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Bioethics and the Power of Reason in Medicine

Editors’ Note: On May 24, Dr. Andrew Racine gave the keynote address at Albert Einstein College of Medicine’s joint Masters Degree ceremony for Einstein’s Clinical Research Training Program and the Einstein-Cardozo Master of Bioethics program. Dr. Racine, professor of clinical pediatrics at Einstein and system senior vice president and chief medical officer at Montefiore Health System, shared his insights about the progress of medical research and the role of those who help set standards of care. We are sharing his comments to the Bioethics graduates in this post, which has been edited for the blog format.

Dr. Andrew Racine speaking at a  joint Masters Degree ceremony for Einstein's Clinical Research Training Program and the Einstein-Cardozo Master of Bioethics program at Einstein

Dr. Racine delivering his graduation address

Our recent progress in the biomedical sciences has so radically expanded the scope of what we are capable of achieving in diagnostic and therapeutic interventions that humankind has become, as in Shakespeare’s words, “in action how like an angel, in apprehension how like a god.” We stand on the threshold of understanding the very mechanisms of life—not just the genetic code, with which we have been familiar for decades, but the rules that govern the expression of this code: how the signals are turned on and off, how they are modulated and how they respond to environmental stimuli to generate the variety of phenotypes we see around us.

As bioethicists, however, you have chosen to focus on a different set of issues altogether. Rather than work to pursue answers to what we can do, you have dwelt on a different set of questions: not what we can do, but what we ought to do; not just what is possible, but what is right. In one sense, this is a much more difficult task, and in another sense, it gets at the very heart of what medicine has always been about. The ancients tell us that at the dawn of medicine Hippocrates was credited with distinguishing medicine as a separate branch of philosophy, which, perhaps, is why Aristotle refers to him in The Politics as “the greatest of all physicians.” The Hippocratic oath itself is imbued with profound notions of duty and obligation—practical philosophical concepts to guide the activities of practicing physicians in the real world.

Your objective has been to deepen our understanding of how to decide among competing options as we consider how we ought to engage with our patients and their families, our colleagues and trainees, the communities we all inhabit and our present and future selves. And unlike many of your contemporaries who have at their disposal vast arrays of technological tools—laboratory tests, imaging studies, physical-examination evidence, computer-generated data—you are armed with one thing and one thing alone: reason.

This is your blessing; this is your burden. I referred a moment ago to a quote from Shakespeare that many of you may recognize comes from Hamlet. Reason’s purpose in Hamlet was to temper the protagonist’s natural inclinations to act in a certain way, and to force those inclinations to pay obeisance to the dictates of rationality. This was best expressed in one of the most famous soliloquies in the entire canon of English literature. We remember well the beginning of that speech: “To be, or not to be; that is the question.” But what we sometimes forget is how the speech ends. Hamlet comes to this conclusion: “Thus the native hue of resolution / Is sicklied o’er with the pale cast of thought, / And enterprises of great pith and moment, / With this regard their currents turn awry, / And lose the name of action.” What he derides as “the pale cast of thought” is what persuades him against his natural suicidal impulse so that he abandons the action he was tempted to pursue. He simply thought better of it.

That is the career upon which you are embarking today—to think better of it. That’s all you have available to you in pursuit of deciding what is right: no stethoscope, no fiber optics, no fMRI, no whole-genome sequencing. Just thought.

That might seem a very slim reed upon which to rely for such a monumental purpose. Yet it is the most ancient instrument we have available to us. It might be said to constitute the Darwinian dowry that accompanied us when we first stood apart from our ancestral roots to emerge as a distinct species possessed of this uber-developed prefrontal cortex. The complexity of neuronal networks in our brains enabled us to contemplate the future as no species before us had ever done. This preoccupation with envisioning the future consequences of our present actions allows us to make plans; it keeps us awake at night wondering, sometimes anxiously, sometimes excitedly, about tomorrow; it permits us to see ourselves as we might someday become.

And it gives us the capacity to consider how our actions might affect others with whom we interact. These “others” appear to us as objects in our world, meaning they are nonself. It takes an act of imagination, of critical thinking, for us to consider those objects as subjects just like ourselves. Simply put, this imaginative act is an intellectual thought exercise that asks us to imagine others as us and to consider what our current actions might mean were we ourselves to be subject to their consequences. This is the origin of ethics—our imagining how the choices we make in the present might be consequential to others around us, were we they.

The deliberate, systematic, universalized application of reason is what you have chosen as a lifelong pursuit. Where you apply it: in a hospital setting, an ICU, an ambulatory practice, a clinical research lab; how you apply it: advising other clinicians, pursuing the scholarship of bioethics, teaching students, training your colleagues; when you apply it: in discussions on rounds, as you advise patients and families, when you are contemplating a vexing clinical decision at the end of a patient’s life—these are decisions for the future. But for today we must acknowledge that there is no going back over the decision whether to apply this special reasoning in your clinical lives.

Thinking your way through difficulties armed only with reason is not meant to be easy. You have not chosen bioethics because it is easy, but because it is hard. As Aeschylus wrote: “He who learns must suffer and even in our sleep pain that cannot forget falls drop by drop upon the heart. And in our own despair, against our will, comes wisdom to us by the awful grace of God.” My wish for you as you go forth today is for you to trust in what you have been taught. Believe in the power of reason to deliver you, to ennoble your decisions. It is the best tool at your disposal, and the most powerful tool in all of creation.

Think about it.

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