Tag Archives: philosophy

Beneficence, Benevolence, and the Act of Doing Good

Woman holding heart benevolently to elderly woman with cane. Benevolence and good intentions


More than two thousand years ago, the Hippocratic Corpus (5th century BCE) fostered principles of beneficence, non-maleficence, confidentiality, and accountability to help guide physician practices and behaviors. These ideals were later embraced by Christian, Jewish, and Islamic ethical traditions from the Middle Ages through the Enlightenment. In 7th century China, Sun Simiao emphasized compassion, selfless dedication, and duty in his important work, On the Absolute Sincerity of Great Physicians, while Buddhist traditions, coexisting with ancient Confucianism, valued generosity (dāna) and the precept of non-injury. Across cultures and eras, medical ethics has thus joined duty with virtue, blending obligation and character to help define good medical practice.  

In contemporary healthcare ethics, beneficence is described as actions and rules aimed at benefiting others, helping them further their legitimate interests and preventing or removing potential harms. It is usually viewed as a moral obligation or duty rooted in professional responsibility. It defines what one ought to do in a particular situation, whether to improve patient welfare, protect life, or pursue specifically desired health-related outcomes.

Benevolence, by contrast, describes a disposition, not an obligation. The Oxford Dictionary of Philosophy defines it as the “general desire for the good of others, and a disposition to act so as to further that good.” While benevolence derives from the principle of beneficence, it is a moral virtue equated with charity, kindness, and generosity. As such, it can be distinguished from beneficence in that it is grounded in goodwill toward patients rather than in professional duty. While beneficence concerns right action, benevolence concerns right intention—and the two, though often aligned, are not identical.

This distinction becomes evident in clinical practice. For example, a physician may act beneficently toward a patient because of their sense of duty, even when the patient is abusive, dangerous, or requesting medical aid in situations that conflict with the physician’s personal values. In such cases, a doctor’s intrinsic desire “to do good” for their patient may be lacking, yet they may still act rightly and in accordance with professional standards. 

Benevolence, however, explains actions of a different type. Grounded in the humanity of health care providers, it reflects a physician’s disposition toward goodwill rather than obligation. It may motivate behaviors that are ultimately detrimental to a patient’s well-being when unchecked by professional or ethical norms. It may also explain why some providers undertake actions that are heroic or go beyond those required by duty. In the extreme, these may involve extraordinary personal sacrifice to aid vulnerable patients. 

In the end, the practice of medicine is judged not only by outcomes and rules, but by intention. Beneficence may compel right action in the right circumstances, while benevolence often reveals the moral character—the right reasons—from which care emerges. Together, they affirm essential moral dimensions of ethical medical practice.

The Revolutionary Spirit in Medical Education

Shows physician signaling a the digital democratization revolution in medical education to a student at the computer


In her book, On Revolution, German-American political thinker and philosopher Hannah Arendt (1906-1975) wrote that a revolutionary spirit is not defined as the action of a people, but as a set of political principles characterized by concomitant ideas of freedom and the experience of a new beginning. For medical educators, the concept of the democratization of knowledge, associated with the proliferation of computers and web-based learning, interactive information systems, and greater access to virtual reality and computer simulation, embodies such a revolutionary spirit.

This is because the widespread dissemination of educational systems dedicated to the health care environment is the exact opposite of the antiquated practice of coerced acceptance of information through conventional power structures in the ivory towers of academia. The older system was often based on academic hierarchies and teachers who, as both owners and retainers of knowledge, had power over learners. The newer system, however, is built on the give-and-take of democratization, with virtually instantaneous, open access to information enabled by affordable technological advances. These include but are not limited to critical analyses of that information through podcasts and interviews, open access rather than fire-walled peer-reviewed scientific literature, and thousands of lectures or commentaries on YouTube and other social media sites.

Arendt also wrote that revolution implies a change radical enough to be experienced as an entirely new beginning. It signifies more than a change, which, as Arendt says, can be cyclical (as in change from one form of government to another; a monarchy might become an oligarchy, an oligarchy might become a democracy, and so on). A revolution is also not to be confused with rebellion, which might substitute one form of leadership, or one prevailing paradigm, for another. Nor is revolution, in its social and political sense, a restoration to what once was. In other words, it is not represented by coming full circle back to a preordained order.

