Tag Archives: bronchosophy

Dimensions of Medical Altruism


Medical altruism is usually considered a virtue that is critical to defining a physician’s moral character. However, one of its more noticeable manifestations is behavioral, reflecting compassion, responsibility, and a sense of moral obligation. Indeed, medical altruism translates into a commitment by health care providers to use their power, position, privilege, and knowledge in the best interests of others, even at great personal cost and varying degrees of effacement of self-interest. Therefore, medical altruism represents physicians’ spoken and often unspoken commitment to act selflessly for their patients’ well-being, regardless of potentially conflicting professional duties, even at the expense of personal gain, safety, or well-being.

American philosophers Pellegrino and Thomasma thus argued that beneficent altruism was morally obligatory for physicians, placing it at the root of a “virtuous” physician’s character. “No one can make the conscientious professional do what she thinks is not in the interests of the patient or client,” they write, and “The physician of character will…reliably be expected to exhibit the virtues of fidelity to trust and effacement of self-interest.”

Other manifestations of medical altruism might have their roots in a person’s psychological profile. In part, this is because medical altruism is almost always viewed as being individual-centered, and therefore, potentially at the core of a physician’s personal identity. For example, some physicians’ altruistic behaviors are linked to their heartfelt desire to relieve suffering. This is reflected by physician and bioethicist Eric Cassell’s (1928-2021) belief that “The relief of suffering and the cure of disease must be seen as twin obligations of a medical profession that is truly dedicated to the care of the sick.”  Dr. Cassell viewed suffering as a primarily subjective experience, describing it as “the state of severe distress associated with events that threaten the intactness of the person.”

A slightly different perspective was presented by Daniel Sulmasy, who is well known for his writings about the connection between spirituality and medicine.  He argued to reaffirm Sir William Osler’s declaration that medicine was a calling, not a business. Dr. Sulmasy is a physician and philosopher who once lived as a Franciscan friar. Focusing on a physician’s character, he suggests that altruism is a virtue easily threatened by a malfunctioning or flawed medico-industrial complex. He warns that unsound training environments and the stress/realities of day-to-day medical business practices can potentially erode altruistic ideals.

Richard and Sylvia Cruess argue that if medicine is a profession, then medical altruism is a professional duty. They believe altruism is at the core of the physician-patient contract and a centerpiece of the social contract between physicians and society: “Based on the literature, society’s expectations of medicine are the services of the healer, assured competence, altruistic service, morality and integrity, accountability, transparency, objective advice, and promotion of the public good.” According to this position, physicians have a professional obligation to engage in altruistic behaviors, the degrees of which can be hotly debated. Additionally, medical institutions and health care policies should promote and support altruism from a systems perspective because altruism is both expected and contractually anticipated by society-at-large.

This brief discussion of the various dimensions of medical altruism would be incomplete without acknowledging the work of recently defunct physician and anthropologist Paul Farmer (1959-2022). Dr. Farmer supported Article 25 of the Universal Declaration of Human Rights: “Everyone has the right to a standard of living adequate for the health and well-being of himself and his family, including food, clothing, housing, and medical care….” He expanded upon patient-focused boundaries of medical altruism by proposing that health care providers be individual caregivers but also advocates in the battle to overcome social inequalities.

  • Pellegrino, ED and Thomasma DC. The virtues of medical practice. Oxford University Press, 1993.
  • Cassell, E. J. 1982. “The Nature of Suffering and the Goals of Medicine.” N Engl J Med 306 (11): 639–45.
  • Sulmasy, Daniel P. (1993). What’s so special about medicine? Theoretical Medicine and Bioethics 14 (1):379-380.
  • Cruess SR. Professionalism and medicine’s social contract with society. Clin Orthop Relat Res. 2006 Aug; 449:170-6.
  • Farmer, P. Pathologies of power: Health, human rights, and the new war on the poor. University of California Press, 2003.

Medical Altruism: It’s not simple


The concept of medical altruism, which is central to health care delivery and both patient and physician well-being, is extraordinarily complex. Filled with nuance and interconnected layers, even its definition is problematic. Usually understood as a dynamic, context-dependent virtue, medical altruism can be viewed as a commitment by medical providers (physicians, nurses, and other providers) to use their power, position, privilege, and knowledge in the best interests of others (their patients) even at personal cost and varying degrees of effacement of self-interest. Seen in this light, medical altruism includes in its essence altruism (“other-regarding,” as coined by nineteenth-century French philosopher August Comte), and the morally obligatory trait of altruistic beneficence (as described by American ethicists Edmund Pellegrino and David Thomasma), which goes beyond the principles of benevolence (wishing others well) and nonmaleficence (not doing others harm).  

