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(This is the text of an address given to the Guild of St. Luke at their annual White Mass in Boston. Dr. Corcoran, a family practitioner from Needham, Massachusetts was the president of the Boston Guild from 1990 to 2000. )

GUILD OF ST. LUKE WHITE MASS

November 3, 2000

"IS THERE A NEED FOR A CATHOLIC STANDARD OF CARE?"

Gerald P. Corcoran, M.D.

Across the Kidron valley from the old city of Jerusalem near the Dome of the Rock and the Temple Mount, is a unique church built in the shape of a teardrop. It is called Dominus Flevit. Tradition states that this is where Our Lord wept over the city of Jerusalem and what was to come. We don't know whether He was saddened by the visions of repeated destructions of this holy city, by the Romans in the first century, the Persians in the 7th, the Crusaders in the 11th century or the Saracens in the 13th century, or whether it was the thought of two millennia of terrible ideological and military conflicts among the three monotheistic, Abrahamic religions...Christianity, Islam and Judaism.

If we take this imagery of weeping over future events and apply it to Medicine. I can't help but wonder what the feelings would be if the great minds of medicine from years past were to be able to have foreseen what doctors of today in America would be doing. What would Osler and Holmes, and Cushing, and Halstead of a century ago; what would Hippocrates himself, 25 centuries ago, even what would Corcoran, leaving Medical School 35 years ago, have to say about what doctors are doing in 2000 A.D.?

Sure, there have been many great advances---Antibiotics, Immunology, Transplants, but I think you know the real answer!

We, the caretakers of what was a noble profession, have not been good stewards. We have allowed this heritage of a noble profession, a godly craft, a humanistic art, to be perverted into some sort of technological trade, whereby we do what is newest and trendiest, what is demanded by a spoiled and willful populace without any thought given to its appropriateness, its correctness, or, especially, even to its morality.

What would those medical giants, (the latter excepted, of course) find us doing today:

Doctors administering lethal doses of medicine to patients not valued by Society or by themselves.

Doctors scraping and sucking tiny, individual persons out of the wombs where they were meant to be safe and secure and discarding them as detritus.!

Doctors creating new individuals out of germ cells, using the tissues of that individual and then throwing out what is left in the trash when it is no longer needed.

Doctors being the means by which that most basic human relationship--mother and child--immortalized by generations of artists in the Madonna, is so confused and distorted for some newborns that ID badges are needed for those present in the Delivery Room. The helpless infant has to ask:

"Are you my mother?

"Are you my birth mother?

"Are you my surrogate mother?

"Are you my biological mother?

or are you my adoptive mother?

Doctors, struggling under the demands of the third-party payers, have time for only the barest essentials of treatment, omitting or discarding what Doctor Sulmasy last year called the "Samaritan values of "the wine of fervent zeal and the oil of compassion'

Doctors serving as the policemen and enforcers of the third-party payers enumerating their rules and regulations to our patients, rather than presenting our patients' needs to the insurers.

Doctors focussing solely on treating the disease, rather than healing a patient.

Doctors playing God, manipulating genetic codes without a thought to the long-term effects on the individual, the Society, even the genus and species Homo Sapiens.

Doctors whose primary concern in each patient encounter is to avoid being sued, rather than healing.

Previewing such phenomena in the field of medicine would be enough to make anyone weep for the profession. These are examples of the care that is, or soon will be "standard care."

But, as Dickens’ Ebeneezer Scrooge asked the Ghost of Christmas-yet-to-come, [quote]"Are these the shadows of things that will be, or are they the shadows of things that may be only?" [end quote] Is this profession, our profession, to continue in this headlong rush to serve the Technological Imperative? Must we continue to allow economic interests to dominate and dictate the methods and style of the practice of the Healing Arts? Must we continue to abandon our sacred Oaths to satisfy the every whim and proclivity of members of an increasingly hedonistic and amoral Society?

The answer, of course, is NO!

"Standard of Care" is a new buzz word utilized to end arguments, win malpractice trials and generally foster the belief that somewhere, sometime, there will be a giant cookbook of medicine that will make the personal intervention of a practitioner of the healing arts---obsolete

Where do these standards come from? They arise anonymously and progress very insidiously:

Advice becomes algorithms.

Algorithms become guidelines,

Guidelines become protocols

and protocols then become standards.

