Atul Gawande
Graduates, wherever you go from here, and whatever you do, you will be tested. And the test will be about your ability to hold onto your principles. The foundational principle of medicine, going back centuries, is that all lives are of equal worth.
This is a radical idea, one ultimately inscribed in our nation’s founding documents: we are all created equal and should be respected as such. I do not think it a mere coincidence that among the fifty-six founding fathers who signed the declaration of our independence was a physician, Dr. Benjamin Rush. He was a committed revolutionary and abolitionist precisely because of his belief in the principle.
We in medicine do not always live up to that principle. History has been about the struggle to close the gap between the aspiration and the reality. But when that gap is exposed—when it turns out that some people get worse or no treatment because of their lack of money, lack of connections, background, darker skin pigment, or additional X chromosome—we are at least ashamed about it. We believe a C.E.O. and a cabbie with the same heart disease deserve the same chance at survival.
Hospitals are one of the very few places left where you encounter the whole span of society. Walking the halls, you begin to understand that the average American is someone who has a high-school education and thirty thousand dollars a year in per-capita earnings, out of which thirty per cent goes to taxes and another thirty per cent to housing and health-care costs. (These Americans are also told, by the way, that people like them, the majority of the population, have no future in a knowledge economy, because, hey, what can anyone do about it, anyway?) Working in health care, you also know, more than most, that we incarcerate more people than any other economically developed country; that thirty per cent of adults carry a criminal arrest record; that seven million people are currently incarcerated, on parole, or on probation; and that a massive and troubling proportion of all of them are mentally ill or black.
Video From The New Yorker
Most people don’t have this broad vantage. We all occupy our own bubbles. Trust in others, even our neighbors, is at an historic low. Much of society has become like an airplane boarding line, with different rights and privileges for zones one to ninety-seven, depending on your wealth, frequent-flier miles, credit rating, and S.A.T. scores; and many of those in line think—though no one likes to admit it—that they deserve what they have more than the others behind them. Then the boarding agent catches some people from zone eighty-four jumping ahead of the people in zone fifty-seven, and all hell breaks loose.
Insisting that people are equally worthy of respect is an especially challenging idea today. In medicine, you see people who are troublesome in every way: the complainer, the person with the unfriendly tone, the unwitting bigot, the guy who, as they say, makes “poor life choices.” People can be untrustworthy, even scary. When they’re an actual threat—as the inmate was for my chief resident—you have to walk away. But you will also see lots of people whom you might have written off prove generous, caring, resourceful, brilliant. You don’t have to like or trust everyone to believe their lives are worth preserving.
We’ve divided the world into us versus them—an ever-shrinking population of good people against bad ones. But it’s not a dichotomy. People can be doers of good in many circumstances. And they can be doers of bad in others. It’s true of all of us. We are not sufficiently described by the best thing we have ever done, nor are we sufficiently described by the worst thing we have ever done. We are all of it.
Regarding people as having lives of equal worth means recognizing each as having a common core of humanity. Without being open to their humanity, it is impossible to provide good care to people—to insure, for instance, that you’ve given them enough anesthetic before doing a procedure. To see their humanity, you must put yourself in their shoes. That requires a willingness to ask people what it’s like in those shoes. It requires curiosity about others and the world beyond your boarding zone.
We are in a dangerous moment because every kind of curiosity is under attack—scientific curiosity, journalistic curiosity, artistic curiosity, cultural curiosity. This is what happens when the abiding emotions have become anger and fear. Underneath that anger and fear are often legitimate feelings of being ignored and unheard—a sense, for many, that others don’t care what it’s like in their shoes. So why offer curiosity to anyone else?
Once we lose the desire to understand—to be surprised, to listen and bear witness—we lose our humanity. Among the most important capacities that you take with you today is your curiosity. You must guard it, for curiosity is the beginning of empathy. When others say that someone is evil or crazy, or even a hero or an angel, they are usually trying to shut off curiosity. Don’t let them. We are all capable of heroic and of evil things. No one and nothing that you encounter in your life and career will be simply heroic or evil. Virtue is a capacity. It can always be lost or gained. That potential is why all of our lives are of equal worth.
In medicine, you are asked to open yourself to others’ lives and perspectives—to people as well as to circumstances you do not and perhaps will not understand. This is part of what I love most about this profession. It aims to sustain bedrock values that matter across all of society.
But the work of preserving those values is hard. When I began my story, I made a point of not telling you the inmate’s crime, although one of the policemen told me. I wasn’t sure whether it’d change how open you’d be to putting yourself in my shoes as I wrestled with what to do.
The man’s vital signs were normal. He had no abdominal tenderness. An X-ray showed the razor hadn’t perforated his gastrointestinal tract. I put on gloves and unwrapped his blood-soaked dressing. I held pressure. He’d made numerous slashes but none deep enough to reach an artery. I’d heard that inmates sometimes swallowed blades wrapped in cellophane or inflicted wounds on themselves that, though not life-threatening, were severe enough to get them time out of prison. This man had done both.
I tried to summon enough curiosity to wonder what it had taken to push him over that edge, but I couldn’t. I only saw a bully. As I reluctantly set about suturing together the long strips of skin on his forearm, he kept up a stream of invective: about the hospital, the policemen, the inexpert job I was doing. I don’t do well when I feel humiliated. I had the urge to tell him to shut up and be a little appreciative. I thought about abandoning him.
But he’d controlled himself enough to hold still for my ministrations. And I suddenly remembered a lesson a professor had taught about brain function. When people speak, they aren’t just expressing their ideas; they are, even more, expressing their emotions. And it’s the emotions that they really want heard. So I stopped listening to the man’s words and tried to listen for the emotions.
“You seem really angry and like you feel disrespected,” I said.
“Yes,” he said. “I am. I am angry and disrespected.”
His voice changed. He told me that I have no idea what it was like inside. He’d been in solitary for two years straight. His eyes began to water. He calmed down. I did, too. For the next hour, I just sewed and listened, trying to hear the feelings behind his words.
I didn’t understand him or like him. But all it took to see his humanity—to be able to treat him—was to supply that tiny bit of openness and curiosity.
Graduates, you have studied for thousands of hours on end. You will be licensed to make diagnoses and prescribe an armament of drugs and procedures. Most of all, you will be given trust to see human beings at their most vulnerable and serve them. That trust is earned because of your values, your commitment to serving all as equals, and your openness to people’s humanity. The renewal of these values is why we’re all so grateful to be here—and so grateful that you will carry those values on, beyond us.
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