MedConference 2009

Hope and care

Keynote talk by Giancarlo Cesana, MD

My intention is to document, through the historical and cultural development of medicine, the main statements contained in Giussani’s conference on nursing (1) that you have chosen as an inspiration and a reference point for this meeting. At the beginning of his talk Giussani invites the nurses “to put their heart in their profession (…) According to biblical language, the word ‘heart’ indicates the complex of needs and evidences that constitutes the God-given nature of man and with which we face life”. In the Bible, the heart is conceived as the opposite of what we commonly think, that is, a bunch of subjective feelings, that may be inconstant and quite different in different subjects. The biblical heart is rather described as the objective component of the subject, who, through his heart, is linked – affection – to the whole reality, its appearance and its meaning. This is the reason why, putting the heart in one’s own profession, as well as in any other human expressions, is the condition to understand reality and to live it with the awareness which is necessary to eventually experience happiness. “The human being is that level of nature in which nature acquires the awareness of itself”. Giussani calls it the religious sense, “the sense of responsibility toward destiny”, the great mystery who makes all of us, in which all of us live. Such a sense of responsibility is at the very beginning of the medical profession, as we know it. Hippocrates and his school, in the V-IV century BC, are considered the founders of western medicine because they, following the “scientist philosophers” (Thales, Anaximander, Anaximenes, Pythagoras, Alcmeon, Heraclitus, Democritus, Hempedocles, VI-IV century BC), took the medical practice away from priests and magicians. They are considered the initiators of a new lay approach which, against the previous obscure and religious one, based the knowledge of health disorders on the five senses and not on the interpretation of the will of an obscure god. Actually, if we look at the beginning of the Hippocratic Oath, gods and goddesses – the mysterious truth – are not eliminated but invocated as witnesses to the rightness of medical ability and judgment. There is something or someone greater than human mind and acts; there is something or someone to which or to whom physicians should respond. This awareness is the religious sense: phyisicians do not identify themselves with god like the shamans or pretend to decode the 1 ________________________________________

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thought of god like the ancient priests; their intervention is not magic or omnipotent. Hippocrates’ religiosity is confirmed by his absolute respect for life. Contrary to the contemporaneous Plato, who conceived human existence as a function of social necessity, admitting abortion and euthanasia, for Hippocrates life was a gift and health a gifted equilibrium of humors. The experience of life and nature as a gift has always been the starting point of a difficult, slow and fascinating exploration, so much so medicine has been defined as the “long art”. The knowledge of anatomy, physiology, pathology and medical treatment exploded quite recently, over the course of the last two centuries, after enormous efforts that are made understandable only by the curiosity of penetrating a world incommensurably greater than ourselves. And we have not yet finished. However in the classic world there were not hospitals. People considered illnesses as a malediction and they were terrified by them. Patients with infectious diseases were not assisted but chased away from the cities and left alone in their suffering and death. Even in the very spiritual and humanitarian Jewish society, persons affected by leprosy were not allowed to live in the village and, in case of an unexpected recovery, their readmission had to be certified by the priests. The religious sense of Hippocrates, Galen and their followers was not sufficient to sustain the care of people affected with infectious diseases, who were considered dangerous because they carried contagious illnesses. Whether contagious or critically ill, they carried only one message for themselves and everybody else: death. Giussani says: “….in order to spend one’s life helping others, a great love for life is required, a love that is given only by a Christian sense. The religious sense doesn’t suffice: only the revelation that God loves man, that the mystery of life is love for man and therefore is forgiveness (in fact without forgiveness, without mercy, there’s no love for man because man sooner or later fails), only this can sustain the person”. And he surprisingly continues: “what I struggle to convey is that the first imitation of God that man can live is love toward self. Human beings don’t know how to love themselves, they are all self- centered but they don’t love themselves”. In order to love others, we must be able to love ourselves, and this comes from the recognition that death is no longer the last word on our life. As Gabriel Marcel said, “you love when you say: you won’t die”. God has become a man, has loved and forgiven us, sharing our mortal destiny and winning it, promising a new eternal destiny for each one of us. Faith in this promise, which is an historical fact, changed the world and the medical profession with it. In the fifth century A.D., after the barbarian invasions, Rome – caput mundi – was ________________________________________

