morality. To use a crass but illustrative example, is it wrong to urinate on a dead man’s face? There is an initial revulsion to this idea. Yet, people who are WEIRD then begin to apply their moral apparatus to the question. Well, the man is dead, so technically no harm is done; the act is not wrong. The initial revulsion, however, points to a moral intuition that is generally shared by all cultures whereas this secondary rationalization process is formed by cultural milieus. While WEIRD people may express their unease with the situation, they lack the moral language to describe what could be wrong with it (Haidt, 2012, 95–96).

To many from other cultures, this is straightforward. There is something sacred about the human body, and to urinate on the man is to seriously transgress a boundary of respect. WEIRD people lack the language to express why it is wrong because the idea of the sacred has largely been lost in the culture, despite the intuition that wrong has occurred. Other cultures are able to see this wrongness in terms other than harm. Haidt thus argues that there are several foundations to morality like the sacred that inform a moral outlook beyond the WEIRD framework (Haidt, 2012). He applies (and expands) these different foundational elements to political parties to demonstrate that many disagreements are a reflection of variable emphases on different foundations such as care, liberty, fairness, loyalty, authority, and sanctity. This scaffold can equally be applied to cultural differences.

This builds on the work of the cultural anthropologist Richard Shweder (1997) who identified the “big three of ethical discourse” based on autonomy, community, and divinity. Each of these presupposes a particular “conceptualization of the self” as either an “individual preference structure,” “an office holder,” or “a spiritual entity connected to some sacred or natural order of things and as a responsible bearer of a legacy that is elevated and divine.” These conceptualizations impact what values should be upheld and even how one would define harm. Having spent much time in India to do his fieldwork, Shweder embedded himself in a non-WEIRD culture that opened his eyes to different perspectives on ethics. He argues that through the practice of cultural psychology, “the conceptions held by others are available to us, in the sense that when we truly understand their conception of things we come to recognize possibilities latent within our own rationality” (Shweder, 1991, 5). This is significant. It is not only the case that we can begin to recognize that other cultures value things differently. Recognizing these different ethics or moral foundations can enable us to understand at a rational level why such practices are upheld and how they make sense in a non-WEIRD framework.

In considering the above, it becomes evident that ethical orientations are not isolated. They flow from a particular metaphysical orientation, a conception of what actually constitutes reality. Is the self an isolated being or necessarily socially understood? Are there real spiritual entities or are there not? This is where the weird trio comes in.

III. THE WEIRD TRIO AS A PHILOSOPHY

Secularism, individualism, and existentialism combined tend to a certain metaphysics that shape ethics for the many medical learners who (possibly unknowingly) subscribe to these ideas. For many, these are not carefully deliberated propositions, and hence, it would not be surprising to find that there may be contradictions within this weird trio and being WEIRD. My project in this portion is descriptive. Furthermore, because I here focus on the general learner swarmed by both flashing screens and medical texts, the manifestation of this trio in ethics is felt or experienced more than it is rationally adopted. This is not surprising, because this weird trio is often absorbed unconsciously. This is the cultural air of the WEIRD.

While I briefly define each of these three terms, I am primarily hoping to capture the ideas insofar as our medical learners experience them. Each philosophy also relates to the others, such that when the three are taken together, they each modify and shape the others to fit within their own boundaries (e.g., individualistic and collectivistic secularism are distinct).

Turning first to secularism, this is in some ways the broadest of the philosophies. It refers to the idea that there is no meaningful connection between God, whether or not He exists, and ourselves in the world of medicine. This is an outlook that will be familiar to many. No appeal to God is made during the ethics consultation process or when deciding between therapies. Much can be said about the wisdom of this approach. However, my concern is the striking contrast between patients and physicians around medical decisions. Patients often appeal to God. For many Muslim patients, the very first question is, what is the will of God? The metaphysical question (does a God involved in humanity exist?) leads to the ethical question (does God have something to say about this situation?). Disparate metaphysics begets disparate ethics. For many learners, this is a flustering situation, because the WEIRD context has not furnished them with either the language or experience to engage this foreign metaphysic. Either patients are written off as irrational, which as seen above is a dismissal that fails to appreciate the rationality of certain actions based on an ethic of either community or divinity outside the WEIRD context, or these appeals to God are uncomfortably accepted but largely ignored.

