Does The Moral Arc of the Universe Really Bend Toward Justice

I frequently meet with idealistic UCSF medical students who want to influence health policy in order to help those who are less fortunate. I am impressed by their talent and idealism. But a nagging worry persists: Has our political fabric become so corrupted that introducing these bright young people to health policy puts them on a path that will break their hearts, make them cynical, and waste their time? For those who care about social justice, these are troubling times. Here are some recent examples: When, in a debate among presidential candidates, Congressman Paul, himself a physician, said that persons who voluntarily went without health insurance should face the consequences of death if unable to pay for care, the audience applauded. One of our two major parties, and about half our population, favor repealing the 2010 Affordable Care Act (ACA) that extends health insurance coverage to 32 million people. These opponents offer no alternative for expanding coverage. When consultation for palliative care was introduced as a benefit in the House version of the ACA, it was falsely labeled as government-sanctioned death panels by people who knew better. And, to the shame of our profession, no organized group of physicians stood up to argue the absurdity of that claim. Significant proportions of the American public believe that both evolution and the threat of global climate change are fabrications foisted upon a guileless public by sinister scientific elites. In wrestling with how to reconcile my intrinsic belief in activism with my despair at the current situation, I revisited one of my favorite sayings: “The moral arc of the universe is long, but it bends toward justice.” Dr. Martin Luther King made these remarks on March 25, 1965 on the steps of the Alabama State Capitol, having completed the third march to Montgomery. He told the crowd: I know you are asking today, how long will it take?.... I come to say to you this afternoon, however difficult the moment, however frustrating the hour, it will not be long, because truth crushed to earth will rise again. How long? Not long, because no lie can live forever. How long? Not long, because you shall reap what you sow.... How long? Not long, because the arc of the moral universe is long, but it bends toward justice." As I pondered those words I reflected upon the amazing changes that have occurred since I entered medical school 52 years ago. In my graduating medical school class, there were 145 men and five women, one “negro,” as African Americans were then called, and three students of Asian descent. My medical internship was a similarly homogeneous cohort of 16 white men. By contrast, photos of today’s graduating classes look very different. We assumed that all our medical school classmates were heterosexual, because those who were not were too embarrassed or too ashamed to declare openly their sexual preference. So much has happened in this country since 1960 concerning racial relations, the status of women, and gay rights. A few personal examples: Graduates of my 1964 class who interned at southern hospitals worked in segregated institutions. There was one ward for white men, one for “colored men,” one for white women, and one for “colored women.” It was only the passage of Medicare legislation — and the reality that segregated hospitals would not receive Medicare payments — that desegregated those hospitals. Later in that decade, medical schools began increasing their proportions of students of color. The results — though short of what was hoped — have been impressive. The corporate sector was slower to adjust to these new priorities, but it did. For example, when I joined the Robert Wood Johnson Foundation in 1990, I was the youngest of 18 white male board members. Over time, our board did diversify, and when I left at the end of 2002, my successor was an African American woman, whose appointment was remarkable only because she was so superbly qualified. Of the five women in my medical school class, four married other medical students. One was confronted by a faculty member after marrying a classmate the summer between her second and third year. “I am surprised to find you back here,” he remarked. “After all, you got what you came for!” Today, about 50 % of medical students are women. Although we subsequently learned that several of our medical school classmates were gay or lesbian, they kept their status carefully hidden, because in that era it was not safe to be “out.” In fact, the DSM manual of mental disorders classified homosexuality as a pathologic condition. A decade later, one of my classmates led the successful fight to remove homosexuality from the DSM . Now, it would be fatuous to assert that all the problems surrounding issues of race, gender, and sexual preference have been solved. But few would want to roll back the clock, because in these domains, the moral arc has bent toward justice. And polls show a much higher rate of acceptance of these changes among the younger generation. Those who promote hateful and mean-spirited policies and rhetoric are fighting a rear guard action. They are on the wrong side of history. There are other areas of progress. The rights of all people to receive basic medical care advanced with the passage and enforcement of Medicare, Medicaid, the SCHIP program, and the ACA. Yet, because our country remains fundamentally divided on this issue, it will not be easy to sustain — let alone expand — gains in access to care. In public health, we have witnessed impressive gains against the scourges of tobacco, alcohol, motor vehicle fatalities, and HIV/AIDS. The clinical science we now employ offers many more ways to help our patients, and despite such emerging challenges as obesity and physical inactivity, people live longer and healthier lives than ever before. But those benefits are not uniformly distributed. They are concentrated among the most fortunate, so that there is a widening health gap between the better off and those on the lower rungs of the social class ladder. And, of course, the daily fabric of our clinical practice as general internists is fraught with obstacles that require both professional and political changes to ameliorate. Thus, the central challenge remains: how to sustain hope in the face of what can seem like overwhelming obstacles. Here I want to share a quotation from Thomas Carlyle, which inspired William Osler: “Our main business is not to see what lies dimly at a distance, but to do what lies clearly at hand.” Here are six suggestions, gleaned from watching many people over the years, some of whom really made a difference, and others who fell short of their potential: Work on things that are important to you. Too often people settle for assignments they don’t really care about in order to get to a place they aspire to. That type of compromise diminishes what you do and who you are. Try to align what you do with what you care about, both in your careers and as citizens. Be reliable. Follow Osler’s maxim to do what lies clearly at hand. The best colleague is one on whom you can depend. That means not overpromising, as well as taking pride in what you do and being counted on to finish the task. Model your values in your day-to-day interactions with patients, colleagues, and trainees, as well as in your choices of scholarship and teaching. One important quality is generosity. People who are generous inspire and attract others. Just as your children learn more about us from how we act than what we say, the moral arc of our own conduct is the best measure of our humanity. Avoid the false dichotomy of choosing between professional and personal satisfaction. I realize that “having a life” has become a mantra for many people. Freud put it differently. He said that the secret of fulfillment was work and love, and in that order. Of course, Freud also smoked cigars and died of oral cancer, so you might question his judgment. That said, many of the most fulfilled people I know had both rewarding careers and families. Be resilient. In an era of increasingly constrained resources, coping with disappointment is all too familiar. Yet, those disappointments are part of the human condition. How you cope will determine your effectiveness. Finally, the arc of historycanbe bent, as Martin Luther King and his brave colleagues demonstrated. Just as civil rights for blacks, women, and gays are moral issues, so too is the opportunity for all people to have access to high quality, affordable health care. Our country is not there yet, and we are struggling. You can help us get there faster by your actions and advocacy, both in your professional and civic lives. You can help by demonstrating to those who deny it that health care coverage really matters, and by acting to expand that coverage. I hope that you have come to the same conclusion that Martin Luther King did:--the moral arc of the universe does bend toward justice, even if it might take an unseemly long time to do so.