Volume 2, Issue 3 -- May 1999

Harmonizing Knowledge and Wisdom

Are health care decisions exclusively "medical" decisions?

This question was simply and eloquently put forward by George Webster and Pat Murphy in the PHEN Newsletter of March 1999. In answer, they state, "If they are, this would mean that doctors, by virtue of their extensive medical knowledge and training about the human body, how to diagnose diseases and how to treat diseases, would know what, overall, is "best" for their patients." They go on to suggest that this is not "an accurate, or full account, of what is involved in coming to a decision about someone's health care." That in fact, "although medical knowledge plays an essential role in health care decision making, it is incomplete without another kind of knowledge; knowledge that only patients themselves... can contribute."

This is an extremely important point, and represents a conundrum increasingly experienced not only by physicians, but by all health care providers and decision makers. We work against a scientific backdrop where outcome and evidence based practice is of paramount importance. Yet we must make choices that respect patients' concerns and input with regard to the ultimate goals of treatment.

Medicine and Humanism

Can a physician utilize both scientific knowledge and human understanding in a world that increasingly demands a reliance on "evidence"? Robertson Davies addresses this question in a work entitled "Can a doctor be a humanist?" published posthumously in a collection of unfinished titles, The Merry Heart.

In order to better understand these "two kinds of knowledge", Davies begins by examining a symbol that has for centuries been the special mark of our profession, a symbol that represents the power of healing we have inherited from the past, and from the world of mythology. This symbol is of course the Caduceus - the Staff of Mercury, entwined by two great serpents. But what possible importance could this symbol have in our modern, daily lives?

Mercury, (or the Greek god, Hermes), originated much earlier as an adaptation of the Egyptian god Thoth. This Thoth, the god with a man's body and the head of a bird, was the god of all intellect, the inventor of the arts and sciences, of music, of astronomy, of speech, and of all written word. His Staff embodied his power.

Legend has it that Thoth came upon two powerful "serpent spirits" engaged in mortal combat. With the serpents writhing at his feet, the god thrust his staff between them. They entwined around it, forever in contention, and yet forever reconciled in a mutuality of power. This balance became essential to the healing power of the Staff.

Knowledge and Wisdom

Who are these mythical serpents from the distant and irrelevant past? These snakes are Knowledge and Wisdom.

KNOWLEDGE, or "medical knowledge" as Webster and Murphy call it, comes from outside ourselves. It is acquired through long and dedicated education and practice - a knowledge brought from the outside as it were, to our encounter with our patients.

The "other kind of knowledge" is WISDOM, the introspective element having its origin from within. It is what unites the practitioner with his or her patient, the partnership that brings the magic and the cure. Truly, this 'magic' is far more significant than any of us know or understand.

Forces Toward Science

New problems exist today that make it ever more difficult to balance these two serpents. In a society that demands an accountability of physicians not felt by other practitioners, it is easy and ever tempting to rely solely on the god of Science. Clearly, Science has contributed enormously to the control of terrible illness. But it continually seeks to devour the other god, the god of wisdom and humanity. Physicians are often charged as uncaring, insensitive, distant, and failing to treat their patients as people. Indeed we all hear of far too much insensitivity in our professions, but I would suggest that this is far deeper than mere personal style. I believe the problem to be inherent to the environment of medicine in which we work every day, an environment which we inevitably become a part of.

As medical students, we are taught to focus on the transfer of highly objective information. Our language is thin and sparse, uncluttered by unnecessary words or subtle innuendo. A technically excellent medical history may in fact be unrecognizable to the patient as his or her own story. It becomes voiceless. I recognize this in myself as my computer grammar program continually reprimands me for writing only in the "passive voice". Clearly there are important, pre-determined elements of time constraints, intolerance of ambiguity, and disregard for patient-initiated queries and perspectives that are modelled and learned.

Further, we practice within a climate of constant economic upheaval and fiscal restraint, yet we remain too naive of how our decisions are influenced by institutional structures and policies that are committed to resource allocation, rather than our patients' best interest. This, in my experience, is too often at the root of the wrong decisions I make and live to regret.

Writing a DNR

I was recently asked to "get a DNR order" for a patient's chart. The patient was a 56 year old woman who was initially admitted for surgical resection of a pelvic tumor. Unfortunately, the tumor was far more extensive than initially appreciated, and was not only unresectable, but beyond any further efforts directed toward a cure.

This patient was now clearly "palliative", but because she was still on an acute surgical floor, it seemed only reasonable that a DNR order be a part of her treatment plan. Within moments of broaching the subject, it became eminently clear that neither the patient nor the family were anywhere near the emotional mindset to even discuss this, much less agree to it. As a result, I could only plant the seed for more thought and discussion over the next few days.

A DNR order was an appropriate treatment approach for this woman. Indeed, experience suggests that to resuscitate her would likely prove to be less than kind. It is easy to understand how a DNR order could be seen by "medical people" to be in the patient's best interest. At that moment however, it was entirely inappropriate within the context of the situation as seen by the patient and family.

I often wonder how much we understand of the subtle influence on our work of the broader institutional frameworks we have become a part of on the one hand, and of the constant admonitions to be "gatekeepers" of scarce resources, on the other. Truly such matters as writing DNR orders are difficult decisions. And it is, in the end, the physician that must make them.

Preserving the Balance

At the basis of preserving the balance between knowledge and wisdom in a healing relationship is the cultivation of an attitude of "close, caring attention". Wisdom in this situation represents the ability to put aside our institutional needs and concerns in order to attend fully to our patients' needs - patients whose experiences may be totally different from our own. This kind of wisdom shifts our thinking away from a picture of a physician applying objective evidence to a "medical decision", to a picture of a person deeply connected to another through a shared vocabulary and an understanding of the life events described.

The impact of the caduceus should be this - that it constantly remind us of the aspects of our relationship with our patients that are important. It does not do away with ambiguity and uncertainty. And though there are no algorithms that will always guarantee the right responses, we must continue to respond with sensitivity and imagination to the human issues that make up our daily fare. We must struggle against external forces to harmonize Knowledge and Wisdom in the delivery of health care.  

Announcements

• The next deadline for applications to PHEN's User Fund is September 1, 1999.

• PHEN is very pleased to announce that Marika Warren, a recent graduate from the University of Alberta's philosophy program, will be working with the Network's Northern Alberta Office.

• PHEN has received federal funding to hire two research assistants to work in our Northern Alberta Office for the summer. Joanne Ogaranko and Jennifer Storms will be assisting the staff in Edmonton with Network activities.

  We welcome Marika, Joanne and Jennifer, and look forward to working with them over the next few months.

11^th Annual Canadian Bioethics Society Conference

The University of Alberta's John Dossetor Health Ethics Centre, in concert with St. Joseph's College Ethics Centre and the Provincial Health Ethics Network, is pleased to announce the call for abstracts and a new information website for the 11th Annual Canadian Bioethics Society Conference to be held in Edmonton on October 28-31, 1999. 

Views offered in this article are those of the author and do not necessarily reflect the position of the Provincial Health Ethics Network.