The sociobiology of humanism.

As medical educators, we encourage humanism in our medical students. Often, however, we don't know quite what humanism is or whether it is possible to encourage it. Some people just seem to have it. Others seem like they will never acquire it. And only those who have it seem to know it when they see it. The Gold Foundation has created humanism societies in medical schools, and they sponsor award ceremonies each year in which a group of graduating medical students are recognized and commended for their humanism. The Foundation's Web site states that, "to be a complete doctor, both science and humanism must be fostered. Gold Foundation awards seek to elevate those humanistic qualities essential to good doctoring: integrity, excellence, compassion, altruism, respect, empathy and service." Of all these words, altruism seems the most psychologically problematic. It is both understandable and straightforwardly self-serving for a physician to aspire to integrity, excellence, and empathy. Altruism and service, on the other hand, raise fundamental questions about motivation. Why should we ever try to help people whom we don't even know? Why give of ourselves to help a stranger? It is a question that lies at the very center of concerns about humanism--or the lack of it--in medicine. Evolutionary biologists have long been puzzled by cases of apparent altruism in certain animal societies. For example, vampire bats regularly donate regurgitated blood to unrelated members of their group who have failed to feed that night, ensuring they do not starve. In many bird species, a breeding pair receives help in raising its young from "helper" birds, who protect the nest from predators and help to feed the fledglings. Vervet monkeys give alarm calls to warn fellow monkeys of the presence of predators even though in doing so they attract attention to themselves and increase their chances of being attacked. One explanation is that altruism is really just a complex form of self-interested behavior, built on the expectation that a favor I give today may make me more likely to receive a similar favor in the future. Some people have felt such theories devalue altruism by explaining away the self-sacrificing components of the behaviors. The question of whether we ever truly act against our self-interest in order to help another person lies at the heart of the tensions and challenges faced by any physician who would seek to maintain humanism. In the practice of medicine today, humanism often seems to be more of a luxury item than a necessity. Many of medicine's most successful interventions--anesthesia, immunizations, medications--work whether the doctor has a human connection with the patient or not. And it is precisely in the domains of medicine that are most scientific, and therefore most effective, that humanism is least important. Doctors working in these domains go about their technological business--making diagnoses, delivering effective therapy, offering precise prognoses--with a skill and competence unclouded by the messy emotions that accompany humanistic interactions. Think of a pilot flying a 747, leaving on time and arriving halfway around the globe on time, touching down four hundred tons onto the runway like a feather. We don't care if the pilot connects with us, has a relationship with us, or comes to know our hopes and fears. Increasingly, we may have the same views about the heart surgeon who does our bypass operation, or the neonatologist who deftly intubates our premature baby, or the colonoscopist who finds and excises our polyps. Still, there are the other aspects of medicine--those that take place, often, in the domains where the light of science has not yet penetrated or the ability to cure has met its limit. The true test of humanism may be in how doctors behave when medical treatment fails, but the patient is still there. Good medicine may need both science and humanism, but while it has an easy relationship with science, it challenges humanism. …