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reduced to a forest, in which some fifteen thousand people inhabited ruined buildings. In those terrible times, Benedict from Norcia, in the country of Montecassino, founded a new type of city, the monastery, a community of men dedicated to God. In the monastery people could find refuge, work, education and, if they were poor or ill, hospitality. For the first time in history, in spite of the extremely poor conditions of life, sick people could find other people who took care of them, at risk of their own life. Christ has resurrected therefore no longer death, but hope has become the last word on life. In the beginning, hospitals made no distinction between the poor and the ill, both struck by misfortune and needing everything. However, some centuries later, Guy from Montpellier (XII century), another monk, founded a hospital association (Association of the Holy Spirit) completely devoted to the sick. Italy is full of paintings and sculptures representing the image of the Madonna della misericordia, Our Lady of mercy, who gathers under her mantle (pallium) all those who are in need. The concept of palliative care, applicable to incurable and curable diseases, is derived from this image. It was in the Middle Ages that the Hippocratic Oath became the rule of the medical profession; the religious sense answered by Christ allowed caregivers to “put the heart into the medical and, above all, nursing profession” – for centuries physicians had been able to do very little and medical care was almost exclusively nursing. A pope, Clemens VII (1523- 34), made the oath mandatory for those who wanted to practice medicine. Later on, in what is erroneously known as the “obscure Middle Ages”, the abbots of Montecassino promoted the Scuola Medica Salernitana (Medical School of Salerno). This school was founded in the IX century, according to the legend, by a Greek, a Jew, a Muslim and a Christian who represented together the universal principle of knowledge at that time. Other religious congregations, Dominicans in particular, promoted the first University in Bologna (1088), then in Paris, Oxford and Cambridge. In the meantime the monks transcribed the texts of Hippocrates and Galen; they cultivated in their botanical gardens the medical herbs, which, according to the old traditions of the Mediterranean people, were the most efficacious drugs available, as it was documented by Fra’ Domenico Palombi in his Medicina Sempliciorum and Hildegard of Bingen, a nun and a saint, in her Liber simplicis medicinae. Moreover, the experimental method had its beginning with some procedures such as those set up by Robert Grosseteste, the first Chancellor of Oxford and later bishop of Lincoln, the largest dioceses in England. This approach was greatly developed, much before the time of Galileo and Newton, by Albert the Great, Thomas Aquinas’ teacher, and Roger Bacon.

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Giussani says: “In your profession, more than in others, one could possibly imply a division between faith, a spiritual dimension on one hand, and the professional reality on the other”. The origin of this division is clearly manifested in the Galileo ‘case’, which has been often reported as the paradigm of the impossible unity of faith and reason. As you know, Galileo (XVI century) adhered to the Copernican theory, which entails that the earth turns around the sun and not vice versa, as it was believed at that time because of the direct evidence and the tradition portrayed by the Bible. The Church saw in this theory, which would have been definitively demonstrated two centuries later, an attack to the Holy Scriptures and therefore to the historical fundament of the faith. The ecclesiastical authority, not without grounds, asked Galileo to abjure. Galileo abjured and, in doing so, it is reported that he said: “yet it (the earth) moves”. Certainly the Church made a mistake, as Pope John Paul II recognized, not without grounds, but the Church made a mistake. Since, the Church has been continuously accused to be antiscientific and faith has been regarded as a subjective and unrealistic approach to the objective knowledge and its applications. The problem is not solved yet, and the division between faith and reason, faith and science dominates not only biomedicine like other sciences, but also the medical and nursing profession. Giussani underlines: “the nursing (medical) profession is just matter of precise and measured techniques”. But he adds: “it’s as if, in music, one was looking just for technical perfection. A true artist instead, besides good technique, also invests music with heart, color, and feelings”.  Giussani spent his life to demonstrate that faith is a necessary condition for knowledge. A little child could not learn anything without trust in the mother, a pupil in the teacher, a friend in the friend, a scientist in other scientists, and so on. There is no knowledge without affection, without being struck or moved by someone. It is very interesting that in English ‘to be emotionally struck’ can also be expressed by ‘to be affected’. Koch could not have found the bacillus of tuberculosis without firmly believing in its existence, in spite of the fact that it had not been documented before. That’s why Giussani in the premise of his talk says “if faith determines your work, the unity of your person is preserved”. The crucial alliance between faith and reason seems to be the main concern of Pope Benedict XVI. Starting with his speech at Regensburg, he has been stressing it as the original and decisive contribution that Christianity, after interaction with Greek culture, has given to the western civilization. That faith promotes reason and vice versa is an undeniable experience for people working in the medical field, because of the commitment and the sacrifices required by

