“Necessary for the Future” ft. Duke University’s Farr Curlin I Saturdays at Seven – Season Three, Episode Twenty

Click here to listen to the episode on Spotify

In the twentieth episode of the third season of the “Saturdays at Seven” conversation series, Todd Ream talks with Farr Curlin, the Josiah Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities, & History of Medicine and Co-Director of the Theology, Medicine, and Culture Initiative at Duke University. Curlin opens by discussing whether a distinctively Christian way of practicing medicine exists. While he believes one does exist, he contends the answer to such a question does not simply depend upon whether a physician is a Christian but how one who is a Christian understands the good or purpose of her or his vocation. In contrast to mounting views of physicians as service providers, Curlin lobbies for physicians to view themselves as healers. Curlin goes on to discuss his own formation as a physician at the University of North Carolina at Chapel Hill and at the University of Chicago. Discontent with how he was coming to view his own vocation led Curlin to discern how to re-form those views, inevitably also leading him to create comparable opportunities for other physicians. He then discusses the discernment process that led him to Duke University, the joint appointment he shares between the divinity and medical schools, his practice in palliative care, and the commitments that led him to write (with Christopher Tollefsen) The Way of Medicine. Curlin closes by exploring the virtues physicians who view themselves as healers need to cultivate as well as the virtues they need to be prepared to confront.

Todd Ream: Welcome to Saturdays at Seven, Christian Scholar’s Review’s conversation series with thought leaders about the academic vocation and the relationship that vocation shares with the Church. My name is Todd Ream. I have the privilege of serving as the publisher for Christian Scholar’s Review and as the host for Saturdays at Seven. I also have the privilege of serving on the faculty and the administration at Indiana Wesleyan University. 

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Our guest is Farr Curlin, the Josiah Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities and History of Medicine, and Co-Director of the Theology, Medicine and Culture Initiative at Duke University. Thank you for joining us.

Farr Curlin: I am delighted to be with you. Thank you.

Todd Ream: In a recent lecture you offered in Chicago, you asked quote, “Is there a way of medicine for Christians?” End quote. Before asking you about the answer you offered in that lecture, I’d like to ask you what prompted you to pose it? In particular, were there any vocational realities, cultural realities, historical realities, maybe even financial realities that prompted that question to be asked?

Farr Curlin: Well, what prompts it is the recognition that Christians, along with many other types of medical practitioners have been wrestling in a new way in our time with we are up to in medicine. And there’s a widespread dis-ease and loss of morale among medical practitioners. And it has led to a lot of soul searching to ask, well, what, what does good medicine look like? What, what is medicine, in fact? And what’s getting in the way of good medicine?

I’m frequently, because of my work at this intersection of medicine and religion or medicine and specifically Christian theology, I’m talking to Christian groups and I think it’s important to ask, what, what, does the Christian tradition have to say about this? Do we have our own medicine? What is it that makes the medicine that’s distinctively Christian, Christian or is there any such thing? And so there’s a widespread concern about whether what good medicine is, and then I’m interested in what the sources are for that, particularly for Christians.

Todd Ream: Yeah. Thank you. In your estimation then, does a culturally accepted good or purpose animate the practice of medicine amongst North Atlantic nations? Or perhaps given the circumstances that you noted, was there one in some ways that’s under some duress today?

Farr Curlin: Yeah, it’s, it’s my impression that historically it’s pretty obvious uh, it was taken for granted for centuries, certainly from the Hippocratic reform movement in ancient Greece through to the middle of the 20th century, that medicine is for the patient’s health. Um, it doesn’t mean that people had uniform ideas on the boundaries about what a person’s health requires or that they would exactly define health in the same way. But there was a, a recognition there is such a thing as health human health is important to humans. And that’s what medical practitioners do as medical practitioners.

That I think is sensible. There’s a reasonable basis for that. Um, interestingly, it seems to me that if you look at the early Christian writers about suffering and illness and how the Church should respond, they seem to take for granted, in my opinion and reading their writings of people like Basil for granted that that what they called secular medicine, which was just their term for science, scientific medicine of the day, that it was for health, for the, the patient’s health.