Regardless of whether medical altruism is approached from a philosophical, psychological, theological, evolutionary, professional, or cultural perspective, it must be distinguished from the concept of altruism in medicine. While medical altruism is individual and profession-centered, altruism in medicine is viewed as a commitment of the health care collective, including its professional organizations, institutions, economics, sociocultural environment, populations, and political systems to address healthcare based on altruistic rather than egoistic or self-centered values. Altruism in medicine, therefore, might also apply to selfless patient-originated decisions to donate blood, stem cells, organs, and other tissues, as well as healthcare provider-originated decisions to volunteer for humanitarian activities, combat global inequities, or share knowledge, time, and experience in degrees that are above and beyond what is expected of their professional duties and, in the case of physicians, their social contract with society. 

Further complicating discussions of medical altruism and altruism in medicine is the rapidly changing face of medical practice and health care environments. There are obvious tensions regarding the value and sustainability of selfless motivation, just as there are significant vulnerabilities and systemic weaknesses of existing health care institution-based frameworks and societal policies regarding professionalism and what constitutes ethical medical practice in a technology-driven, soon to be AI-dominated twenty-first century. These and other elements relating to altruism will be the focus of several future reflections on Colt’s Corner. Please subscribe and share.

  • Pellegrino, ED and Thomasma DC. The virtues of medical practice. Oxford University Press, 1993.
  • Creuss SR and Creuss RL. Professionalism and Medicine’s social contract with society. Virtual Mentor 2004;6(4):185-188.

Personality, Patients, and Personal Care


The Five Factor model of personality traits, also known as The Big Five, was conceived by psychologists to help explain features of human thinking, feeling, and behavior that are shared across all human populations regardless of race, gender, age, or language, differing only in the degree of their individual manifestations.  Research shows this hierarchal model, which organizes personality traits according to five dimensions: conscientiousness, extraversion, agreeableness, neuroticism, and openness to experience, is applicable across observers and cultures.

Understanding how these traits affect medical practice is important, not only to the physician patient relationship, but also to nurturing self-care, and to recognizing how certain strengths and vulnerabilities might impact teamwork, clinical care, overall performance, and professional well-being. Acquiring an awareness of these traits might also prompt initiatives that are crucial to personal growth during the lifetime of every practitioner. 

It is impossible to describe the details of these five dimensions in the space of a few paragraphs, but briefly, openness entails a doctor’s degree of willingness to embrace new ideas, technologies, structures, and perspectives. Conscientiousness might reflect a practitioner’s respect of ethical responsibility, manifesting itself, for example, as dependability and integrity. Extraversion, agreeableness, and neuroticism highlight interpersonal and emotional aspects of medical practice. They contribute to what is also referred to as Emotional Intelligence (EI), which is the ability to recognize, understand, and regulate one’s own emotions as well as the awareness of how those emotions might affect or influence others.

Health care providers face multiple challenges in the workplace, not the least of which are found in their interactions with patients. One often unspoken consequence of these interactions is the deleterious effect of a patient’s death or suffering on caregivers themselves. Being aware of how this manifests itself within the dimensions of The Big Five can be helpful in building personal resilience as well as a capacity for greater empathy and compassion, not only for patients and their families, but also for other caregivers, and importantly, toward oneself.

  • McCrae RR, John OP. An introduction to the five-factor model and its applications. J Pers. 1992 Jun;60(2):175-215. doi: 10.1111/j.1467-6494.1992.tb00970.x. PMID: 1635039.
  • Novikova, I.A. (2013). Big Five (The Five-Factor Model and The Five-Factor Theory). In The Encyclopedia of Cross-Cultural Psychology, K.D. Keith (Ed.). https://doi.org/10.1002/9781118339893.wbeccp054

Vulnerability and Resilience


At a recent pulmonary conference hosted by Sharp Healthcare in San Diego, I had the opportunity to discuss vulnerability and resilience issues in healthcare. One of my goals was to raise awareness about the tragedy of suicide among physicians and other healthcare professionals. Recent studies have shown that suicides are on the rise, and that among female physicians, for example, rates exceed those from among the general population. Registered nurses and health care support workers also have higher suicide rates compared to non-healthcare workers (16 versus 12.6 per 100,000 persons) in the United States. 