Secularism in its present form in the West can be understood in philosophical and sociological terms. Historically, many sociologists subscribed to the secularization theory, which was the simple idea that as societies modernized, religion would decline. Yet, at the turn of the century, the empirical realities of an explosion of religion across the world caused sociologists to rethink this thesis (Berger, 1999). Peter Berger noted, however, that there were two realms where secularization did hold true, and this is in Europe and amongst international intelligentsia (Berger, Davie, and Fokas, 2016). This very secularization thesis ironically grew out of those secularized circles. The sociocultural context even shaped ideas of secularism. Berger thus set forth an amended proposal. He argued that the main outcome of modernization is pluralism, or the “co-existence of different worldviews and value systems in the same society” (2014, ix). As people within these new societies engage with one another, their different viewpoints inevitably impact one another in a process called “cognitive contamination,” leading to a degree of relativization of one’s own beliefs. The significance of this pluralistic setting is that many patients inhabit this reality. Pluralism is accepted as a part of life in North America, and yet in many of our institutions of higher learning, like our medical schools, secularism is the dominant mindset. To further provide contextual nuance, while scientists are indeed more secular than the general population in many countries, the opposite is true in Eastern countries like Taiwan and Hong Kong (Ecklund et al., 2016). Science itself does not cause unbelief, nor is it true that there are no religious scientists (Ecklund, 2012). It also is not the case in Britain and the United States that religion is favored more by those who are poor or marginalized, as the middle classes and the more educated have recently been more supportive of Christianity (Putnam and Campbell, 2010; McLeod and Ustorf, 2003). This trend has similarly been noted in Turkey, India, and China (Micklethwait and Wooldridge, 2010). All of this suggests that there is a secular phenomenon that exists in our medical schools today that cannot be chalked up to science or socioeconomic status alone, making it all the more peculiar.

Yet, secularism’s role in medical education can also be seen from a philosophical lens. Secularism in its most popular forms developed as what Charles Taylor calls “subtraction stories” (2007, 22). To many, these narratives suggest that after God and all other superstitious phenomena are subtracted from our worldview, with what we are left is what is neutral and real. This story is oversimplified, however, as the new science of the seventeenth century did not threaten the existence of God so much as it did the idea that the universe was enchanted. Even the very ideas of “science” and “religion” as we think of them today are relatively recent inventions in the history of Western societies and narratives of stark conflict between the two are misguided (Harrison, 2015). Furthermore, these subtraction stories fail to recognize that with the sidelining of a divine principle in the world in combination with the Copernican Revolution, a certain bewilderment was experienced by the thinkers of the Renaissance age. As the poet John Donne put it, “New philosophy calls all in doubt… ‘Tis all in pieces, all coherence gone” (1996, 276). Thus, the arduous work of reconstruction was required to make meaning out of an immanent world without reference to the transcendent. This new philosophy completely reshaped how human beings conceived of themselves, including the requirement of confidence in our powers of moral ordering (Taylor, 2007).

My point is not necessarily to argue for or against the validity of such narratives, but to highlight that they are precisely that: narratives that exist in a particular philosophical tradition in the West. Not all cultures have struggled with the idea that God is dead. Not all cultures have engaged with Protestantism, which some have argued was a key vehicle for secularization in the West (Gregory, 2012). Many learners and physicians make no appeal to God, because they believe the divine is largely irrelevant if not nonexistent in any given ethical situation. Thus, other considerations apart from divine commands take precedence. This is not the case for many patients. They continue to pray, to consult spiritual leaders, to pray for miracles, and so on. The disparity that exists here is not between ethical frameworks alone but between underlying metaphysics. Given the wider pluralism of our society, learners should be mindful of their own metaphysical presuppositions. Especially in the context of advocating on behalf of patients, learners should develop some familiarity with the array of beliefs patients hold, and recognize their own traditions as endorsing particular narratives.

Individualism is another prevalent idea. The focus of our ethical encounters is typically on the best interests not of the community or the family but the individual patient (Canadian Medical Association, 2018; Coughlin, 2018). Individualism has a strong tradition in the West, developing from the importance of the individual soul against the religious family structure of Ancient Greece and Rome down to the Reformation and subsequent liberalism (Siedentop, 2014). We value individuals in their own right apart from their wider social context. We believe people should make their own decisions and must do what is right for them. A few historical traditions are worth highlighting. Through the Reformation and Martin Luther challenging the Catholic Church, individual conscience was unleashed, leading to an “unintended shattering of authority” (Furedi, 2013, 149–155). The French Catholic philosopher Jacques Maritain attributed the “advent of the self” to Luther (1929, 3–50). Furthermore, Rousseau famously put forward an insightful thought experiment in imagining what human beings were like in a state of nature to separate “artificial” versus “natural” influences on the present state of humanity. He looked favorably on the pre-societal state of humanity and felt that social relations and organized society corrupted human behavior. This emancipatory notion of human nature further highlighted the individual versus the community. Combined with rapid population growth and the increasing size of families, which put pressure on conventional ties and beliefs, individualism gained ground (Stearns, O’Neill, and Censer, 2019). These ideas were not developed in the East.