But that way of understanding medicine has clearly been under pressure probably steadily for a couple of centuries with the rise of the modernity and all that goes with modernity. And modernity’s emphasis on individuals authentically living out their own lives according to their own choices free from the restrictions posed by other people’s expectations, dated cultural norms, including religious traditions and ideas, as has led to the rise of an emphasis on patient autonomy ,where autonomy is not understood as the ancients understood, or certainly not as Kant understood it, which Kant understood autonomy as following the moral law in one’s actions. So the truly autonomous action is the action according to the moral law.

Now, autonomy has come to mean, or an emphasis on autonomy has come to mean that we have an obligation to respect each individual’s desires and choices regarding what they want, what they think is helpful for them, with respect to their lives, including their body, and that insofar as medical practitioners have tools they can use to bring about some state of affairs that people value, then they have an obligation to do so.

And so I and uh, my colleague Chris Tollefsen have described this as the difference between what we call the way of medicine, the more traditional understanding of medicine oriented to health and what we call the provider of services model. Um, and that’s not unique, that’s not just our observation. Lots of people have observed that there’s this movement to see patients as customers or clients who have a right to healthcare services that doctors are obligated to provide. And these two models are not ultimately reconcilable.

Todd Ream: Yeah. Thank you. This perception of the good or purpose of medicine as you’ve described it and how it’s historically changed then, when we look at other regions of the world per se, in what ways, if any, does it compare?

Farr Curlin: Yeah, it’s a good question. And I haven’t done a lot of in-depth, cross-cultural work. Uh, my sense is that insofar as the medicine and the culture around the medicine of the North Atlantic Industrial West has been imported into and adopted by other countries. Just insofar as that’s true, there is, there’s more emphasis on Western notions of respect for autonomy and, and so on.

But because that has only happened to a limited extent, in my observation in places like Guatemala and Honduras and which are probably more influenced by Western, these Western notions than, than certainly regions in Africa and South Asia, there’s not as much of the emphasis it seems to me on autonomy.

Um, and really the emphasis on autonomy requires a good deal of money and leisure that and resources, that medicine in these less well-financed countries really don’t, don’t, doesn’t have access to.

Todd Ream: Yeah. Thank you. Before moving on to other questions then, I’d like to now sort of double back and ask you this question formally. You hinted at it in some ways by citing, you know, some of the fathers, say such as Basil and so on, but you know, is there a way or could a way be recovered perhaps that Christians could practice amidst these other pressures that could become somewhat of a motto, at least for a sub-community?

Farr Curlin: Yeah, I think, I think the way of medicine for Christians begins with and builds on what we call the way of medicine. So it begins with a recognition that part of human nature is, is health and part of human flourishing, if we are, we are doing well as the kinds of creatures God has made us to be as humans, that includes health. It’s not the whole of human flourishing. It’s not the highest good. It’s not the only good. But it is good, it is health and the preservation and restoration of health that gives Christians a good reason to look to medicine as a gift. 

Uh, Basil kind of reckoned medicine, a craft like and talked about it like agriculture. And he said, insofar as humans have, particularly after the fall, of course, have a disposition toward hunger or a tendency toward hunger, God has given us the gift of agriculture so that we might eat, and we should respect that and appreciate that and, and receive that as a gift. Similarly, insofar as humans are predisposed toward or tendency toward injury and illness and ultimately death, God has given us the gift of medicine, what again, they called secular medicine, as a gift to help preserve and restore our health.

So that I think is what it, that’s where it begins. And then Christian medicine, and this is clear in Basil’s writing and in others, the challenge is to not make of medicine more than we should as a Christian or differently it’s to look to medicine in ways that are befitting us as those who know ourselves to be created by a good God, who has called us to be about all that goes in our vocation, which includes worship, serving our neighbor, courage in, in various situations and so on.

Where too much attention to the body could actually get in the way of fulfilling our vocations and or we could have an anxiety driven by an anxiety, that’s not fitting for one whose Savior said, “Do not worry about tomorrow, you know, for who of you by anxiety can add a single hour to his life.” So there’s that kind of conditioning or framing in how Christians approach medicine.

But the basic structure of medicine is one of appreciating the gift of a craft that can attend to health needs and preserve and restore them to some extent. And when it can do that without posing undue burden, without interfering too much in our lives or without violating God’s law in some way, then we receive that as a gift.