These standards of care will answer the needs of the average medical practitioner trying to do the minimum in patient care. But current standards of care don’t address healing!. Although we practice medicine, we are supposed to be healers. If we practice our art, following only these standards of care, can we actually bring healing to our patients? No!

We need a different standard of care, one that relates to the essence and very nature of those whom we treat. One which will allow us to truly be Healers.

But this raises some questions. How can we introduce a moral perspective into the practice of medicine. Many years ago priests and healers were one and the same. Now we have, for the most part, separated them. Can we get our colleagues to recognize the need for the Christian theme in treatment of patients?

or to say it a different way...

Is there a way to introduce "Love of Neighbor" into the daily lives of all physicians, Christian and non-Christian?

Many would say that it is near-impossible to introduce a religious theme into the pluralistic society that is America today, and that's true. But we are trying to change a way of thinking, not change religious views. How can we change doctors' minds about this?

Our language and our wits should be up to the task. As Robert Bolt has St. Thomas More say in "A Man for All Seasons" God made the angels to show Him splendor, as he made animals for innocence and plants for simplicity. But Man He made to serve Him wittily, in the tangle of his mind.

Thomas Jefferson put it another way, brilliantly and succinctly. In 1776, the Constitutional delegates questioned why a Declaration of Independence was necessary. Jefferson said, "To present to mankind, the common sense of the subject in terms so plain and so firm as to command their assent."

"Command their assent." What does that connote? The human is a rational, thinking being. If we present the correct, irrefutable arguments---men and women will use logic to think about it and all will come to the same conclusion. This is the very principle engendering the fight against laws banning Partial Birth Abortion. As soon as Partial Birth Abortion is recognized as the illegal destruction of a human being which it most assuredly is, Logic will dictate a ban on all abortion. because the truth is then obvious. The difference between the two slaughtered individuals is one of degree, not of substance. The abortion industry is terrified that this realization will occur which is why they fight so fiercely about partial Birth Abortion, an obvious new mammoth edition of the Slaughter of the Innocents.

So, how can we frame this new standard of care in basic terms and principles that will appeal to all faiths, all persuasions of physicians? The answer lies in focussing on the patient---on the nature of the patient---on the dignity of the human person.

Not the superficial dignity, although that is important too:

We should give our patients gowns that close in the back,

we should ask them the name they prefer to be called, rather than jumping to the friendly, cozy diminutive like Jimmy or Johnny,

And we should never do an elderly woman's hair in pigtails or give them stuffed animals to hold,

and never ever call anyone over 65 "cute".

These are obvious examples of abuse of "dignity", but it is external.

The human patient, however, has a dignity that comes from their nature, as being made up of body and soul, created in the image of God from the moment of conception. This dignity is what needs to be addressed as a Standard of Care and it needs to be placed above all other standards. If we do not cognitively recognize this nature in each patient, then we will have failed to grasp the essentials of our vocation and will fail to complete the mission.

Can we prove our case? Do all our patients, at any age, in any situation, possess this dignity? We need to look at individual circumstances where this principle is called into question.

Many of our life issues involve very early life, when cells become a person. This occurs at the moment of conception. Medical genetics instructs us that when the sperm meets the egg, cells with 23 chromosomes each, a 46-chromosome individual is formed, with the characteristics of hair color, temperament, eye color, personality, etc. already formed. Because they were human germ cells, they have formed a distinct, human, unique individual, never again to be seen on the face of the earth. That isn’t religious doctrine, it isn’t faith ... it is scientific fact and must be agreed to by any Biology major in college. Life experience even bears that out for those of us with more than one child. The same father and the same mother produce very different children, different looks, different personalities

Such an individual has the potential to become a Mozart, a Schweitzer, a Jefferson or a Karol Wojtyla. The crying baby Wojtyla and the person sitting in the chair of Peter are one and the same person. The only difference is growth. Such an individual must be given the dignity and identity of a human person from the first moment, or none of us can claim that dignity as our own.

And just recognizing that dignity, thinking about it for a nanosecond before a patient visit, makes the heinous practices that I mentioned a few moments ago not acceptable to any physician of any religion. Recognizing each distinct individual at conception redefines abortion as killing, turns discarded embryos into the victims of mass murder and reveals the "spare parts" business for the unthinkable horror it really is.

It goes further.

