Psychoanalysis and Medical Ethics

by Rachel C. Conrad

On the first day of both my undergraduate (premed) and med school courses on medical ethics, I present a case without a clear answer: “We have one liver and two dying patients. How do we decide who should get the liver?”

I want them to linger with a common dilemma in medical practice—one that doesn’t have a simple answer. I want to open up space for them to acknowledge, both to themselves and to one another, that they can’t always know the “right” answer—that they have to accept ambiguity and allow themselves to feel the irreconcilable tensions that, unfortunately, their education as doctors doesn’t ordinarily acknowledge.

From the first day of college through advanced subspecialty training, the U.S. medical education system frequently instills in future doctors the notion that every question has a “right” answer. The requirements for premed undergraduates who are applying to med school include a six-hour multiple-choice test, fifteen science courses…and one humanities course. Most of the exams they take reinforce the only-one-correct-answer mentality. Physicians mock “Dr. Google,” yet much of our medical curriculum is based on the memorization and regurgitation of factual information. This sort of pedagogy encourages dissociation from irreconcilable dilemmas and uncomfortable feelings; disconnection from the more complex causes of our patients’ suffering; and the abandonment of intellectual humility.

Ethics training among premeds and med students alike seeks to challenge this mindset, and to explore questions that have no single “correct” answer—questions like, which of these two transplant candidates should be given a chance to live? In my own experience, psychoanalysis can be an invaluable asset to such ethical training. For example, it can help us better to understand the enormous complexity of both conscious and unconscious motivations.

Indeed, both the study of ethics and the experience of psychoanalysis help develop practices of reflection and a greater tolerance for uncertainty. Neither offer the sorts of definitive answers routinely sought in contemporary medical education. During my own medical ethics fellowship, we got into the habit of responding a bit sarcastically to every question with: “It depends.” And, indeed, “it” usually does depend upon a variety of complex, intersecting personal and social factors.

Premed and med school students must quickly grow accustomed to an endless parade of traumatic events. We proceed from crisis to crisis, day after day, night after night: A high school student hit by a car while biking to school. Hysterical parents being asked whether they will donate their dying child’s organs. These are not multiple-choice scenarios.

But hospitals have little time and few resources for helping our students to process such encounters with individuals and families who are enduring the worst moments of their lives. Everyone is busy and tired and trying not to become overwhelmed, themselves, by their own feelings—not to mention sheer fatigue and the toll it takes on psychological well-being. There are always more patients waiting.

During my medical school training, students were administered a “professionalism” self-assessment in which we were asked either to confirm or deny the statement: “I can control my feelings.” The correct response, obviously, was “true.” Such remnants of an antiquated culture of (largely masculine) stoicism tend to pathologize emotionality, to blame doctors for their personal and ethical struggles, and to ignore the often debilitating pressures of our healthcare-delivery systems.

Four days a week, I travel from the hospital, where I am both a doctor and teacher, to the couch, where I am a patient myself. Just as I encourage my students to get used to sitting with their discomfort, so too must I sit with mine. The thoughts and feelings we are taught to suppress during hospital hours are, of course, welcomed and encouraged, without judgment, in the psychoanalytic session.

And like the psychoanalytic consulting room, the medical ethics classroom is a space designed for feelings that the rest of our education tells us either to suppress or to “deal with” on our own. In my own undergraduate medical ethics course, my classmates and I joked that it wasn’t really medical ethics until someone cried. Some might say the same sort of thing about psychoanalysis. Both ask us to face honestly and openly whatever causes us distress. Medical training and practice certainly give us plenty to cry about—but no space or permission to do so. No allowance is made for the fact that physicians’ pain and conflicting feelings are both inevitable and meaningful and that it takes time and help from others to manage that pain and to make wise use of those feelings.

I began psychoanalysis at a point when I was particularly distressed about the cruel inequities of our healthcare system. Much of my medical training was spent in large public hospitals, treating patients who often lived in precarious and unbearable situations. These are patients for whom our medical interventions are often undermined and even rendered useless by their socioeconomic circumstances—like the 60-year-old patient who waits years for a liver transplant but misses several appointments because he’s lost his home. Without more comprehensive care and assistance, how is a 60-year-old unhoused person going to be capable of managing the demanding treatment that is needed after a liver transplant?

When such patients come to our hospitals, they might undergo extremely expensive procedures only to return to living situations that are inherently incompatible with good health: situations of domestic abuse, poverty, isolation, undiagnosed mental illness, substance abuse, and homelessness. Higher-resolution MRIs, genetic sequencing, and the latest antiviral treatments can’t adequately address—much less hope to resolve—the suffering of such patients.

With every passing year, I develop a deeper awareness of the many problems with the way we currently teach and practice medicine in this country. The multiple-choice mindset undermines patient care and stifles our own empathy and humility. Our diagnostic protocols refuse to acknowledge that diagnoses are never definitive or comprehensive, which means that misdiagnoses and errors of judgment are all too common—for example, in the case of a 20-year-old who comes to the ER with liver failure and evidence of alcohol abuse, but who also presents with a genetic disease that might or might not be recognized as the true cause of his failing liver.

Humanistic study—such as the study of psychoanalysis, or literature, or philosophy, or anthropology—would help students learn to probe the varied and complex questions about human experience that are rarely prioritized in the education of doctors. While a liberal arts major nicely complemented premed requirements during my own undergraduate years, I found that, as my medical school training proceeded, I was made to feel that reading novels, for example, was self-indulgent and should be relegated to occasional vacations.

During my first year of medical school, a friend happened to make a reference to Shakespeare, which was met with blank looks as something both unfamiliar and presumably irrelevant. Yet the works of such authors immerse us in the vast range of human experience and the complex ethical questions we all face—including pressing questions of medical ethics. If I ask my students how they feel about those who risk death through self-destructive behavior, what resources can they draw on to formulate compassionate and insightful answers? Humanistic study, including the study of psychoanalysis—now almost never taught at the undergraduate level, and increasingly rarely even in psychiatry departments—could better equip future doctors to address, with both enhanced empathy and fuller understanding, such life-or-death questions.