Todd Ream: In terms of cultivating this perception of medicine as a craft then, in what ways, if any, can the Church be a partner for in the shaping of medical practitioners?

Farr Curlin: Uh, it’s a good question. I think it begins with shaping of just the people in the pews. Uh, Stanley Hauerwas has famously said, well, he certainly said to, to me and to others here many times that if we want a well-formed medicine as Christians, then Christians have to practice patience in the face of our mortality and in the face of the limits of medicine. Otherwise, we’re basically asking of medicine, what medicine ends up giving, which is a kind of the hubris of presuming to deliver us from our mortal condition and to give us the lives that we want rather than serving us in the ways that it should.

So it begins to there, and it begins by reminding people of part of our human condition is we’re, we’re going to get sick, that we owe to one another solidarity, letting people know that medicine is of course good, but we don’t need to take for granted everything that the doctor says or the doctor recommends, that the authority of God’s call in our life is one that supersedes, can supersede the recommendations of a physician.

And I think it helps in that respect, I observe that clergy including Christian clergy, tend to the most part, when someone is sick, to just not want to get in the way and kind of encourage them to get to the most equipped, most skilled, most high tech, most capacious healthcare system available and experts available and then not get in the way of that medical treatment. And then just to focus on helping them cope with medical treatment.

But I think we are at a point where we need to be able to acknowledge that, that often, in a way, abandons someone to a system and a community that don’t really know the identity of a Christian and what they reasonably hope for and how they reasonably or order their lives and avoids problematically offering the kind of pastoral counsel that really a, a pastor is authorized to give to someone, to challenge them to seek the good that’s available in a way that fits their vocation. But don’t make too much of medicine. Don’t put your hope in what medicine can offer.

Todd Ream: Yeah. Thank you. Thank you. I want to ask you now about your own formation personally as a physician. You earned a bachelor’s and an M.D. uh, from the University of North Carolina Chapel Hill.

And at what point did you discern medicine would prove to be central to how you understood and in turn, exercised your vocation?

Farr Curlin: My father was an OB/GYN, so I grew up watching him respond to being paged at all hours of the night, always responding, always going back, and never communicating that he resented the demands of medicine, even though those demands were great, and he sometimes was so exhausted that he was almost at the point of tears with exhaustion. And yet, I think it struck me that there was a kind of moral substance and seriousness to this work, a goodness to it that found it very fulfilling to be a doctor. That captivated me. My grandfather was a general surgeon who also loved his work. He loved encountering people. He loved holding their hands and talking to them and trying to help them get through serious illness.

So I saw that and then I was fed by my parents biographies of missionaries, including once I told them I thought I might be interested in medicine, medical missionaries. And so I read the biographies of people like Helen Roseveare and Carl Becker and the, and what was then the Belgian Congo, Thomas and Cynthia Hale in, in Nepal and Paul Brand who worked as a hand surgeon in India. And I was just captivated and thought I wanted to be a medical missionary. Um, so by the time I went off to undergraduate, I was determined to do what it took to get into medical school.

Todd Ream: Thank you. In addition to your father and your grandfather then, were there other mentors along the way that helped with this discernment process?

Farr Curlin: I wouldn’t say necessarily mentors that helped with the discernment to go into medicine. I was pretty resolved on that based on their, their witness and my own attraction. There’s certainly mentors along the way about what it looks like, teaching me what it looks like to be a good doctor

And interestingly, the person to whom I owe the most so insofar as I’m conscious of it owe the most with respect to teaching me how to be a good doctor was a colleague and friend, a Jewish colleague and friend who was my senior resident for two months during my intern year and was relentlessly demanding of me and was unfailingly committed to providing his patients the best available care according to his best judgment that he could, and insisting that we did that as well.

And um, and I saw that he enjoyed his colleagues, he enjoyed all the people who worked in the hospital and learned their names. I regret, I’ve never learned to do that like he did, but that genuine interest in the human person in front of him and a relentless determination to do what can be done well to care for them I think imprinted on me and still inspires me today.

Todd Ream: Yeah. Thank you. In addition to those biographies of medical missionaries you read when you were younger any other authors that contributed to your formation as a physician?

