A DOCTOR MUSES ON THE SELFISHNESS OF ALTRUISM
(Forbes) - By Daniel Fisher
Sometimes you come across a piece of writing so good, you just want to hang it up and become a plumber instead. The speech below, delivered to the Yale Medical School class of 2011, is one of those. The writer is Frank Bia, medical director at Americares, the Stamford, Conn. disaster-relief and medical aid organization. Before joining Americares, Bia had a long career as an infectious-diseases specialist at Yale Medical School (full disclosure: My wife worked under him there.)
Bia does an excellent job of explaining what motivates clinicians as well as puncturing the myth of selfless service. He also works in a mention of a certain libertarian author whose works are rarely celebrated within the halls of ivy. Well worth a read:
Dean Alpern, colleagues in the Yale Faculty, parents, grandparents, siblings, partners other voluntary members of the intricate support structure surrounding our group of new Yale physicians – today we celebrate and launch Yale Medical School’s Bicentennial class of 2011, who are seated before you. Forty years ago I received my medical degree from Cornell University Medical College on a similar spring day at the NY Hospital in Manhattan, epicenter of my known universe. I dutifully sang Far Above Cayuga’s Waters (which I had never seen) and set out on a medical career. I must honestly remind myself that forty years from now, in the year 2051, some of you will be doing exactly what I am today. Like me, you will have absolutely no idea who spoke at your commencement. Nevertheless, I thank you all, the last Yale class I was privileged to teach in the classroom and at the bedside.
I am fond of reading NY Times obituaries, as they often trace the arc of a person’s life. Before my own obituary becomes a permanent document, I take this commencement opportunity as a gift from you. I can actually dictate it myself – right now.
Seven billion of our species inhabit this invitingly vibrant planet. In 1945, as World War ll ended, and I dropped in at the Bronx Maternity Hospital, there were about 2 billion of us – not all in the Bronx, although it sometimes felt that way. By the time my wife, now Dr. Peggy Bia, and I entered medical school in the late sixties great hopes were emerging, based on ideas like equality, civil rights and social justice. Some have come to fruition, and others have clearly not reached maturity. What characterizes most human societies today, including our own, could, to some extent, be characterized in a single phrase – increasing disparity and inequality. In our own country, we have reached a point where one-quarter of all yearly income accrues to just 1 percent of the population. Disparities like this are unprecedented in our country; they are not sustainable; they are dangerous and they extend deeply into virtually every society – ultimately weaving themselves into the torn fabric of human healthcare. If we sincerely believe that healthcare is a basic human right for every member of our species, and not just a privilege for those who can afford it, then clearly, my colleagues in the Class of 2011, you have your work cut out for you.
So how is it that I came to the place where I am in my life now – a physician and medical director of a humanitarian and disaster relief organization, called AmeriCares. And why does this new role contribute to my personal sense of satisfaction and happiness? More importantly, does it even matter whether I am happy or not? Isn’t this all about some form of ethical altruism – helping, serving or living for others, erasing disparities, and doing so at the sacrifice of our own self-interests?
Not on your life. And not on mine either.
The story I wish to share with you is a blatantly personal one beginning with a kind of literary relationship between two very different women, both of whom greatly influenced my life. The first was a Russian immigrant, Alisa Zinovyevna Rosenbaum, who arrived in the United States in 1926, while in her early twenties, and began writing. The second was my mother, Anita Ioppolo Bia, born in that same year, 1926, youngest of seven in an immigrant Sicilian family, patiently practicing their one true faith – an abiding faith in education. I can still see my mother, in her early thirties, raising four sons in the Bronx, stealing precious time to read, before ethnic Mediterranean havoc completely overtook the dinner table in our apartment. You have all seen that movie, I am sure. Often I found her avidly reading the works of Alisa Rosenbaum, whom she revered….but I am getting ahead in my story.