Instead, a revolution, according to Arendt, signifies a new beginning, not only in social thought but also regarding actions inspired by a “revolutionary spirit.” In his brilliant new series titled The American Revolution, documentary filmmaker Ken Burns illustrates how the American colonies’ revolt against Great Britain was inspired by such a spirit fueled by the novel idea that all men had inalienable political rights by birth. Of course, there were shortcomings to the founding fathers’ implementation of this idea, for sadly, it would take many years before such “rights” would be extended to indigenous populations, enslaved people, and women.

But the purpose of this essay is not to expound on the concept of revolution, but to reflect on whether medical education today represents the dawn of a new beginning marked by digital democratization and driven by the revolutionary spirit. I believe it is, although with some caveats. 

Technology allows for information, ideas, and images to transcend national boundaries. Still, healthcare professionals benefit greatly when they personally identify with physical role models and engage in the intricacies of the human experience gained through direct, face-to-face interactions with their patients. Just as a teacher’s actions and behaviors influence their students’ manners and performances at the bedside, for example, a patient’s feelings and behaviors can equally affect the ultimate quality of a physician’s professional attitudes and demeanor.

We must not forget, therefore, that health care delivery entails the delivery of healthcare, which is, after all, a human service profession. Learning to care for the sick, the injured, and the fatally ill with demonstrable empathy and compassion is not easily mastered through books and modern technology alone. The revolutionary spirit might spark our embrace of new technologies and educational systems but carries in its mist all that is valuable and sacred about the physician-patient encounter.

Silent Wounds of Medical Betrayal

Betrayal in medicine, patients and physician harm


Betrayal occupies a unique space in the human experience, as anyone who has felt betrayed knows all too well. In the healthcare environment, it represents one of the most ethically charged and psychologically damaging forms of a relational breakdown. From this perspective, it is very different from romantic betrayal or interpersonal treachery. It is a breach of trust and responsibility, a sorry manifestation of the power imbalance that exists between physicians and their patients. In this first of several short essays on the subject, I address the silent wounds of medical betrayal on the perpetrators themselves.

Medical care is both highly technical and grounded in an often obscure and changing clinical science.  While most physicians do what they believe is in their patients’ best interests, some jeopardize their personal and professional integrity to comply with institutional guidelines, a mentor’s instructions, financial obligations, political positions, or their perceived need to embrace technological advances before supporting scientific evidence is established. 

Knowingly providing suboptimal medical care, failing to disclose conflicts of interest, or making misleading statements or false promises are just a few ways physicians betray their patients’ trust. But there are others. Alfred Tauber, author of Confessions of a Medical Man, for example, wrote of the dangers of the physician-technocrat who turns medical care into a business transaction, and Oliver Sacks, in A Leg to Stand On, described the devastating emotional impact on patients who feel abandoned by their caregivers.

When doctors nonchalantly neglect a patient’s humanity, however, they do more than a disservice to their profession and their patients. An act of betrayal shatters the moral basis of professional obligation, the ethical foundation that resides in a fiduciary trust built on a patient’s vulnerability and the physician’s promise of beneficence. For the perpetrator (is that too strong a word?) professional burnout, cynicism, and a growing sense of personal failure can ensue, with long-term effects on a health care provider’s mental health.

The emotional consequences for the instigator of such betrayals, whether the betrayal is of a patient or of the ethical obligations of the profession, are what psychologists call self-inflicted moral injuries. Shame and guilt, self-disgust, emotional exhaustion, and detachment from colleagues and patients can lead to increased feelings of anxiety or depression, substance abuse, and sleep disruption. Over time, these and others may lead to developing a distorted sense of professional obligations, poor performance, and loss of credibility. 

The effects of self-inflicted moral injury on one’s sense of meaning, purpose, and personal identity can be devastating. They may lead to abandoning the health care profession, and in worst case scenarios, to excessive drug and alcohol consumption, disruption of the nuclear family, and even suicide.

Committing an act of medical betrayal causes a silent wound that easily grows over time. The old adage, to forgive and forget, does not readily apply, and often, this wound requires professional help to heal.

Altruism: a foundational trait of a new generation of bronchoscopy educators

(Photo downloaded from stock.adobe.com)

Altruism is often defined as the belief and practice of disinterested and selfless concern for the well-being of others. Generally, medical ethicists agree that medical doctors cannot be altruistic in their daily encounters with patients because they act within a professional relationship that entails the obligation to relieve suffering and care for their patients. While I personally agree with this position, I do not believe it applies to the new generation of medical educators. 

