Carl Sandburg’s poem,1 about fog rolling in “on little cat feet” comes to mind:
Some moral choices arrive with drama, but most do not. Most come unannounced, silent in arrival—on little cat feet—and are gone almost before we notice.
Forty-five years ago, I was a medical student interviewing for the match. The night before my Peter Bent Brigham Hospital interview, I was on overnight duty.
“I’m having my Brigham interview tomorrow and I’m nervous,” I told my resident.
“You should be,” he said. “They’re brutal. I still remember the question they opened with. It was impossible.”
“Tell me more,” I said.
“Well, they told me a story from the very first days of hemodialysis, which the Brigham pioneered. They said that a patient on dialysis had become confused and then delirious. They called the medical resident to come and see him. The resident examined the man. He noticed nystagmus, immediately made the correct diagnosis, began the correct treatment, and, arguably, saved the man’s life. They asked me, ‘What was that diagnosis?’”
“I have no idea,” I said.
“Neither did I,” said the resident. “Later on someone told me the answer. The man had Wernicke’s encephalopathy. He was acutely thiamine deficient. Dialysis was removing water-soluble vitamins from his body, and no one had, up to that time, realized that the dialysis could cause acute vitamin deficiency. The resident gave him thiamine, and rescued him.”
“I’m cooked,” I said.
The Brigham interview the next day was a marathon of three-person panels, each of which peppered the candidates with questions for 5 or 10 minutes. I was half way through when I entered the room with what I instantly knew was THE panel… the chief of medicine, the head of the residency program, and another world-famous physician. They paused and glared down at me. I gulped, and then the chief began.
“Mr Berwick, some years ago, during the first days of dialysis here, a patient suddenly became disoriented and dizzy. A resident was called, he noticed nystagmus, and he made the correct diagnosis….”
To this day, I recall the surge of feeling. The impulse to burst out laughing. The sweat breaking on my body. Unannounced. On little cat feet. The test was to be not of my knowledge or promise as a doctor. It was to be of my character.
I am not proud of this story. I failed that test. With cold-blooded precision, I furrowed my brow and faked it. I pretended I was reasoning my way to the right answer, even though, without forewarning, I could no more have done that on my own than I could perform an Olympic gymnastics floor routine.
I could see it in their eyes. They wanted me. The questions stopped, and they spent the rest of the interview telling me how fine a place the Brigham was for training.
A day or two later, I could not resist telling a close friend and mentor the funny story. His reaction woke me up. He did not laugh. Instead he said, “I am a bit disappointed in you, Don.”
I realized, I was too. I dropped the Brigham from my match list. But that has never, not to this day, felt like absolution for me. A choice came, on little cat feet, and I did not see it at the time for what it was.
This is the moral choice in its simplest, purest, most elemental form. To tell the truth, or not, when “not” is perhaps in your short-term self-interest.
I say “perhaps” because when I recall that moment of choice, which I have done a thousand times, I can’t help but wonder what would have been the consequence of honesty. “Sirs,” I would have said to the panel, “this is an incredible coincidence, but last night I asked my resident about his interview here, and he told me that same story and the correct answer, which I assure you I would not by any stretch of the imagination, have arrived at.” I wonder what would have happened then. I will never know.
A second form of choice comes in equal silence and has to do with one’s self-image as a physician. It is the choice between being a hero and being a citizen.
The white coat, stethoscope, and prescription rights tempt some physicians into hero mode. Physicians have the power to look and act like we know what to do, even when we do not. We have the power to assert prerogatives denied to others: “my schedule,” “my OR time,” “my air time,” “my excellence.”
But health care is an exercise in interdependency, not personal heroism. Physicians simply cannot do the right job alone. This produces a clash between the time-honored, romantic image of the great physician and the greater need for teamwork, generosity, and deference. That greater need demands that the question, “What am I part of?” should supersede prerogative. It counsels a continual inquiry: Who depends on me? And how am I doing in their eyes?
In the past, an exploration of moral choices might have stopped with these two levels: personal honesty and proper organizational citizenship. But times have changed and the stakes are higher. As a newly minted physician, I held unquestioned the belief that the organizations I worked in and for were, at their core, ethical; that health care institutions usually, if not always, put the interests of those they served ahead of their own.
This may or may not have been true then, but it is not true now. At least, ethics cannot be taken for granted, not when the interests to be served are those of society as a whole. The symptoms of organizational gluttony are rampant, and the damage is severe.
For example, the drugs patients depend on are experiencing price increases that cannot withstand the scrutiny of public interest or moral compass. New biologics of undeniable value are being priced at levels that are not just like extortion—they are extortion, holding patients hostage. Old, invaluable preparations, like insulin, epinephrine, 17-hydroxyprogesterone, colchicine, and others, are being captured or patented under legal loopholes and then priced 10-fold, 30-fold, 100-fold more than their prior, customary levels.
Hospitals today play the games afforded by an opaque and fragmented payment system and by the concentration of market share to near-monopoly levels that allow them to elevate costs and prices nearly at will, confiscating resources from other badly needed enterprises, both inside health (like prevention) and outside (like schools, housing, and jobs).
And this unfairness—this self-interest—this defense of local stakes at the expense of fragile communities and disadvantaged populations goes far, far beyond health care itself. So does the physician’s ethical duty. Two examples help make the point.
In my view, the biggest travesty in current US social policy is not the failure to fund health care properly or the pricing games of health care companies. It is the nation’s criminal justice system, incarcerating and then stealing the spirit and hope of by far a larger proportion of our population than in any other developed nation on earth.2 If taking the life-years and self-respect of millions of youth (with black individuals being imprisoned at more than five times the rate of whites),3 leaving them without choice, freedom, or the hope of growth is not a health problem, then what is?
Second, the harm done to our planet by inattention to and denial of the facts of science is grievous too. If poisoning the air, drying up the rivers, and drowning the cities—our own, and those of the poorest people on earth, and creating a tsunami of displaced people greater than the world has ever known before, is not a health problem, then what is?
Healers cannot deny that leaving refugees at our gates unwanted, or children unfed, or families unhoused, or basic medical care uncovered, or relying on conflict, rather than compassion, are health problems. So is war. So is ignorance. So is hopelessness. So is blaming the blameless.
The work of a physician as healer cannot stop at the door of an office, the threshold of an operating room, or the front gate of a hospital. The rescue of a society and the restoration of a political ethos that remembers to heal have become the physician’s jobs, too. Professional silence in the face of social injustice is wrong.
It is chilling to see the great institutions of health care, hospitals, physician groups, scientific bodies assume that the seat of bystander is available. That seat is gone. To try to avoid the political fray through silence is impossible, because silence is now political. Either engage, or assist the harm. There is no third choice.
Conflict of Interest Disclosures: The author has completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.
Disclaimer: The views expressed herein are those of the author and do not necessarily reflect the views of the Institute for Healthcare Improvement.
Additional Information: This essay is adapted from a graduation address given at Dartmouth Medical School on June 3, 2017.