Recognizing that "overutilizing" patient as a dignified creation of God with distinct individual needs, puts medical economics and insurance company guidelines into perspective. "Should this elderly woman go home today?" or, as we often say, "Should I send the pneumonia in Rm 212 home today?" Would I want my grandmother (whom I recognize and deal with as a person) to go home today so soon after pneumonia? What am I really doing? Is this a healing relationship of one of God's creatures to another? Or is the relationship really one of doctor to disease, with the insurer tucked in between?

And should we be faced with treating a person with a terminal illness, dignity demands that we value that life for its accomplishments from its beginnings. When a patient contemplates suicide, they lose all hope and claim their life is so useless as to not be worth living. If we assist in that suicide then we are agreeing that that life is useless, and that the person really is better off dead. What a terrible message for a physician to give to a patient.!

Certainly curing disease is important, but healing the patient is what we are supposed to be about.

Many of the issues of which I spoke earlier are concerned with value of life. The abortion issue has festered at the soul of this country for at least the past 27 years. Is this a Catholic issue that separates us from our fellow non-Catholic practitioners? Are we imposing our own faith-ethic on our patients by being against abortion?

It is not a matter of religion we are discussing here. When we ask a pregnant patient to carry the baby to term, does that meet the current standards of good medical practice. Some would say No. I maintain that it does! We are prescribing good care, not imposing religious values. Tradition and some testimony bear that out. There are enough statistics showing the psychic trauma endured by those choosing abortion to justify our sparing them from that terrible self-recrimination. by advising them to keep the pregnancy. As in those people in despair who choose suicide, the pregnant patients choosing abortion have made a permanent decision to solve a temporary problem. We are advised to counsel suicidal patients against this very personal wrong choice, but not counsel patients against abortion, another personal wrong choice! Which is the right thing to do? I'm confused. Pregnancy seems overwhelming at the moment, but time will place it all in perspective. Where abortion is concerned, you can never undo what has been done. Nothing that is done will change the fact that they are carrying a life within them now. Whether they cease to be pregnant in 9 weeks or 9 months won't change that fact. The decision they make, however, will change their life. Abortion is murder, and coming to this realization after the fact is very painful to live with.

Father Richard Neuhaus, a former speaker from this podium, spoke from the unique perspective of having been a Lutheran minister for about twenty years and viewing the Catholic church from the outside. He said that one of the great legacies of the Roman Catholic Church in America would be its history of a rigid, undying fight against abortion and its position on the other life issues. We may be in the minority now, but I have every confidence we will be vindicated by the moral community and eventually even the medical community in years to come.

How can I have that confidence? Because we are dealing with simple facts, true facts. We are dealing with the Truth, and Truth...has a power all its own.

Every day for four years I read a quote from the Bible: "You shall come to know the truth, and the truth shall set you free."

I read it because this was chiseled into stone over the steps of Lyons Hall at Boston College. I read it every day because Lyons Hall housed the cafeteria and coffee shop. (Who says that the Jesuits aren't devious? "You shall come to know the truth and the truth shall set you free"

Marcus Aurelius wrote, "Truth is one name for Nature, the first cause of all things true" A pagan, thinking like a Christian.

Ralph Waldo Emerson said that "truth is the highest compact we can make with our fellow man"

My favorite observation on Truth, however, is by Orestes Brownsen, with whom you are all familiar. He spoke of the "buoyancy of truth" and that is a phrase for the ages. Life teaches us that. (For those cursing their ignorance now, Orestes Brownsen was a Massachusetts Catholic who tried to run against Martin Van Buren in the election of 1836. He did not get the nomination, but wrote extensively on subjects of ethics and morality.

Those of us who have a dedication to the truth in all that we do, can take heart in that statement. "The buoyancy of truth" should sustain those who seek the truth and act according to it.

Abortion, however is only one part of the life legacy that we, as physicians, must endorse. If we listen to ourselves speak against abortion, the same principles apply to euthanasia. They are two sides of the same coin since they utilize the same principle of thought. Deny the person-hood of the individual, deny this dignity of the human person and, embryo or senile elder, you can kill them with impunity.

We are physicians. Life is what we believe in Life is what we have dedicated our lives to. Catholic or not, a physician can do no less than fight to preserve human life wherever it is found.

-----------------------------------

I have talked in lofty terms of intellectual convictions, but lets get down to the practical. I am just one doctor, slogging away in the trenches, trying to see my 15-25 patients per day, prying some money out of the insurers to pay for their care. How can I make a difference?