Farr Curlin: It’s a great question. The truth is, I did not start to read about medicine philosophically, theologically, intellectually, until I was almost done with my training. Um, and so part of my story is I thought I wanted to be a medical missionary, and I basically began with the sense that medicine is good. What it means to be a Christian medical practitioner is to take the good of medicine and make it available to people who don’t have access to it. Do that in Jesus’ name, and hopefully as a part of bearing witness to God’s love for them. So that’s the way I thought of medicine.

And then when I went through training, both medical school and residency, I increasingly became disenchanted with that understanding. And it became more and more obvious to me that standard medicine was not necessarily good, that it was filled with all kinds of distortions and corruptions, that it was built on anxieties that were not reasonable, that it had hopes that were not reasonable, that it was motivated by money and, you know, avoiding risk and so on in ways that were not, not the way we would practice if we began with the Christian story. And just kind of constructed medical practice out of that.

And so it was then that I started reading. One of the first things I read was Stanley Hauerwas’s book, Suffering Presence and it was a collection of his essays. And then I started linking up with others who networking, who had read and, and reading things that they encouraged me to read. And I slowly developed over years my own education as a Christian.

Alan Verhey, late colleague here, theological ethicist written some important books, including one Reading the Bible in the Strange World of Medicine. And began to think as a Christian about medicine in a way that I had not before.

Todd Ream: This process that you just described after you graduated from medical school, you did a residency and eventually joined the faculty at the University of Chicago. So did this process that you went through then take place during the years you were in Hyde Park?

Farr Curlin: It did. Yes. So I was a resident there in internal medicine. And I was living on the west side in an inner city community to learn from people at the Lawndale Christian Health Center, which is a really remarkable health center for underserved community on the west side of Chicago. I was thinking that was the kind of work I might do if I stayed in the U.S.

And I basically at some point there decided I really want to pursue these questions. So I did a postdoctoral fellowship, learned how to do research, studying how religious characteristics of doctors track on to differences in their practices. And then I joined the faculty and did a fellowship in clinical ethics and started wearing the hat of a clinical ethicist, started to think about the ethical disputes within medicine.

Again, started creating space within the university, they’re at the University of Chicago and then with colleagues a national conference, which is still ongoing, a conference on medicine and religion where we could take seriously the substance of faith and how it informs the practice of medicine. So all that happened during the about 15 years that I was at the University of Chicago.

Todd Ream: And is that through what eventually became the program on medicine and religion that you founded and then co-directed during those years?

Farr Curlin: That’s right. So that’s right. I, with Dan Sulmasy who’s a remarkable philosopher, internist, bioethicist now is the director of the Kennedy Institute for Ethics at Georgetown. He and I were there together and, and started the program on medicine and religion. We trained eight junior faculty through a grant from the Templeton Foundation who have gone on from there to do their own work in this area. We did a good bit of research together there, through the program on medicine and religion.

Todd Ream: For a Chapel Hill grad, twice over I would note then, would you describe the discernment process that led you to accept an appointment at Duke University?

Farr Curlin: Yeah, I mean it, I’ve told people since that I work for the Devils, but I’m on the side of the Angels. Oh, and I also say, I’m a big fan of Duke Medical School and a big fan of Duke Divinity School, not so crazy about the Blue Devils, at least not when they’re playing the Tar Heels.

The truth is this was not a hard decision for me. Um, like I love my time at the University of Chicago but it is hard to do this work in part because in academic medicine, you can only eat what you can kill, as they say. You have to find funding for whatever you do. And I had had some success at that at the University of Chicago, but Duke offered an endowed professorship and in its ethics center which is a terrific center on the medical school side.

It also offered, and this was a dream come true, I could have never possibly imagined this would happen, but through the leadership of, of the late Richard Hays, who was then dean of the Divinity School, and his stewarding this, I was offered a joint appointment in the divinity school and invited with colleagues here, including Warren Kinghorn, who’s a theologian and psychiatrist to create this theology, medicine and culture initiative we’ve been running since. So it was an absolute dream job. It remains a dream job, and um, even though it was at Duke, as a former Tar Heel, it was a no-brainer.