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such a profession. The advance in clinical care and in medical research would not be explainable without the dedication of many men and women over the course of centuries. A French motto of the XV century defines medical care as: “curing sometimes, caring often, comforting always”. However medical science has been strongly influenced by a viewpoint, called ‘biological reductionism’, which not only conceives of the person exclusively as his or her biological component, therefore negating a metaphysic dimension, but also forces the focus of medical knowledge to smaller and smaller aspects of biology. Hippocrates did not even name the diseases, certainly because of the limits of the knowledge at that time, but, more importantly, for him the whole person was ill. He had a really holistic approach and inspection and palpation were human acts helping another suffering human being. Five centuries later, his most important disciple Galen, focused the attention on the organs as the source of diseases, but his contribution had important consequences only after the revolution brought about by the study of anatomy. It was Morgagni (XVIII century) who realized that the organ damages commonly attributed to degeneration mortis were actually the cause of diseases. In his fundamental book, De sedibus et causis morborum per anatomen indagatis, he exposed what is known as the ‘localistic approach’ in medicine, which decisively influenced the relationship with the patient and the organization of the hospitals.  In the same century Bishat identified the damage in tissues, Virchow (XIX century) in cells, Pauling (American Nobel prize in 1954) in molecules, up to the genetic and proteomic analyses which seem to dominate the current biomedical research. Therefore the leading trend in medical investigation appears to be the knowledge of everything that is ‘smaller’ and the abandonment of everything that is ‘greater’.  It is useless to say how much the biological reductionism reduces the engagement of health care professionals and the expectation of patients. I do not know what Giussani means by saying that “the health reform that should have been a great social reform has turned out to be very disastrous”, but he probably refers to the poor culture, which grinds the improvements that have been introduced into the health system. (“I can’t make any judgment on your lives from a technical standpoint, but I can assert this truthfully from the human point of view”). “The fact that modern medicine does not have an own (identifiable) doctrine on the diseased person is surprising but undeniable”, said Viktor von Weizsacher (1926). The weakness of this situation has induced the World Health Organization (WHO) to expand the concept of health proposing an all-embracing definition: “health is a state of complete physical, mental and social well-being and not merely the absence of disease or

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infirmity (…) the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition”. (2) The intention of the WHO has been to give life to a global medicine, engaged not only with the ill, but also with the healthy. It has been promoting extensive programs with utopian titles such: “Health for all by the year 2000”, followed by “Health for all in the 21stcentury”, because of the historical failure of the former. It has been noted that the WHO health concept, while indefinitely increases the number of sick people, can easily be translated into a definition of happiness. In this sense, while the WHO has undoubtedly contributed to the creation in Europe of health systems with ‘universal coverage’ – that is, the state guarantees medical assistance to all citizens – it has also legitimated an unlimited demand of health services. The WHO definition of health, supporting the concept that medicine is more than a natural science, aims to ‘socialize’ medicine with some consequences, as pointed out by the acute analysis of Ivan Illich. ‘Medicalization’ is the invasion of medical care into a ground which includes problems that are not necessarily considered of ‘medical competence’ such as menstrual period, pregnancy, childbirth, menopause, old age, solitude, social isolation, and unhappiness. Moreover it constitutes a myth according to which society will be perfect only when scientifically organized. The WHO concept does not exceed the positivistic view of Virchow: “medicine is a social science and politics is nothing but medicine on a grand scale”. And in fact, the aim of a ‘complete physical, mental and social well-being’ coexists quietly with the biological reductionism and with the idea of man “as a bundle of mechanical parts”, and “the sick patient as an object, like a table with a broken leg that needs to be replaced or fixed”(1). A wonderful report, entitled “Beyond therapy”, by the President’s Council on Bioethics (3) deals with the dangers of some application of medicine: “better children, superior performance, ageless bodies, and happy souls”, mostly obtained through (eu)genetics, hormones and drugs that affect the mind. With health as a criterion for social and personal success, insecurity is not tackled but increased. I saw once, many years ago, the advertisement of a private health centre: “Are you well? Who does tell you? If you want to be sure, come to our centre and have a check up”. Prevention was proposed as a form of dependence. Ethical committees and consensus conferences, gathering experts, consumers, politicians and even theologians or priests, are continuously convened to tackle the possible dehumanization of medicine and the insecurity of medical procedures. Their meetings, their massive production of warnings and guidelines do not eliminate the loneliness of the patients, but also of physicians and