We might first consider some critical aspects of your social contract – the one that defines your medical professionalism from this point on, once you take that Hippocratic oath. They include your putting patient welfare and autonomy first and placing them within a greater commitment to social justice. In return for your service to individual patients and contributing to the public good, for your assurance of competence and a high level of morality, for your integrity, your accountability, transparency and objective advice – you will be accorded very significant privileges as physicians. They include deep trust, autonomy and self-regulation, participation in public policy, funding for what we value in both patient care and medical research in addition to many personal rewards. However, there is one other proviso. The medical social contract calls for altruistic service. But ethical altruism stipulates that one’s deeds benefit the recipient, and not necessarily one’s self. The word altruism is derived from Latin through French and refers to “other people.” Auguste Comte, a French philosopher, coined the term, and he believed that individuals had a moral obligation to renounce self-interest and live for others. Frankly, I do not agree with this concept.
In fact, I never understood why I felt such discomfort with this idea of altruism as solely for the benefit of others until 1982. My father died suddenly and within months so did my mother, both at a young age. My mom died just two weeks before Peggy and I left on our first trip to Hôpital Albert Schweitzer in Haiti’s Artibonite Valley. That hospital, built by Dr. and Mrs. Mellon, provided ample opportunity to practice our craft using the skills that Peggy has been so insistent upon transmitting to you – listening to and with one’s heart and using one’s hands to both diagnose and touch another person’s life. On our return to Yale, I did my requisite medical Grand Rounds. During question and answers, I was lauded by a generous colleague for my “altruism.” I knew in my marrow there was something very wrong in that. “You don’t understand,” I said. “At this point in my life, I needed Haiti one hell of a lot more than Haiti needed me.” It was really in my own moral and physical self-interest to be in Haiti, where I achieved some healing. But healing whom? Healing myself, mostly. Haiti and its people had intersected with both my personal grief and medical skills. Together they had become part of a personal re-emergence. At that time, without telephone lines, computers, third party payers and with seemingly endless medical needs in rural Haiti, I found myself appreciating how I could make a difference – one patient at a time. It made me happy, and that very much mattered to me.
You see, no set of religious or societal mandates could have sent me there, nor would any forced marching orders have produced this kind of response in me. So I began to understand something about professional altruism. I think my mother, Anita, or Alisa Rosenbaum, for that matter, would have grabbed me by the shirt and said, “Listen Frankie. (She called me Frankie). You have to own it. If your good works are not yours, then no matter how good you are at them, no matter how much you give – if they are done solely at the request or even the mandate of others you will not be happy –not as happy as you deserve to be.”
They both would have understood that ultimately it was very much about me, and reject the classical concept of altruism, or selfless giving to others, because it excludes benefit to the person who does the giving. As if receiving something in return diluted or contaminated the effort. No, there is always something very much about service that is critical to one’s own inner needs. Once a person recognizes those needs, the rest will follow. I regretted not being able to return from Haiti, and tell my own mother she was right in person, except while standing quietly in a cemetery before a stolid, granite stone with the newly carved names of my parents in it.
So what formula for professional happiness can I offer you over your next forty years? It is a contract – the social contract. It is one that has already been written, not for you but by you. And will you have to “altruistically” surrender your personal interests, your autonomy and the primary reason for your existence – life, liberty and the pursuit of your own personal happiness? My answer is decidedly, no.
Others have wrestled with this moral issue beautifully during their lives. I found one solution written on the walls of the Schweitzer Hospital itself. In his own words:
I do not know what your destiny will be, but one thing I do know: the only ones among you who will be really happy are those who will have sought and found how to serve.
You see “Self-ishness” becomes a virtue when your own happiness is tied to service, just as Schweitzer described – finding whatever uses you up to your fullest capacity, and knowing that you are loving nearly every minute of work. It really matters very little what peculiar gemisch of motivations leads you to this end. We are all different in that regard, as different as our destinies. In Hebrew one says tikkun olam, a sort of taking the world in for repairs. In Hindi, paropakari sewa which is not selfless service but includes benefit for the one who gives. In Spanish, probably best expressed when working together in solidaridad, and in Kiswahili, huduma or simply, service. Regardless, what matters is that you own your own motives completely.