The focus on the individual has also progressed in practical ways. Technology has re-configured the very nature of our social relations (Turkle, 2015). Technology has also shaped our tendency to be in our own worlds, whether through echo chambers or tailored newsfeeds (Sunstein, 2017). Our worlds are self-focused. Thus, we have moved from communities of interdependence to what the late sociologist Robert Bellah (2007) called “lifestyle enclaves” where people gather with similar interests but often fail to foster stronger relationships. Of course, these technological factors are not unique to the West. However, they likely build on the individualist tendencies already present, as the practical tendency to individualism created by technology fits within the prevailing philosophical paradigm. These effects are received differently in Eastern countries (Sun and Ryder, 2016; Hamamura, 2012).

Appreciating other cultures reminds us that the inherent worth of individuals is not a default position. Individualism is not, as Charles Taylor has pointed out, just “common sense” or the natural state of self-understanding. For this, too, is based on a subtraction story that tells us when all old horizons eroded, the individual was born (Taylor, 2007). Culture is critical in fostering individualism. Rather than being a default position, individualism had to develop in a particular cultural and social milieu.

Other cultures contain much stronger notions of interdependent selves (Markus and Kitayama, 1991). People come to understand their identities not so much in their individual attributes and achievements but in their social roles and responsibilities. They are fathers and sons before they are doctors and businessmen. Embedded in the very language of Taiwanese are identifiers for specific relatives. There are different terms used to address one’s father’s younger versus older brother, which also differs from one’s mother’s brothers. The social and familial dynamic is significant because identities are linked to a wider community, and so decisions are not purely individual. Others have argued that this social dynamic is embedded in our practical identities, and thus the notion of individual autonomy is misleading, insofar as it conceives of individual commitments apart from social context (Mackenzie, 2008). While certainly there are various strains of utilitarian thought that diminish the individual patient in light of wider needs, the guiding principle for the clinician (as opposed to the policymaker) is typically individualistic.

Finally, existentialism has become increasingly prominent in contemporary culture. The world is neither a morally good nor divinely structured place, and so questions of right or wrong and meaning must be self-defined. There are no greater purposes “out there.” The vision of the good life becomes one where I am able to find myself and fulfill my personal desires. While there have been existentialist thinkers who were deeply religious, such as Soren Kierkegaard, as earlier noted it is the secular strain within existentialism that has shaped the minds of many medical learners today. The history of existentialism points to various ideas that developed in Western society. It grew out of the Romantic tradition and its roots in German pietism that emphasized a personal, feeling relationship with God (Berlin, 2013, 43–45). Perhaps articulated most forcefully by Nietzsche, this movement was focused on the indomitable will, such that “human beings… create themselves” (2001, 189). Sartre similarly stated, “man is nothing other than what he makes of himself” (2007, 22). This begins to sound familiar when we think of phrases such as “you be you” or “follow your heart.” Authenticity has become a moral ideal (Taylor, 1992). Others have referred to this need for authenticity and its externalization as “expressive individualism” (Bellah et al., 2007, 27). Existentialism places value on emotion, personality, and the “irrational man” (Barrett, 1990).

As a brief aside, it is important to note that while this tendency may appear to conflict with instrumental rationality, it seems to pose minimal cognitive dissonance. As Jonathan Haidt (2012) has shown, many of our rationalizations are post hoc justifications. We are not as rational as we hope to be, which means holding contradictory values may not be bothersome. Furthermore, existentialism also connotes a general mindset to which instrumental rationality is often subservient. We are often rational in our means but existential in our ends. In other words, we use medicine and technology to help us make our own meaning.