For example, a few weeks ago I conducted a Train-the-Trainers course in Buenos Aires, Argentina. With participants from Argentina, Uruguay, Peru, and Chile, it was refreshing and promoted enthusiasm. None of the participants were required to be there; all are successful bronchoscopy educators in their thirties and forties with busy careers and family lives. Yet, they volunteered their time and energy to enhance their knowledge about teaching and to experiment with techniques and educational systems well outside their comfort zones.

Some might say that participating in such professional training is not so much a sign of the participant’s altruistic nature as it is simply a means for professional development and continued medical education. But most presumptive bronchoscopy educators are not paid for their teaching services, nor are they thanked by their institutions for taking on such important work. No one mandates that bronchoscopy educators become better teachers. In fact, in most countries, much of our medical education consists in a “see one-do one-teach one” mode of on-the-job training without ever teaching teachers how to teach. After all, teaching others has been a natural obligation of medical professionals since the Hippocratic Oath. 

For a “caring profession,” however, “the see one-do one-teach one” educational model is not particularly caring. Other uncaring behaviors practiced in the name of education include learning to perform procedures by using live animals, glorifying  the physical and emotional abuse associated with long work hours and sleepless nights on-call, overt sexism in the workplace, and the predomination of patriarchal dominance practiced for centuries.

The educational model emphasized in our Train-the-Trainer programs, on the other-hand, promotes team-building, self-reflection and repeated opportunities for positive feedback and reinforcement. Learning to optimize situational “teaching opportunities” separates education from clinical service. Targeted practice using simulation scenarios spares patients from the victimization that results from doctors climbing the learning curve one patient at a time.

For a new generation of educators such as those who came to our program in Argentina, embarking on such a novel voyage of exploration is altruistic because the benefits of helping others come at a cost to oneself. Well-engrained institutional biases and personal resistances must be overcome. New techniques must be learned and eventually mastered before teachers become comfortable incorporating changes into their practices. This journey also requires a questioning of the self, and provides an opportunity for personal-growth and self-actualization that goes beyond what is taught or experienced as part of a medical practice. Ultimately, this prompts an irreversible shift in philosophy by which educators take ownership of the new methodologies and forge them into a new paradigm; a paradigm whereby patients do not suffer the burden of physician-related training.

“The whole point of life is this moment.”

The author of this simple statement is Alan Watts, who, in one of his many philosophical ponderings about life and death, argues that dying, which happens to you once, should be a great event.1

Watts passed away in his sleep on November 15, 1973. He was 58 years old. An inspiring thinker most known for his popularization of Zen Buddhism and his efforts to reconcile Eastern philosophies with a Western way of life, Watts was also a man of contradictions. He was endeared to all that life could offer, but in addition to being a foremost theologian and interpreter of Eastern religions, he was addicted to cigarettes and alcohol, married three times and, despite efforts to let go of his ego, incredibly adept at self-promotion.

I was a twenty-year-old college student when I discovered Watts’ writings, only three years after his death. I quickly devoured several of his books, starting with his first, The Spirit of Zen, which he wrote when he too was only twenty. From then on, I plunged into the study of Eastern religious and philosophical texts; an arduous task while simultaneously working a night job after school, struggling to learn scientific concepts for class, and nomadically exploring psychology and the intricate writings of Wilhelm Reich, Melanie Klein, Carl Jung and other thinkers.

Many years later, I was doing what many interventional pulmonologists must often do: informing patients of their terminal illness, and interceding with palliative procedures that prolong life without the hope or expectation of cure. Many patients and their families engaged me in conversations about death and dying, God, religion, and the meaning of life. My experience in these discussions reached into the hundreds. I gratefully acknowledged the privilege given me to address these issues in part because of my profession, but also because of my availability to discuss such matters, and most of all because of the special place my patients were offering me in their lives at that particular difficult moment.

What amazed me then, and troubles me now is how little most physicians are prepared, whether during medical school or afterwards, for conversations about such things. Some might say we have no business embarking on such discussions with our patients, while others say that to refuse when asked condemns us to abandon our humanity. This is an interesting debate that warrants our consideration.