Yale alumni have been known for their unusual sense of service over the past 200 years. One of your predecessors, Dr. Kinari Webb, Yale class of 2002 found her passion for medicine growing adjacent to the threatened rain forests of Borneo. Her motivations are complex, and may not match your own, but you can always bring your skills to her new hospital when it suits you. And I hope you will contact our Medical Outreach Program at AmeriCares for the pharmaceuticals and supplies when you need them. In our own community Dr. Suzanne Lagarde, my longtime friend and colleague – and respected gastroenterologist – visited post-Katrina Mississippi and did not like what she saw. Access to her medical specialty is virtually impossible for the uninsured. So while she continued her successful career here, she negotiated the byzantine process of obtaining a Mississippi medical license. For one very busy week every three months she cares for patients in Mississippi and performs procedures, such as endoscopy, to which they would never have access. Technology and new professional colleagues in Mississippi allow for more than adequate follow up. No wonder that Sue is an optimistic and happy person. Dr. Vivek Murthy, a recent Yale graduate, is co- founder and president of Doctors for America. He will make his own difference serving on President Obama’s Health Advisory Panel.
Personally, I could not be doing what I do on a daily basis, if I did not also practice medicine at AmeriCares Free Clinics for the uninsured because I need this piece to define myself as a physician. And you don’t have to go abroad or provide care for the uninsured to commit yourself to service. You just need to remain patient-centered, and neither dictated to nor consumed by a flawed system of healthcare. Then you will find your own happiness of personal excellence in service.
I find that in keeping with Yale tradition the class of 2011 has crafted its own version of the Hippocratic oath. But make no mistake, it all began with many of the people seated behind and around you – parents, grandparents and siblings who first taught you the language of service. Recall one of the first words they slipped into your vocabulary – share. Share your crayons, your bike, your stuff – your life. And that word echoes throughout the oath you wrote. I know because I asked Dean Nancy Angoff for a copy of it.
I will serve those in need without bias or prejudice, and I will never lose sight of the fundamental humanity that links us all.
These are your words, not mine
I will practice the art of medicine for the benefit of my patients above all else…..
You listened well to those early lessons. But you end it with a very important proviso. You say:
I know that I cannot effectively care for patients without also caring for myself. I will maintain perspective by seeking wellness, balance, and happiness in my own life, both within and outside my career.
This is the virtue in selfishness, because without meeting your own personal needs, you will be of very little use to others. You cannot share, what you don’t even have.
And I think you have gotten it right.
Returning to the two women who influenced me. Following my father, Anita and Alisa died within weeks of one another in the spring of 1982. Neither had lived to see the steady rise of Alisa’s literary and philosophical influences that followed. In 1991 – a survey was conducted for the Library of Congress. Respondents were asked about the most influential books in their lives. Alisa’s work came in second after something called The Bible. When Alisa Rosenbaum reached the United States in 1926 she adopted and wrote extensively under her new name, Ayn Rand, and that book was Atlas Shrugged. Unbelievable. Can this be true?
Alisa’s work has been hijacked and co-opted by elements in our society that are the most eager to maintain inequalities. They quote her philosophy of objectivism as their excuse for continued disparities – they speak of individualism versus your personal social contract with society, free market capitalism versus intelligent economic and social policy, and severely limiting the role of government, rather than bending it to the public good, especially in healthcare. This is an egregious distortion of her work and it serves to foster even more inequalities in healthcare. The antidote for this movement is to both find and connect with your own personal prescription for service. This will not only enhance your professional lives, it will mitigate against such inequalities and healthcare disparities.
I believe the life we have been given to lead is our own responsibility, and does have our happiness as a primary goal. To the extent that we forfeit that primary goal we defeat the purpose of our own lives. My mother knew that to be a truly moral human being one must act upon one’s own rational self-interests. You also deserve to be the beneficiary of your own moral actions. Let no institution, no system, no healthcare industry or “business ethic” take that away from you, and you are guaranteed a great measure of personal happiness. And that, I can assure you, is one of this world’s most infectious entities. My best to you all.