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  • The Editor

Can respect be a vice?

by Bill Smith, MD

"The basis of optimism is sheer terror."

~Oscar Wilde

"Virtue is more to be feared than vice, because its excesses are not subject to the regulation of conscience."

~Adam Smith

We toil under a murmuring downpour of advice on how to respect and value our patients. A bright-eyed parade of emails, articles, and lectures exhort us towards professional rectitude and compassion, avoiding burnout, and to see the golden core of humanity in our afflicted patients and their obliterated families. Some of these entreaties are effusive and sanctimonious, while others are thoughtful and nuanced. Yet beneath all of them is a reservoir of panic, a foreboding that if we don’t find a way to respect our patients, a yawning chasm of contempt will open beneath us.

Respect, however, is not a behavior. It is often defined as “a feeling of esteem for the qualities of a person or institution” and, like all feelings, it cannot be summoned on command. Although it is sought after, respect is not inherently virtuous or reasonable. It is much like love: it can be faked, or overlooked, or craved, but in the end, respect can only be freely and spontaneously and unfairly given.

The censorious scolds of medicine will expertly split hairs, desperate to avoid voicing a reviled truth: it is a moral wrong to respect some of our patients. If we feel sincere respect for the addict who breaks his child’s arm to get access to narcotics, or the teenager brought in by police for clearance after burning his paralyzed grandmother with a cigarette lighter, or the man bitten by the dog he was beating with a hammer, there is something profoundly wrong with us. Presenting ourselves as people who see “beyond individual failings into the core of dignity and worth inside of every human being” is a self-flattering dodge to avoid responsibility for every toxic and wicked life that we save.

While we are implored to feel respect, we’re instructed never to feel its opposite: contempt—an emotion that is just as unreasonable and capricious. We are rightfully warned not to succumb to it but all too often we exaggerate this sensible precaution into a prideful lie: we teach that feeling contempt is morally equivalent to acting upon it. By pretending that contempt can be purged from the soul with enough positive reflection, we prepare our students for failure: like a coiled spring, refusal to acknowledge contempt creates dangerous tensions that lead to the worst abuses and personal implosions. As we come to believe our lies about our own purity, our insight and self-skepticism wither and when our negative feelings finally break free of the shoddy cage we have built, we are unprepared. We turn to drugs, we lash out at others. We either ruin our own lives or try to ruin someone else's in a death-rattle effort at vindication.

We should do what any good scientist does: consciously acknowledge our most shamefully negative and fatuously positive feelings and then practice being skeptical of them. There is a cryptic balance that many of us in the emergency department attain, a sort of anti-enlightenment. Each of us reaches this epiphany on our own, without seeking or being told: living with many conflicting beliefs is far better than living with any one certainty. We never teach this truth for fear of the righteous neophyte or bureaucrat around the corner, eager to earn their indignation credibility by taking great offense if they overhear. Without speaking of it, we learn this skill every time we hear a patient scream as we perform a painful procedure on them; we close our hearts to our agonies of conscience and go through the motions of compassion without really feeling it. It damages us, but serves the profession in its goal of healing. We should train ourselves to treat them all as if we respect them, without actually welcoming the lie into our souls. This is a crucial difference, because unlike a feeling, a polite imitation can be learned and taught.

We are obligated to present pleasing lies about human nature to others if we expect to be healers, but we risk ruin if we believe them ourselves. The white cloak of falsehood we present to the world should be light and easily cast off from time to time otherwise it will weigh us down with either self-loathing or dishonest, brittle virtue. We must learn to neither fully reject nor fully accept the gratifying emotions of contempt and respect, without pretending we can summon or banish them when we wish.

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