Todd Ream: On a day-to-day basis then, the appointments that you share between the School of Medicine and the Divinity school, what does that look like? How much travel back and forth? How much are you able to integrate the two cultures maybe with one another on behalf of students? And what is, what are the paces of the day and that, those intersections, what do they look like for you?

Farr Curlin: I, I don’t think this would be possible at very many universities. Uh, the University of Chicago had a divinity school right across the road from the medical school. Um, but not many schools do. But here, my office is a five-minute walk. My office in the medical school is a five-minute walk from my office in the divinity school.

Um, there’s not really a typical week for me because as part of this, this job is, I, I do eight weeks of full-time inpatient work in Duke hospitals. At which time I’m barely keeping up with my email inbox generally falling behind on it throughout the week. because it’s full-time clinical work. Um, those are scattered out throughout the year. Otherwise, I’m kind of back and forth. I was there at my medical school office this morning. I’m in my divinity office this afternoon.

In the medical side, I, I both do research, writing about medical ethics. I also teach an annual course in clinical medical ethics for the medical students. I teach other one-off lectures on medical ethics. I’ve done a couple, you know, even in the last few weeks. And work with colleagues to foster the programming of the Trent Center for Bioethics, Humanities and History of Medicine.

Then I come over to the Divinity School where we have students in residence with us. These are people on their way to being medical practitioners. We invite them to come spend a year or two studying with us full-time at the divinity school, we wrap around the cohorts of, of these future medical practitioners or current medical practitioners, spiritual formation, training as public intellectuals, food, eating together, breaking bread together, retreats so that they have a kind of in-depth fellowship experience during the course of their time with us.

And so I’m back, back and forth and it varies quite a lot depending on what is what’s most pressing. I do teach a course, a full semester length course in the divinity school every year on healthcare and theological context with a particular focus on the ethical questions that arise in, in medicine. And I also teach at times as I’m teaching this spring other courses. I’m offering a course on suffering, the limits of medicine for divinity students, among whom many of them are healthcare practitioners who have come to study with us in our programs.

Todd Ream: Your clinical appointment is in palliative care so when you do clinical rounds then, is that the focus of your efforts as a clinician?

Farr Curlin: It is. I was trained as a general internist, but several years into my faculty role at the University of Chicago, I started doing hospice and palliative medicine. And since I came to Duke in 2014, I’ve done just hospice and palliative medicine. So I’m either that week, the medical director for the inpatient hospice of Duke which is a 12-bed inpatient unit off-campus, or I am seeing inpatient or doing consultations for inpatients at one of Duke’s hospitals.

Todd Ream: Okay, thank you. Your bio notes that one of the efforts you’re currently seeking to establish is called the Hippocratic Society, an association of students and practitioners dedicated to fulfilling the profession to heal.

Would you offer some details concerning your, your perceived need? Some of it we could estimate probably from what you’ve already said, but that push this initiative to the surface in terms of something that you’re seeking to accomplish and bring.

Farr Curlin: Hippocratic Society is motivated by a recognition that there’s a lot that demoralizes medical trainees. Medical trainees there, there are a lot of dynamics that bear in on medical trainees that effectively teach them that their own clinical judgment and their own moral judgment, which is a part of their clinical judgment is less a resource to their patient than a threat to being consistent as a member of the medical bureaucracy, to being efficient as a part or a cog in the medical industry, to being a provider of services to satisfy the autonomy rights of patients and so on. And we think that’s inadequate for medicine and it’s deeply dispiriting to medical practitioners.

So the Hippocratic Society is devoted to forming clinicians in the practice and pursuit of good medicine. We do that in a couple ways. One, we have chapters at academic medical centers where students, trainees, and faculty get together roughly monthly, break bread together and discuss cases that we’ve curated to consider how different virtues that arguably are really important for good physicians, different virtues would be expressed in clinical practice.

So we look at a clinical case and we’ll recognize the places where we’re drawn into more vicious practices often by our own problems and problems of the system, and then think together about how we can grow ourselves into becoming more virtuous physicians, which is another way of saying physicians characterize by practicing good medicine.

