Andrew Coates: Caregiving As Humankind's Shared Project
In two recent essays Dr. Arthur Kleinman, the eminent Harvard anthropologist and psychiatrist, writes in the world's leading medical journals about caregiving as a moral experience.
One essay appeared last November in The Lancet. A few weeks ago The New England Journal of Medicine published another article by Dr. Kleinman with a similar theme but a slightly different emphasis.
“Consider how central caregiving is to what it means to be human,” Dr. Kleinman writes. “Caregiving is an indelible part of relations between partners, the raising of children, and response to the infirmities of aged parents and grandparents. It is, of course, the very definition of how families and friendship networks cope with sickness or disability among their own.”
He goes on to say there’s “an ancient lineage to caregiving across historical periods and societies,” and in today’s world “[n]ursing, medicine, and the allied health disciplines justify their status as healing professions by underlining their professional commitment to caregiving.”
Dr. Kleinman's words in these essays have delivered for me, a physician, the kind of a jolt you get if you pull off your clothes on a hot June day and jump into a Catskill mountain pond. A systemic shock, then the deep breaths that bring a liberating awareness of the world around us.
Kleinman has drawn a bright line around the sphere of caregiving. He reminds us that our relationships with those we care for give our lives meaning. He then extends this truth to the caregiving professions.
The shock and awareness come refreshingly thanks to Kleinman's gentle assertion that market forces and money interests -- profit-seeking -- serve only to poison and undermine the very relationships that are most defining of our humanity and our profession.
Kleinman writes: “Everyone who has been in love or built a family knows that there are things, essential things, that money can’t buy.
Patients with serious illness and their network of caregivers know this too, because those things that really matter to us are threatened and must be defended.”
He then says many clinicians “reflecting on what is at stake in health care not only for patients but for themselves, know the same thing: the market has an important role in health-care financing and health systems reform, but it should not reach into those quintessentials of caregiving that speak to what is most deeply human in medicine and in living.”
To briefly digress, I so admire Dr. Kleinman's courage. It is not easy to explain the experience of becoming a physician, let alone the ongoing work we do to be the best we can be for our patients and our fellow caregivers. Kleinman locates our profession within a continuity of sharing, self-sacrifice and humanity -- a profession with profound rewards on the most basic and human level, rewards not measurable with money.
He introduces, courageously, a deeply personal element. He offers reflections on the personal role of caregiving for his wife, who developed early Alzheimer's disease.
Dr. Kleinman alludes to the corrosive, corrupting external pressures of what he calls “the market model” and “the clarion call of efficiency” weighing upon doctors and nurses and family members. Yet, from the standpoint of personal responsibility, he doesn’t let any of us off the hook. He challenges all of us to insist that health policies and programs place caregiving at their core.
If we don’t demand this, Kleinman writes, “all of us are demeaned and the profession of medicine and the processes of health care are transmuted into something that is hollowed of its humanity and moral value.”
Dr. Kleinman's honesty brings a liberating awareness. He invites us to face our contemporary crisis in health care with sober senses. Every effort to turn caregiving into a marketplace transaction does indeed demean us – not just we doctors and our patients, but all of us.
As distressing as the idea is that money interests threaten to steal humanity from our professional efforts at caregiving, Kleinman encouragingly notes that among many clinicians the passion for caregiving is still very much alive. This is true in my experience too. The urgent task, however, is to elevate that passion – through medical education and other means – to a new level in the face of challenging, market-oriented headwinds.
In my view, the first step toward protecting the sphere of caregiving from the corrupting influence of money would be to enact a national health program, publicly financed, truly universal, and stripped of the corporate profiteering that afflicts us today. It’s an achievable goal, as other nations have shown us. And it will bring us closer to what Dr. Kleinman calls “enact[ing] care as humankind’s shared project.”
Dr. Andrew Coates practices internal medicine in upstate New York. He is President of Physicians for a National Health Program.
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