“I grasp the hands of those next me, and take my place in the ring to suffer and to work, taught by an instinct, that so shall the dumb abyss be vocal with speech.” —Ralph Waldo Emerson
I met the patient i will call Amy early in my residency. “She looks sick,” our nurse told me, displaying a concerned look I had learned to trust. I walked into the examination room to meet a frail, middle-aged woman fervently pacing, tearful and wheezing through a dense miasma of perfume and cigarette smoke.
Amy presented with an unforgettable constellation of physical exam findings: bilateral ear infections, leukoplakia (white patches) on her tongue, and a stab wound. She was homeless, and the stab wound came from her boyfriend, who also provided the meth she had smoked that morning. It was the oral leukoplakia that proved the most ominous; she was diagnosed soon after with metastatic cancer of the mouth and throat.
I’ve thought about Amy many times over the last few years. As a resident physician, I participated in her admissions and bounce-backs, working with fellow residents and faculty to coordinate social support and care. But a life of unhealth, addiction, and violence led irrevocably to profound alienation from family, friends, and medical resources. As if driven to the point of no return, Amy no-showed visits, left AMA (against medical advice), and refused to see specialists. We hung our heads as she was systematically kicked out of every boarding home and refuge in the area. Her family stopped answering our calls.
The last time I took care of Amy, she was almost unrecognizable: emaciated and brittle, and in terrible pain. We admitted her, in part, because she was threatening to take her own life. I visited her hospital room shortly after. She begged for our hospital’s applesauce, which was the only food she could stomach. Her requests were peppered with a truly impressive repertoire of profanity, garbled by the surgical removal of part of her tongue. Even when she was asleep, the folds and furrows of her face seemed locked in an expression of bitterness and misery.
Amy was one of the few patients whom no one seemed to like. She was, literally, friendless. Even the most empathetic among us were seemingly unmoved by Amy. She was suffering, yes, but she had become insufferable.
Much has been said about the “epidemic of loneliness” in the West – the great unmooring of neighborly life, the bewildering rates of anxiety, depression, and “deaths of despair” that seem dose-dependent on social media use, as some studies have suggested. This epidemic demands renewed attention to how, and whom, we befriend, especially in institutions such as hospitals that host human beings at their most vulnerable. The very idea of the hospital, after all, is born of the call toward hospital-ity and love of the poor and the stranger. But friendless patients like Amy press most clearly on the failure of contemporary medical ethics to inspire and sustain the moral imagination of medical trainees.
The classic framework of principlism taught in all medical schools, in its emphasis on the four principles of respect for autonomy, beneficence, non-maleficence, and justice, leaves patients like Amy in a precarious place. On the wards, I remember, we repeated the word “autonomy” frequently, as if to justify a Pyrrhic victory: she was dying, but at least we had maintained our principle. I remember someone saying, “She made her bed; she can sleep in it.” I don’t remember speaking up. I do remember vaguely nodding along.
Beneficence and non-maleficence were little help either. “We’ve done everything we can possibly do” was repeated each morning, suggesting that the tasks of pursuing good and avoiding harm had been exhausted and the best we could hope for seemed to be the maintenance of the status quo. A senior resident on the team put it starkly: “The best we can do in this situation is discharge her with pain control. She’ll probably come back again in two weeks or die on someone’s doorstep.”
As for justice, someone commented, in one of the team’s most cynical and burnt-out moments, that the only “just” thing to do was to “just let her die.” Here was justice, cut down to an adverb. An older physician took it so far I still can’t believe he said it aloud, a whiff of the hidden curriculum that still rots behind the closed doors of medicine: “What we need here is not a TOC, ‘transition of care,’ but a TOB – ‘take out back.’”
Such comments often come from clinicians who by all other accounts are competent and compassionate. They’re often doctors who win teaching awards. I had heard the same physician call for renewed care for marginalized patients. And that is precisely the tension: there are some forms of suffering so abysmal, some patients so insufferable, that they reveal our ethical posturing. With Amy, we yielded to a dehumanizing and grisly gallows humor because it made a kind of awful, dissonant sense. This was how we got through morning rounds when we realized we couldn’t heal a patient.
How we conceive of autonomy, goodness, and justice (or their absence) serves as a fulcrum to reimagine the care clinicians offer for patients like Amy. The philosopher Andreas Esheté argues that in the revolutionary triad of liberty, equality, and fraternity, it is fraternity that serves as the scaffold for both liberty and equality. And yet, ironically, fraternity is the feature most likely to be omitted from modern descriptions of justice. In other words, in the context of a contemporary emphasis on personal fulfillment and social fairness, we eclipse the role of fraternity – mere friendship – in our pursuit of justice. With Amy and other insufferable patients, an emphasis on liberty and equality (autonomy and justice) proves inadequate. As Sheldon Vanauken writes in Under the Mercy, “We can all agree that we ought to love our neighbors, except of course the awful ones we happen to have.”
But fraternity might breathe new life into our medical ethics. Aristotle says that a life without friends is not worth living, even a life possessed of “all other goods,” such as health, community, or beauty (Nicomachean Ethics, 1155a). If so, then what about a life, like Amy’s, stripped of all other goods and void of friendship?
The number of “close friendships” in the United States has declined dramatically over the last three decades. According to the Survey Center on American Life, 12 percent of Americans reported they had no close friendships in 2021 compared with only 3 percent in 1990.
Of course, a medical ethic of fraternalism cannot mean what we popularly mean by friendship: emotional affection built on shared interests or experiences. Indeed, Aristotle famously categorized friendship into three types: friendships of utility, pleasure, and virtue (Nicomachean Ethics, bk. 7).