Um, similarly, we try to address the ethical questions that emerge in clinical practice, not so much to just focus on the issues that set people’s teeth on edge, but truly really try to reckon with what is the character of the doctor-patient relationship? What is medicine for? How do we practice conscientiously? What kind of authority do physicians properly have? What are the limits of that? How do we respect the limits of our authority and also respect the responsibilities that come with having that authority? Those kinds of questions.

And we do that, we meet, have these meetings, and then we also put on some public events where people can reason together publicly at, in a season where civil discourse about difficult questions is difficult, is difficult in the university.

Todd Ream: Thank you. I want to ask you now about a book that you mentioned earlier. In 2021, the University of Notre Dame Press published The Way of Medicine: Ethics and The Healing Profession, a book you co-authored with Christopher Tollefsen, who serves as a philosopher at the University of South Carolina. We’ve talked about and probably brought lessons to bear from that book into our conversation already.

But in particular, I want to ask you if you just offer an overview of that book and what do you hope audience members encounter when reading it?

Farr Curlin: So the overview is in this book we note the demoralization that’s happened, then we try to diagnose that. And we diagnose that centrally as a problem of detaching from the traditional understanding of medicine as a healing art, which is oriented to the patient’s health, which is an objective norm of the body. It’s something that we can, we don’t make up, we don’t create, we recognize and we reasonably develop some expertise about as medical practitioners.

And we act in accordance with that reasonably, and that we pursue health in ways that are both respect medicines end, its healing purposes, but are also responsive to the broader demands of morality what C.S. Lewis would’ve called, you know, the Tao, the demands that are, that are just part or what Catholics would’ve called natural law, things like respecting the, the principle of fairness of, of the golden rule. Um, but also principles like we don’t intentionally do, we don’t do evil that good may result.

Medicine has been detaching from that understanding, which has served it in good stead for centuries and sliding steadily and increasingly toward this understanding of medicine as a, we call the provider of services model, where doctors basically presumed to not have any, any particular expertise or opinion about what medicine is for. And instead they defer to patients to say what medicine is for and what they want.

And so long as what the patient wants is legal, it’s not forbidden by the law, it’s technically feasible and it’s not grossly and overtly harmful then as so long as the patient wants it, medical practitioners see themselves as having an obligation to provide it. That way of thinking is present, obviously in many of the areas where medicine has been shifting its moral standards, like with respect to abortion, with respect to medical aid and dying or physician assisted suicide or euthanasia.

Um, but I think it also has been shifting more subtly across medicine as physicians have been, increasingly kind of detaching from the purposes of their work and whether their, their interventions are good and instead receiving the standards of the industry and its efficiency, the standards of following the patient’s wishes, whatever they are, and then doing whatever the law, you know, what the law allows. We think that’s a, this shift is a corruption.

And in the book we show how those two ways of understanding medicine lead to very different conclusions regarding a number of ethically contested questions. And we basically make the case for why medicine should recover what we call the way of medicine, that traditional orientation to patient’s health.

Todd Ream: And I would assume then, if I may ask this, the growing number of advertisements on behalf of pharmaceutical companies that are targeted at patients and patients as consumers here is a reflection of this shift that you’re describing?

Farr Curlin: Absolutely. I mean, absolutely. If we understood medicine as it, it has been understood traditionally as a gift, a profession committed to showing up when people are injured or sick, and using our expertise and the resources available within reason to preserve and restore their health, we wouldn’t need pharmaceutical companies trying to give people these rosy views of, you know enhanced lives. Um, doctors would be aware of what’s available and when patients are sick or injured or their health is threatened, they would offer it.

But we are, yeah, we, those, the direct to consumer advertising very much dovetails with and accentuates this expectation that really the patient knows what they want after they’ve listened to all the commercials and the doctor is there as someone who holds the keys who has under the law the, they have to cooperate with the patient’s desires to make available these things that, pharma and others are pushing.

Todd Ream: Yeah. Thank you. Before we close our conversation today, I want to ask you some additional details about your understanding of your vocation as a physician educator. You’ve just talked about how you sort of personally came to understand that vocation, but what practices proved important to you and what practices do you believe are important to shape the next generation of physicians and perhaps also physician educators too?

