Important values may be lost in a healthcare system dominated by patient autonomy and standard pathways.
Oh, don’t use big words. They mean so little.
«It’s all about people», says the logo of one of the country’s largest hospitals. This is a relevant and important reminder, creatively invented, but also a commitment. Whether we receive help or act as helpers, inside a healthcare institution or outside, it’s all about us as people. As doctors we combine our professional skills and our humanity in the performance of our vocation, whether we are aware of it or not. Our life experience, our sorrows and triumphs are our loyal companions, including in our professional relationships. Our goal is to be the best version of ourselves, every day. This is what the patients and their next of kin reasonably expect. Such an ambition will also be valued by our colleagues. Most of us stand to benefit from addressing this issue in training courses, the community of colleagues and daily practice (1 – 3).
Bent Høie, Minister of Health and Care Services, has been concerned with establishing «the patients’ healthcare services» (4). This revolves around freedom of choice, patient autonomy and not least that we in the healthcare services should meet the patients with respect, as equals – at eye level. To many, patient autonomy has become a mantra, the ultimate value that overrules all others. Most likely, the situation is more nuanced: autonomy is one among several important values (5, 6). First and foremost, the patients call for kindness and competence, rather than autonomy (7).
Kindness is not so easily captured in health statistics. Although it cannot be measured, and despite of its low cost, kindness has value as a subjective experience for most people. The author Roald Dahl underscored this point in an interview on BBC World in November 1988: «I think probably kindness is my number one attribute in a human being. I’ll put it before any of the things like courage or bravery or generosity or anything else».
Competence is more than professional skill. Professional skill, or the ability to constantly pull new treatment alternatives out of one’s sleeve, is hardly the decisive issue in all contexts. Nor does any technical artistry or frictionless eloquence appear to be the crucial matter. Sometimes it may perhaps be more important to pause for a moment to be able to meet the patient as a fellow human – and not merely as the person with an illness. This will give us access to other aspects of illness. It may help us discern more of the life situation, sense the unanswered questions, understand the pressing concerns: worry about the disease, ponderings over the ways of life, the grief over loss (2, 3, 8).
Are we able to, and do we want to, meet the patients in life’s borderlands? Do we still regard it as part of our medical calling to enter the room where the walls are fragile and delicate, where the line between life and death is becoming blurred? A room where medicine and fact are not the final answers, a room filled with uncertainty even when all available information has been provided, a room filled with loneliness despite the daily visits by family and friends, a room tainted by fear of death, although it may not be imminent. And, at the same time, a room that contains hope of life, although the future no longer is what it once was.
Or is there an elephant in this room? Could it be that as a profession, we are in the process of assuming some sort of collective contempt of death? People’s lives are polished and screened in the hope of reducing risks and enhancing preparedness for contingencies. Doctors’ lives are structured by frameworks, regulations, action plans and standardised patient pathways. But passing through these multi-level processes, are we at risk of losing part of what once motivated us to become doctors?
We must continue to tell medical students and our younger colleagues, but also ourselves, that even though we have filled various roles as doctors through a long career, what we are doing is all about people (5, 9). It is all about the patients’ lives – and our own lives. Life experienced with flaws and mistakes, with disappointments as well as sunny days. As doctors, we wish to add extra days to life and increase the survival rates and life expectancies in the population. Sometimes, however, it is even more important to give life to the days that are numbered. The recognition that neither our good will, nor our tools will suffice may give rise to feelings of inadequacy. This may be demanding, but may also make us wiser.