Many cultures, including North American subcultures, reject such existentialism. Some cultures believe we must connect to wider purposes, whether divine or communal. Authority likewise is upheld in many cultures. While it typically creates apprehension for Westerners, in many cultures authority is understood to be essential to the ordering of society. Recognizing authority is pro-relational in this mindset. Children who emigrated from East Asia were more likely to excel at tasks their mothers had chosen for them while children born in the United States excelled at tasks they had chosen for themselves (Iyengar and Lepper, 1999). Even self-expression in speech can be viewed suspiciously insofar as it betrays a sense of ignorance. As one Korean proverb states, “The empty carriage rattles the loudest.” Individual choice and expression can undermine higher goods.

To provide a typical example in pediatrics, should the adolescent or the parent drive decision-making? I recall a case where a teen desired immunoglobulin therapy for a compromised immune system when his parents did not. The team favored the individual’s choice. What was surprising was that the boy chose to defer to his parents. The decision had to be understood as having possible repercussions on a healthy family dynamic, which he valued more than individual choice. That the medical team had difficulty appreciating why the teen had chosen that way is telling. In the end, the family left the hospital after his acute illness, and last I was aware, he had left the country. The repercussions could be severe; he could die without therapy. Yet, the point is not so much the outcome (the preferences of patients and parents could be reversed), but understanding the values behind such decisions. Other scenarios where conflicts arise include whether a disabled neonate’s life is worth preserving (i.e., if one’s ability to self-actualize may be hampered) or even parenting recommendations in primary care.

Given the numerous cultural differences I have described, one must also then realize that these differences are not necessarily clearly geographic, as the mixing of cultural heritages is commonplace in the globalized cities of the world. My concerns extend to such multicultural and even multireligious contexts. Such differences can be seen even within medical schools despite the relatively homogenizing education process. Educators and learners must understand this, seeing their own peculiarities, if they are to engage patients well.

III. CONCLUSION

On both a sociological and philosophical level, learners differ from many of their patients. There is no neutral vantage point (Kaldjian, 2017; Nagel, 1986). I have shown briefly in each domain how other cultures may conceive of the world with a focus not on normativity but description. This attempt has consisted of viewing alternate perspectives, emphasizing the reasons that are found to be compelling from within these other traditions. This has not been aimed at overturning the weird trio but to show how things might otherwise be conceived.

When a patient defers a decision to another family member, or when patients invoke the name of God, or they prohibit certain procedures, this is generally seen with either confusion or a subtle dismissiveness. In its more harmful forms, the tone can be both patronizing. Many learners cannot place themselves in the narratives of other cultures, and this can lead to a breakdown in communication. Underlying assumptions go unrecognized. And so, patients remain categorically “other,” and it undermines mutual understanding and shared decision-making. Cultures shape concepts of health and disease (Kaldjian, 2017).

I have only sketched a rudimentary map of the different worlds between physicians and patients. In this, I have tempered the tendency to jump to solutions, which characterizes our culture in the vein of instrumental rationality and the educational tradition that has overlooked the reflective posture of the humanities and favored the pragmatic STEM disciplines. We must first carefully sift through the underlying issues, to understand the pathophysiology and develop a diagnosis before our treatment. But, I have hinted at where we can begin. As illustrated with the case of the dead man, we share more moral intuitions than one may expect, but it is a matter of learning to identify and communicate them in a language that is mutually understood. We may value being free of obligation, yet many would still uphold the duty to act on behalf of a deserted baby left on your doorstep in winter. It is that inkling of duty that we intuitively share that is a starting point for conversation, for helping others see that it is not irrational to make decisions according to such values. Disagreement may persist, but derision becomes less tenable. Cases illustrating these values can then be used for teaching, and indeed I have brought such examples up in both clinical and formal settings like grand rounds. Undoubtedly, there is a communicative element here that must be trained, namely, a winsome approach to contentious topics that reduces tension and rather creates openness to discussion.

More broadly, we should pursue “cognitive contamination” (Berger, 2014, 2). This means actively exposing ourselves to alternate ways of thinking. The destabilizing effect of pluralism enables us to see outside of our purview. Only after this has been accomplished can a “politics of moral engagement” (Sandel, 2010, 268) be created, wherein we engage one another respectfully without being dismissive, and “confident pluralism” (Inazu, 2016), wherein we foster a state of confidence in our own perspectives while being humble about our potential for error. In our multicultural world, we cannot expect all to agree on ethical issues. We can, however, advocate for those undergirding principles by which we can live together and move toward a just society. Now let us begin with ourselves. The first step is to see that we are, in fact, weird.