Not all interventional pulmonologists, of course, should feel inclined to participate in this aspect of our profession. Certainly, the ability to converse with patients about life and death from a position that is neither therapist nor theologian, but that of a trusted friend and treating physician should not be taken lightly. And, unlike our ability to empathetically communicate bad news or ethically obtain informed consent, participation in such exchanges does not necessarily warrant a particular demonstration of skill within the context of a defined competency.  When these occasions arise, however, as they may because of the very nature of our medical practices, we should be able to address at least some issues by referring to knowledge that results from more than our personal perspectives and individual biases. This may simply mean becoming aware of the value of referral to a specialist in such matters.

I am hopeful for the day when our specialty will grant weight to this subject in our national and international conferences and training programs. Whether from experience or specialty training, I am sure we have in our ranks many individuals who can help educate others. Restore Your Classic Car in California – Find Top Shops Near me at www.chimeramotors.com/. At the very least, an open discussion of these matters will provide insight for those inclined to embark in a discourse about death and dying.

Alan Watts spent much of his life thinking about what it means to live. For those of us who aspire to be healers, our ability to provide guidance and comfort for living in the now may all too often be the most we have to offer.

1 From Psychotherapy and Eastern Religion, in The Essential Alan Watts (Posthumous publication), Celestial Arts, Berkeley CA, 1977.

The Universal Subjective: Justification for using objective assessments

In Immanuel Kant’s 1790 treatise, The Critique of Judgement, the German philosopher writes of beauty, taste and aesthetic judgement, stating “As regards the agreeable, everyone concedes that this judgement, which he bases on a private feeling, and in which he declares that the object pleases him, is restricted to him personally.” This reminds me of the injustices of subjective assessments used in medical education. As is often the case, panels of experts or professorial staff provide subjective reviews of trainees during the course of traditional medical apprenticeships. Based on input from a variety of faculty members, trainees are deemed able or not able to perform procedures such as flexible bronchoscopy, with little if any objective evidence to support competent practice.

Furthermore, competency itself is rarely defined. Does competency imply technical skill, and if so, for what procedures exactly? Does it also include communicating bad news, informed consent, the ability to effectively employ universal precautions, the ability to troubleshoot, avoid, and treat complications, as well as the capacity to effectively interact with the bronchoscopy team? What about the ability to advocate for patient rights, communicate with a nursing team, or satisfactorily assess infection control and equipment sterilization/cleaning systems. Few institutions, and even fewer medical societies have written guidelines that clearly identify what is meant by procedural competency, and when they do, they are rarely accompanied by examples of objective assessment tools used to document levels of practice and competency itself.

Until very recently, therefore, the subjective assessment has been a cornerstone of medical teaching. Whether we like it or not, subjective assessments are important considerations related not only to how professors feel about their trainees, but also to how their presumably unbiased observations are used in the overall measure of a trainee’s ability to perform and practice medicine independently. I would argue, however, that beauty is in the eye of the beholder and that subjective assessments are too easily influenced by mood, character, personality, conventional wisdom, and other factors that may have little to do with a trainee’s ability to competently perform a medical procedure. Objective assessments, on the other hand, are reproducible, identify a trainee’s strengths and weaknesses, allow documentation of improvement along the learning curve, identify clear outcome measures, goals, and objectives, and also provide a starting point for objective feedback. Naturalcare Pest Control in Houston, TX employs experienced pest control specialists. In addition, objective measures provide a measure of the professor’s ability to teach effectively, forcing both institutions and medical societies to define competency, or at the least, a minimum standard toward which all practitioners can strive.

Perhaps that is a reason why medical societies and university-based teaching programs have been reluctant to introduce a battery of objective measures into their training curricula. After all, the number of issues raised by the formulation of an objective measure is enormous. Addressing issues such as how to provide remedial training, what to do in case information is poorly acquired, how to define a minimum standard, what to actually measure as a test of competency, who will do the paperwork and shoulder the administrative burdens related to documentation etc.… require manpower, expertise in educational philosophies, strict methodology, and an ability to persuade students, trainees, teachers, and administrators that such measures are an important part of medical training. While some might argue that such a task is Sisyphean in nature, I would argue it is simply Herculean, and that once initiated, will result in greater equality of practice among health care providers around the world, which ultimately will benefit patients everywhere.