Farr Curlin: Well for physicians I think it’s just essential, it’s absolutely essential that we recover however long it takes and it will be recovered I think, but recover the recognition that medicine is for healing, that medicine is for the patient’s health. It’s not for doing stuff. It’s not for bringing about desired states of affairs. It will lose its bearings and transgress its moral boundaries as it already has if we don’t hang on to that.

And I think doctors have to recover confidence that they have a kind of authority. It’s not the authority to tell everybody what to do, but it is the authority to discern whether a particular intervention is consistent with that profession, that profession, to heal and to say no, I will not cooperate in some use of my technical powers that contradicts that intervention.

When doctors recover that, then it opens up into another kind of moral skill and, and, and practice, which is learning to recover our teaching capacity. You know, docere is the etymology is a teacher, and physicians have historically, primarily had their teaching capacities, what they could offer when we didn’t have nearly the same technical interventions that would do anything, but we could teach people about what they could expect and what they could do to, to preserve their health and so on. I think the teaching that’s going to be necessary for the future is that which helps people see the limits of medicine and its goodness, and helps people discern when, what medicine can offer is something that fits for this particular patient and their situation.

And that’s going to require interest in the patient and in their vocation. Not just the patient as an instance of a pathophysiology that we can do something about, but the patient as a human being who has a vocation in which the things that we can do, we can do will offer certain benefits, but also pose certain burdens. And we have to engage together with the patient in reasoning and judgment to help them make good decisions. And that’s again, not imposed by the physician. It’s not imposed by the patient’s wishes. It’s worked out that two people, both interested in the patient’s good. Um, that I think we have to recover.

And for medical educators similarly, frankly, I’m quite discouraged by what I’ve observed even in my time in medicine. And I’m sure people older than I would say, oh, you don’t, you don’t know the first of it. By the time you came around it was so corrupt. You know, it was in terrible shape. But I have watched, since I’ve been in medicine, medical educators become primarily afraid of their students.

And I, I’m sure I’m overstating this a bit but there is a deep insecurity among medical educators expressed in a constant, kind of putting your finger to the air and testing to see our students happy or not. Are we giving them what they want or not? If the students are criticizing us, are we being responsive or not? I think that’s all a symptom of this demoralization. It’s a symptom of medicine losing its way.

I’ll put it this way to close this question. Stanley Hauerwas has said famously for decades that he’s always respected medicine, because he thought medicine and the military were the last institutions within modern life that were genuinely, morally serious. And he, and he would give this illustration, he’d say, you know, if a person comes to divinity school in 1990 and 2000 and 2020, and they could say, you know, I know I’m supposed to take New Testament, but I’m not really into New Testament, really. I’m really into relating and I want some more pastoral kind of experiences, and I want to know more about diversity and I want whatever, whatever the latest thing is.

And he said, in a divinity school, people would say, oh, well let’s, let’s see if we can create a class for you, how we can accommodate you say, but if you go into medical school and you say, I’m not really into biochemistry, I’m not really into pathophysiology, they tell you, ship out.

Todd Ream: Yeah.

Farr Curlin: Leave. There’s the door. When you come here, we’re not interested in what you want.

I think that was true, and it should be true of medical formation if it’s practiced under the way of medicine and if we basically say, look, we’re going to train you how to show up well and not cause harm, but instead, foster healing in people who are sick, get ready because it’s going to take a lot of hours, it’s going to take a lot of study and we’re going to be on you all the time teaching you directly apprenticing you and correcting you. But we’re not really interested right now in your opinions about what we should teach you until we can see that you’ve internalized what this profession’s about.

But I think that’s been lost for the most part. I think now the medical educators are very much curious what students want, anxious that students are upset with them responsive to student protests in a way that’s actually not good for students and not good for the future of the medical profession.

Todd Ream: Yeah. Thank you. Before we close our conversation then cultivating this sense of identity and way of going about medicine for students involves likely the formation of certain virtues. You talked and echoed that was being part of the Hippocratic Society’s purpose.

What virtues in particular, intellectual and moral virtues, do you think are most important to cultivate, and then for what theological virtues might we need to pray for the most in terms of the formation of physicians?