An ethic of fraternalism cannot be based on Amy’s utility – what she might offer us, an interesting case history or clinical pearl perhaps. Amy’s case may have been interesting at first, but we admitted her so many times that there seemed to be nothing left for us to learn from her. A fraternalism of pleasure was impossible; her care was far from enjoyable.
If an ethic of fraternalism is to contribute to the moral imagination of medicine, it must be this third category, friendship of virtue – sometimes called a moral friendship – in which we commit to seek the good of the other regardless of the experience of caring for them, what they might offer us in return, and perhaps especially what they “deserve.”
It is easy to function as a medical meritocracy, in which the attention and care we offer to the suffering is contingent upon their effort, participation, or “compliance,” and in which we commit to seek the good only insofar as the patient seeks the good too. The good doctor helps those who help themselves?
Whereas principle-based ethics may succeed when patients have the capacity and wherewithal to choose “the good” for themselves, a medical ethic of fraternalism is more fitting when patients are confused, choosing poorly, or not choosing at all. A medicine of moral friendship recognizes that it is precisely those who consistently do not choose the good who may be most in need of accompaniment and healing.
A family member recently asked if it makes me angry “when people don’t take care of themselves.” I pointed out that patients who “don’t take care of themselves” are often burdened by other cares (such as taking care of others who can’t take care of themselves). “Self-care,” a near-perfectly ironic term, is often available to the optimized elite who can afford yoga and counseling. Those who don’t have a vision for bodily well-working – who are apathetic toward their creatureliness – are often the ones most in need of medicine. My family member wasn’t convinced.
Later that night, we watched John Hughes’s classic Planes, Trains and Automobiles, which struck me as an example of moral friendship with the insufferable and those who don’t take care of themselves.
John Candy plays Del Griffith, an obese, overbearing shower-curtain-ring salesman with smelly feet and a long list of peccadilloes. Steve Martin plays Neal Page, a confident and chilly marketing executive just trying to get home for Thanksgiving. The movie’s plot and humor hinge on Del and Neal continuing to cross paths, suffering together the misery of disrupted travel plans and forced companionship.
Planes, Trains and Automobiles is a subversive witness here, because it is the insufferable Del who steadfastly attempts to befriend. Del is clearly annoying, but Neal reveals his own sins in his self-assurance and entitlement. They’re both insufferable, and it is in something like moral friendship (though they aren’t “buddies”) that the movie finds its enduring warmth and staying power.
It’s interesting that Del is always talking about the friends he has made while selling shower curtain rings, while Neal never mentions a single friend. Del is eager to share the unexpected assets of his connections. Neal just wants to pay and be done with it.
But something about Del’s presence begins to slowly soften Neal. It is over a cramped meal that Neal says offhand, “I’m spending too much time away from home,” foreshadowing Neal’s thanks to Del near the end of the movie: “You got me home … a little late … but I’m a little wiser too.” What happens next – when Neal finally gets on his long-awaited subway ride home, puts all the pieces together, and returns to find Del sitting alone in a train station – is one of the most poignant scenes in comedy film. Roger Ebert gave it four stars, calling it a “moral rebirth” akin to Scrooge’s in A Christmas Carol:
The movies that last, the ones we return to, don’t always have lofty themes or Byzantine complexities. Sometimes they last because they are arrows straight to the heart. When Neal unleashes that tirade in the motel room and Del’s face saddens, he says, “Oh. I see.” It is a moment that not only defines Del’s life, but is a turning point in Neal’s, because he also is a lonely soul, and too well organized to know it.
I haven’t forgotten about Amy. She was an arrow straight to the heart of what we were doing in medicine. She continues to reveal to me how strangely lonely we are in medicine and “too well organized to know it.”
What did a medicine of moral friendship mean for Amy? It didn’t mean that we sat in her room swapping stories with her. Most of her tongue had been removed; we spoke very little. We understood there are distinctions between fraternization and an ethic of fraternalism.
What fraternity did mean was that the team did not sacrifice Amy on the altar of her own autonomy. We stopped speaking in terms of her merit – as a vagabond who deserved her state and did not deserve our medicine. But this took explicitly naming all I’ve said above, interrogating it candidly in community, repenting over what we had said, disrupting the momentum of morning rounds to point toward a different way of treating and speaking about the insufferable. Amy forced us to ask crucial questions we should have been asking long before: What are we doing here again? Who are we becoming? What is medicine for … and who is medicine for?
Medicine can be lonely. And I hate to say that we often transmit that loneliness. I think we tried to look at Amy, in all her fragility and mutuality, as a moral friend – unrecognizable in her suffering, perhaps, but no less worth our attention and fumbling attempts at forbearance. At the very least, this ethic of fraternalism allowed us to take a moral breath, fostering a kind of candor to name the paradoxes of her care and the care of many others we struggle to heal: we can’t keep caring for you; we will keep caring for you. Yes, you are responsible for some of this; some of this you are not responsible for. No, you’re not going to get better; no, we won’t abandon you.
I don’t know what happened to Amy or where she is now. I have no peaceful ending to offer here. We eventually discharged her, and she was admitted shortly after at a different hospital. I stopped following her care, but she has followed me.
The poet and pediatrician William Carlos Williams writes, “There’s nothing like a difficult patient to show us ourselves.” Amy, in all her suffering and insufferableness, shows us to ourselves. And sometimes what we see is not pleasant. Our reflection is just as broken and in need of friendship as the friendless patient who revealed it to us in the first place. What we do at the limits of our medical ethics reveals what kind of medicine it is that we are being formed to practice.
My wife was once driving with our sons. As they passed the hospital, she said, “That’s where your daddy works!” My youngest son, all of two years old, declared, “He’s a doctor!” My wife asked him what doctors do, to which he replied, “They have friends.” Laughing, she asked him again, “Yes, but what do they do?” My son answered, “They save friends.”
What a beautiful imagination.