Jesus Christ was the "light of the world." The Christophers have told us to "light one candle rather than curse the darkness." Bush the First had his "thousand points of light.” So how can we, in our tiny medical lives, bring home this concept of human dignity?

Each physician has to incorporate this new standard of care in his/her own way. How do you overtly recognize the nature of the human person in your practice? Let me just give you one tiny example of how you might recognize this new standard of care in your practice

When we enter an exam room, we introduce ourselves and then open the conversation to the medical content.. It is important how we do this, as it sets the tone for the entire visit. "Opening gambit" it is called in Chess and by those who write about "client encounters" rather than "patient visits." Due to our wonderfully diverse and complicated English language, we can set the tone in many different ways. It is called style. As we develop into doctors, we learn and develop a style of practice by trial and error, usually settling on the one that gets the best results..

"What brought you here?" was an initial offering in my career, but after hearing answers ranging from "a bus" to "an '86 Volvo," I dropped that one.

"What is your chief complaint" sounds like you have just read the medical student's book on the initial patient interview. It also makes the patient sound like a whiner.

"What's new?" suggests the interest you are supposed to have in the whole patient, but can make you subject to hearing about the broken garbage disposal and the travails of getting an appliance repairman to your home.

"What can we do for you?" is better, but doesn't make you any different from the average shoe salesman. The use of "we" also makes it a corporate offer, a "team" approach, and shirks the element of personal responsibility of the doctor.

"What is your problem today? defines the visit as being "one more burden" for me and concentrates on the disease, not the patient.

If we think about the whole patient, and think of two people relating to one another, it becomes easier. I like, and would urge you to try, the initial greeting of "How can I help you?" It has a number of reasons to recommend it.

1. It is "I" making the offer, guaranteeing the work, and not shirking the responsibility for what I do. Patients complain about impersonal care, but they can't when you use the first person, subjunctive.

2. It is "you" I am trying to help. Not the disease, not your employer or even your family. It doesn't matter who is paying me. I am concentrating on "you," the whole "you," and nothing but the "you.” We may talk about the disease in you, but I want to know about and treat its effect on you. That may go beyond eradicating the infection and concentrating on eradicating the fear and emotion that the infection has left behind in you. Medical educators call it listening with the “third ear”.

3. And the action word here is the verb, "help" This is a service industry, we are told. We sell and market our services; we don't sell merchandise, we aren’t vendors. When Christ washed the feet of the Apostles, He was performing a service, and by doing it He was showing us the dignity of the person to whom He offered that service. Can we do less? And when we are called upon to perform a mundane and non-technological service, washing out the ears of an office patient, fluffing a pillow of a bed patient, or bringing in the newspaper on the walk of a housebound patient, do we not imitate Christ in doing that kindness? Are we not humbling ourselves? Is it not a good thing to do, to counteract the terrible arrogance that society accepts from us physicians, and fosters in us, and which our egos so desperately enjoy?

Changing a style is not easy. Changing what you have done twenty times a day for many, many years feels awkward. But while you are doing something like this you can feel the power of the words. Sometimes you can see the change in attitude of the patient. Sometimes you can feel the change in the attitude of the physician. It is a step in the right direction. It will make us better doctors.:

Helping the patient in the proper way will allow both of us, the doctor and the patient, to recognize and glorify that dignity of the human person that is so critical to our spiritual lives and will enrich and energize our professional lives.

Standards of Care are here to stay, and we need to adhere to them. But as Catholic physicians we need to prioritize them and we definitely need to recognize that one Standard has a priority over all others. That is the recognition that we are treating human beings, a body and soul created by the individual hand of God. Remembering this at all times will make us and our colleagues constitutionally unable to perform these atrocities that I mentioned previously. And then, remembering for ourselves, we need to spread this to our colleagues, Christian, Jew, Buddhist, Muslim. We all can make a difference.

A teacher once told me, that if you ask a question in the title of a speech, you better be sure that you answered it in the context. I will repeat. "Is there a need for a Catholic standard of care?" A resounding "YES!" But the question was written in capital letters. If it were written in lower case it would be more obvious. Catholic with capital "C" means religion. catholic "small "c" means universal. So the true answer is this: We need to make this Religious belief, a Universal one. Then perhaps future physicians, such as those here today, will be able to look with pride on their work, and we will have taken one step further toward putting the Nobility back in the profession.

Gerald P. Corcoran, M.D.

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