“Against the claim that caring belongs to morality and even constitutes its core, I would like to present a counter claim, according to which we need morality precisely because we do not care. That is, we usually lack an attentive concern for the well-being of most members of the human race.” –Avishai Margalit, The Ethics of Memory
Yesterday I saw a patient who is suffering from metastatic lung cancer. He and his family bared their souls about mortality, suffering, and how much treatment is enough. This was not just another day at work, but a profound existential experience that recalls my original motivations for medical school from my admissions essay so many years ago. Today, I cannot recall his name.
This happens to me all the time. While I am with a particular patient, I have honed the skill of being fully present, and for that hour, nothing but this person, and these diseases, occupy my consciousness. Yet later, after I have seen a few other people with equally gripping human tales, I remember many of the details of lab abnormalities, CT scan shadows and medication side-effects, but the name and face often escape me. Sometimes this horrifies me. Yet it is not so uncommon amongst health care professionals who routinely grapple with 10-20 suffering people daily.
What should we remember? Does memory relate to caring, i.e. do we have to remember to have “cared”? These questions become extraordinarily important for the Jewish philosopher Avishai Margalit in the context of the Holocaust and the fraught questions of societal memory. Margalit begins his reflections with the story of a military commander who is interviewed about a combat where one of his soldiers was killed. The commander cannot recall the name of the soldier. “There followed a flood of outrage directed at the officer who did not remember. Why wasn’t the name of this fallen soldier ‘scorched in iron letters’ on his commander’s heart?”
Does my forgetting of my patients’ names indicate a lack of caring? On what level do I have an obligation to remember a name of someone suffering? On a mundane level, I think I am particularly poor at this task compared to my colleagues, and may suffer from mild prosopagnosia. Yet, certainly there would be a difference in outrage if I could not remember my own daughter’s face or name (which I can!). Margalit introduces the concepts of “thin” and “thick” relations we have to other humans:
“Thick relations are anchored in a shared past or moored in a shared memory. Thin relations, on the other hand, are backed by the attribute of being human… and some attribute of being human, such as being a woman or being sick.”
Thick relations form our ethical duties to our “near and dear”. Thin relations constitute our duties to strangers and are guided by moral rules. Where does the physician-patient relationship fall, ethical or moral? Patients come to me because they are 1) human and 2) sick. Those are the only types of patient I see! On this level, I treat them and move on. And yet, has anyone used one of these e-visit type online apps that present a series of questions and then diagnose a condition? Welcome to “thin” medicine.
Surely any good clinician is also “thickly” entwined in the day-to-day concerns of a patient, in their “shared memories”. The Hippocratic Oath engages us on a thick journey with our patients. And it does not stop there. We get to know them in so many ways and through compassion, we “suffer with” them. I believe that some of the most important relations in our lives are precisely so important because they exist in that liminal area between thick and thin. We interact first on a strictly moral level, such as when we first meet a patient. Then, with time, the relationship “thickens” as we care more and more about their personal outcomes and happenings. Importantly, the physician-patient relationship never becomes entirely thick, for that is the path to inappropriate interactions, the blurred therapeutic line, and outright abuse. We all know some colleague or interaction which has fully congealed: loaning a patient some personal money, giving “VIP” treatment, or giving antibiotics over the phone for a friend. Even worse, we know doctors who float on the surface of a very thin gruel: those who won’t take an add-on patient at 4:30pm, accepts no sliding scale fees, and the worst — lack of empathy in those that treat diseases rather than people.
So remember, don’t forget. But it’s ok not to recall a name from time to time.