job, the patients, the guidelines and everything else. An editorial in the BMJ, published in 2001, was entitled: “Why are doctors so unhappy?”.(4) As Giussani observes: “visiting hospitals and talking to nurses, the only thing emerging was a complaint: I can’t remember even once that a nurse didn’t complain to me”.  The truth is that science is not enough. Karl Popper, who revised the experimental method of modern research, has introduced the principle that results should be reported together with the description of the methods through which they have been obtained, so that they cannot be possibly falsified. As Galileo said, the aim of science is to measure something and not to explain everything, and since it is recognized that science findings are quite provisional, they remain true until the contrary is demonstrated. In fact, the progress of scientific knowledge is based on demonstrations and/or negations of what has been demonstrated. Certainty, as Popper said, belongs to “other kinds of knowledge”, which are as necessary as the scientific one, and perhaps more. People do not live because of scientific certainty; rather the vast majority of existential choices are founded on other than science.  I found a very interesting statement in the introduction to an old edition of the Harrison’s principle of internal medicine (1980). I back translated it into English because I lost the original: “the task of the doctor is to guide the patient through the disease (…) medicine is an art also in the sense that doctors can never be content of the sole fulfilment of the scope to clarify the laws of nature; they cannot proceed in their work with the cold detachment of the scientist, whose aim is the victory of the truth, and who, in doing that, performs a controlled experiment (…) their primary objective is traditional and utilitarian: the prevention and treatment of disease, the alleviation of sufferings, were they of the body or of the mind”. Art is made of and communicates the infinite, the universal sense, which links the particular to the whole. Doctors are not veterinaries, and not because they deal with more complex animals, but because they don’t deal with animals at all. They deal with beings, who search the meaning of their suffering, the link of their life with destiny. The sickness is the sign that the definitive meaning of things and ourselves, if exists, is greater than us. An illness is a warning, the last and most terrible warning, to look for this meaning. Curing and caring go surely beyond kindness and benevolence, they require specific knowledge and training, and moreover a judgement based upon its philosophical or religious components, on the situation of the patient and his/her life goals and the

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context in which the doctor and the patient are inserted. In the fight against disease, numbers are important, but even more important are hope, reciprocal confidence and the awareness of the common destiny on which the relation between physician and patient is based. While an enormous space is apparently given to patient’s decision, up to the assisted suicide, the patient may be insensibly influenced in his decisions, without taking into account an objective morality, which commits the patient and the doctor. The latter, in particular, must surely respond to his/her conscience, but toward a good that is served and not exploited in a way that appears faster, easier and more remunerative. At the limits of what is possible, there is what is forbidden and what is mandatory. In the relation with the patients such problems regard usually informed consent, confidentiality, the limits of professional competence, resource allocation, the definition of death, the care for the incurable and the dying. It is commonly thought that doctors perform better if they learn different viewpoints of different cultures and if they are introduced to the awareness of their mistakes and even to a systematic doubt on what they have been taught. This is abstract and absolutely insufficient. The doubt may be important at the end of a process, to revise what has been done, but not at the beginning; doubt never helps to advance, and to deal properly with dramatic situations. Only certainty, documented by experience, helps; an open certainty, sure of the positive meaning of life, is not afraid of suffering, is able to recognize the unforeseen and the diversity. Certainty is the opposite of presumption and arrogance, which instead are often the paradoxical consequence of insecurity. The short outline of the history of medicine reported above, documents that medical care was born out of a positive and meaningful approach, which finds its consecration in the Christian conception. Without it, it would be impossible to accept that “people always need an extra minute” (1), by which the act of curing and caring can be summarized. Solidarity, sharing the common destiny, is a structural need of the person, who expects it almost as the fulfilment of a right, defined not by fortune or misfortune, but by a dignity, that make us, if not equal, mysteriously brothers. Solidarity is not only an expected help, but also an active impulse: naturally you cannot restrain from assisting a falling child. The difficulty is our weakness in following such an impulse, in particular when a sacrifice is required. Men and women are always tempted to be less ‘man’ and ‘woman’ than they would be and, after all, really are. Medicine calls us to rebuild humanity from the great limit, represented by diseases and from others, more subtle, such as our limits in intelligence and morality. A doctor or a nurse cannot but search for a place, a context, in which such a continuous rebuilding is possible, with the awareness that neither the ________________________________________

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scientific community nor the professional associations are sufficient. These may sustain generosity, philanthropy, skill and expertise, but leave us alone, delivered to our coherence, that, we know, is quite weak. We cannot be really friends of our patients if we do not live by friendship. In an experience of love is mandatory to satisfy and to be satisfied: this is the frame of a friendship guided to destiny, this is the place of the continuous correction (from Latin, to carry together) we need. I conclude with a plea, which is also the most precious suggestion, by Giussani: “It’s only a communion, a lived affection among you who are in the same working environment that can sustain the generosity of your heart and of your commitment, with a capacity for faithfulness that neither depends on the recognition of your patients, on the environment, nor on your personal status (meaning your moods –that is to say, one day you’re very generous, and another day you’re so rude that everyone hopes not to cross paths with you)”. And again: “If you don’t get together, not even faith, not even the Christian sense of life, can keep you faithful in your generosity. What’s needed is for you to be united in a fraternity; otherwise, even if you were extremely generous, you would not last, and sooner or later you would limit your generosity”.  References 1. Giussani L. Always be prepared to give reason to anyone who calls you to account for the hope that is within you. Varese 1985 2. WHO Constitution, 1946 3. www.bioethics.gov 4. Smith R. Why are doctors so unhappy? BMJ 2001;322:1073-1074