Farr Curlin: Yeah, well, you certainly need some of the cardinal virtues. I mean, we, we certainly need prudence prudential judgment, which in medicine is just clinical judgment. And that takes a lot of experience. That’s why medicine’s not taught just with books. It’s taught as apprenticeship, over many years. That certainly needs to be formed, but it cannot be formed by setting aside questions of the good and just focusing on technique and what’s possible. That’s actually a deforming of our prudential judgment.

I think to pick another cardinal virtue that we really need courage in this season. I’m sure that’s always been true, the courage to look patients in the eye with genuine charity, a theological virtue, a genuine concern for them, or to take it down a theological notch, a bit genuine solidarity, a a, commitment to the patient’s good that, to tell them you disagree and that no, you’re not going to do what they want or that you strongly encourage them to let go of, of the idea they have or the thing that they think they want.

And, and the courage to go through the struggle of speaking up when things, when systems are not aligned toward the patient’s health that’s going to be really necessary. And you know, I think for Christians we do need the theological virtues. We need faith, hope and love. We need the hope at a time when there’s a lot of demoralization. We are not without hope because for us, you know, as Christians know, well right at the center of our story, with Jesus’ death and resurrection when everything seems to go badly, does, does not mean that we are without hope.

Our hope is not in winning. Our hope is not in reforming medicine in our time. Um, it will always need reform and we are always going to kind of Augustine said, with respect to politics, everything that’s done must be done again. I think every reform of medicine today will need to be done again in the future.

We recently have submitted a piece in which we observe that it really, well and I also recently co-authored a piece with a student with Anjola Onadipe. Um, it was published in Academic Medicine, which is the, the Premier Medical Education Journal where we argued that Augustine’s idea of ordered love is a better model than what has been the model for the doctor-patient relationship on offer for the past several decades, which is something called detached concern, where you, you’re kind of concerned, but not too much.

I think, no, we need this era, being detached is too easy. We need to cultivate love for our patients. And then just hold that love up to the standard of what is genuinely good for them. That love needs to be well ordered. It can’t just be our, our feeling. It has to be ordered oriented toward the truth. So those are some, some notions on the kind of virtues I think are necessary for good medicine.

Todd Ream: For our last question then today, the converse of what we were just talking about then as a physician educator, what possible vices have you also found to be most important to confront or be ready to confront when they present themselves?

Farr Curlin: There is the vice of hubris which medicine has always been prone to, the presumption that because we have lots of interesting tools and powers that we know what is best and that in our attempts to do good, it’s easy to forget that we can cause a lot of harm.

There’s a vice of impatience that’s present both in patients themselves and uh, and in the physicians. And I think there are impulse, some people call it the therapeutic imperative, that impulse to do something when someone asks for help can really lead us astray. Whereas if we cultivate the virtue of patience, which also requires when you’re dealing in human relationships, courage in the face of someone being upset with you, for the patients to recognize, hey, this problem is a genuine problem. This suffering you have is genuine suffering, but the things that we can do are not actually going to be. They’re probably not going to be wise for you to do. Hang in there, let’s hang in there together. Let’s do what we can do humbly, without impatiently actually ended up causing more, more harm than good.

And I think there’s the, the vice very often the problem, the vice of, of a duplicity and, and dishonesty, frankly. Not because doctors are trying to lie to their patients, but it’s been widely recognized, we struggle to tell the truth candidly with patients. And particularly the truth about the fact that we can’t fix some of the problems they have, the truth about the fact that they’d probably be better off to focus on their lives or the rest of their vocation than to ask us to help with some of the things they ask us with, the truth about the way that all these drugs that are on the TV are not likely to help most of the people they’re being used for. Um, we have to develop that capacity to be truth tellers.

Todd Ream: Yeah. Thank you. Thank you very much. Our guest has been Farr Curlin, the Josiah Trent Professor of Medical Humanities in the Trent Center for Bioethics, Humanities, and History of Medicine, and Co-Director of the Theology, Medicine and Culture Initiative at Duke University. Thank you for taking time to share your insights and wisdom with us.

Farr Curlin: You’re most welcome. Thank you.

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Todd Ream: Thank you for joining us for Saturdays at seven Christian Scholars reviews conversation series with thought leaders about the academic vocation and the relationship that vocation shares with the Church. We invite you to join us again next week for Saturdays at Seven.