Health care providers, especially in high-stress environments and situations, face the risk of emotional exhaustion, moral distress, and burnout. One recent study, for example, showed that at least sixty percent of healthcare professionals feel burned out, costing the US healthcare system more than four billion dollars annually. As we learned during the COVID pandemic, health care systems are also vulnerable to factors such as economic stress, supply-chain disruption, and dwindling resources that can adversely impact their employees’ well-being.

My point, of course, is not the financial burden of this tragedy, but the cause. Vulnerability in healthcare workers’ health is linked for the most part to structural and cultural factors in the medical profession. Long hours, administrative burdens, emotional distress, and the stigma that prevents healthcare workers from seeking professional psychological support are just a few of the factors that contribute to increased risks of burnout, depression, and professional dissatisfaction. Not surprisingly, these might easily overwhelm one’s personal resilience (defined as the ability to cope with and recover from suffering, often in the face of adversity). 

The interconnectedness of resilience and vulnerability underscores the importance of institutional and professional societal structures to strengthen individual coping resources and address systemic contributors that hamper a health care worker’s well-being. It is time that we address these issues explicitly, in journals and national meetings, as well as locally in our medical schools and health care institutions. I am hopeful that, in a collaborative spirit of concern, care, and compassion that extends beyond the patient care arena, the current “younger” generation of health care professionals will give greater value to resilience-building and vulnerability acknowledgment than their predecessors. 

  • Jain L et al. Suicide in Healthcare Workers: An Umbrella Review of Prevalence, Causes, and Preventive Strategies. J Prim Care Community Health. 2024 Jan-Dec;15.
  • West CP, Dyrbye LN, Shanafelt TD. Physician burnout: contributors, consequences, and solutions. J Intern Med. 2018 Jun;283(6):516-529. Epub 2018 Mar 24. PMID: 29505159.

What is ‘Bronchosophy’


Interventional pulmonologists live simultaneously and sequentially in many worlds. One moment, they may find themselves directly responsible for the life or death of a patient with advanced disease; in the next, they might be delivering bad news, making prognoses under uncertain conditions, wrestling with the uncertainties of a novel technology, initiating long-term strategies, or advocating for their approach in a multidisciplinary care meeting. 

Many interventional pulmonologists are naturally curious and enthused to learn how to perform new procedures that require manual dexterity and analytical precision. But the profession demands more than technical skill to truly serve its patients. Equally important are a doctor’s abilities to communicate with clarity, courage, compassion, grace, and humility. Practicing medicine with such depth and professionalism is both a challenge and a virtue. 

It is not surprising, therefore, that bronchoscopy, a fundamental component of interventional pulmonology, is more than just a procedure. It is a way of seeing not only literally into the airways, but also metaphorically into a patient’s life. It is the means by which interventional pulmonologists contribute to another human being’s life story, often at a critical time of their patient’s journey between birth and death. 

More than forty years ago, one of the first bronchoscopies I performed prompted a difficult conversation with my patient about the effects of malignant central airway obstruction on their life and well-being. At that time, most oncologists and pulmonary specialists were still nihilistic about lung cancer treatments, and the value of palliative airway procedures was neither recognized nor accepted. My patient went on to receive chemotherapy and external beam radiation, sadly with little improvement in their symptoms and without a beneficial effect on their quality of life. During those weeks, I learned much from our bedside conversations, including humility. I realized that my ability to see into my patients’ airways granted me the privilege to hear their life stories. What remained was for me to determine the best ways I could help them.  

The results of this experience might be described as bronchosophy (pronounced /ˈbrɒŋ. kəˌsɒf.i or /ˈbrən kasəfi/), which is a term a few of us have used over the years, but has not yet entered common language. Just as philosophy might represent the pursuit of wisdom, truth, and knowledge, bronchosophy represents the pursuit of wisdom in the practice of bronchology. It can be defined as ‘a reflective and principled approach to the art and science of airway examination and intervention, combining technical skill with ethical insight, clinical judgment, and humanistic care.’ In other words, bronchosophy is the cornerstone from which the art and science of bronchology and interventional pulmonology blend with our humanity and heartfelt endeavors to do what is in the best interests of our patients.