“Medicine gives no thought to its metaphysics; it might even deny having one. And it gives no thought to its practices, because medicine is about doing and not about thinking.”
Jeffrey P. Bishop, in “The Anticipatory Corpse: Medicine, Power, and the Care of the Dying”
Contemporary medicine is primarily viewed as an evidence-based scientific project. Since the early twentieth century, medicine has been grounded in a metaphysics of mechanistic causation that has tended to reduce the human body to a machine, if only for heuristic reasons. The body has been viewed as matter in motion, a complex arrangement of physical and biochemical processes. In this framework, diagnostic and therapeutic interventions have been valued largely on the basis of objective, measurable outcomes. The results undeniably speak for themselves: we remove cancer with advanced robotic surgery, keep patients alive with mechanical ventilators and hemodialysis, improve quality of life with airway stents and medications, and we take these extraordinary achievements for granted. Yet medicine remains, at its core, an interpersonal discipline that engages health-care providers and patients in a multifaceted and interactive process in which technical success is but one important aspect. Medicine, fundamentally, is defined by a fiduciary relationship between human beings that necessarily includes ethical, philosophical, and sometimes religious dimensions. Even the more scientific and methodologic aspects of modern medical practice and research are underlined by implicit assumptions and presuppositions that have traditionally been underappreciated, if not ignored, in recent medical scholarship.
These considerations are of critical importance to address the challenges brought forth by modern medicine. Its ever-increasing technological complexities, as seen with the democratization of life-supporting technologies previously available to only a minority of patients, or in those amplified by our modern way of life, as currently experienced with the coronavirus disease 2019 (COVID-19) pandemic, embody these challenges: On what basis should we decide to withhold or withdraw life-sustaining interventions like extracorporeal membrane oxygenation? Is it ever morally permissible to withdraw a mechanical ventilator from a patient to offer it to another who may derive, by a given set of criteria, more benefit from it during such a crisis? Should a COVID-19 vaccine be offered first to those engaged in “essential” activities such as health-care workers, as opposed to those at greater risk of death, such as the frail elderly? The four cardinal principles of medical ethics—beneficence, nonmaleficence, justice, and autonomy—have gained broad acceptance within medical education and clinical care, but their philosophical underpinnings, historical and traditional foundations (and controversies), and sociocultural implications are equally significant, yet unfamiliar to many. Consequently, their theoretical appeal often fails to easily translate into actionable guidance at the bedside. Other ethical frameworks have thus been proposed, such as virtue ethics, best captured in the question “What does it mean to be a good doctor?” and the ethics of care, which hold that moral actions should emphasize interpersonal relationships and care before appealing to normative values or utilitarian calculations.
A new section in CHEST, on the humanities in chest medicine, proposes to explore these concepts from the perspective of liberal arts disciplines, such as philosophy, ethics, religion, history, and fine art, which best express the rich history and backgrounds of health-care providers and their patients and families. This proposed section will provide perspective and insight into distinct and sometimes contradictory worldviews, supporting a holistic and patient-centered approach to delivering pulmonary, critical care, and sleep medicine, overseen by a diverse editorial board (Box 1 ). Manuscripts will be solicited, and priority given to those most conducive to engaging the CHEST readership on issues with immediate and urgent pragmatic value for pulmonologists, intensivists, sleep medicine specialists, and allied health-care providers. Health-care providers with content expertise, bioethicists, philosophers, fine art scholars, patient advocacy representatives, and storytellers, among others, are invited to contribute on a broad range of topics from the ethics of medical research to end-of-life issues. Details on accepted formats and submission guidelines will be available on the journal website.
Box 1. Humanities in CHEST Medicine Editorial Board Members.
Rana Awdish, MD; Pulmonary and Critical Care Medicine, Henry Ford Hospital, Detroit, MI
Michael Neuss, MD, PhD; Internal Medicine, Vanderbilt University Medical Center, Nashville, TN
Jon Tilburt, MD, MPH; Internal Medicine. Mayo Clinic, Rochester, MN
Erin DeMartino, MD; Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
Jessica Turnbull, MD; Pediatric Critical Care Medicine, Vanderbilt University Medical Center, Nashville, TN
Becket Gremmels, PhD; System Vice President, Theology and Ethics, CommonSpirit Health
Benjamin Frush, MD; Vanderbilt, Vanderbilt University Medical Center, Nashville, TN
Douglas B. White, MD, MAS, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA
On behalf of the editorial board for the section on humanities in chest medicine, I am honored to invite you to contribute your thoughts, reflections, research, and stories in this new section. It is good to place our work into perspective. It is even better to explore the varieties of perspectives into which it could be placed. I sincerely hope that these articles will foster interest, introspection, insight, and collaborative research into what makes us what we want to be: good, thoughtful, and compassionate pulmonary, critical care, and sleep physicians.
Footnotes
FINANCIAL/NONFINANCIAL DISCLOSURES: None declared.