의사의 선(善, Virtue) (4) : 겸손함 - 선(善)의 전제조건

(출처 : http://taolifestudio.com/2013/04/24/humility-thinking-of-yourself-less/)

겸손함 : 선(善)의 전제조건

Humility as a Prerequisite Virtue

의사도 종종, 그것도 무의식적으로 환자와 관련된 의사결정에 있어서 환자의 이익보다 자신의 이익을 후선하기도 한다는 것을 겸허히 인정할 필요가 있다. 동료, 환자, 제3자의 통찰력이나 지혜를 빌리지 않고 결정을 내리기도 한다는 것을 겸허히 인정해야 하며, 최선의 선택을 내릴 수 없을 때에는 선(善)한 결정을 위해서 거기에 맞는 환경구조를 갖추어야 한다는 것도 받아들어야 한다. 

It is humbling to think that physicians sometimes make (even unconsciously) patient care decisions that are more consistent with their own financial welfare than their patients’ medical needs. It is humbling to forego making a decision until we have time to ask colleagues, patients, or others to share their perceptions and wisdom, or to structure our lives to reduce the need to rely on virtue in specific situations when we may not be at our best.

겸손함 : 이 시대의 미덕 (Humility: A thoroughly modern virtue)

따라서 겸손함의 미덕을 갖추는 것은 이미 근대 의학이 시작했을 때부터 좋은 의료의 필수요소라는 사실은 전혀 놀라울 것이 없다. 1892년, 미네소타 대학의 의과대학 학생들에게 William Osler경은 이렇게 말했다. 

"의학이라는 길에 들어서는 그 순간부터 항상 겸손함을 놓지 마십시오. 그것은 이 길이 멀다는 것을, 극복해야 할 것들이 많다는 것을, 여러분들이 신뢰하는 교수님들조차 오류를 범할 수 있다는 사실을 받아들인다는 의미이기도 합니다. 

누구나 자신의 권리를 앞세우고, 서로의 경쟁이 심해지고, 누구나 자기의 이름값을 높이고자 하는 요즘, 겸손함의 필요성을 설교하는 것은 어쩌면 시대에 뒤떨어진 것처럼 보일 수도 있습니다. 하지만 그래도 이것은 중요한 것입니다. 겸손함은 진리를 존중할 때에, 그리고 그 진리를 추구하는 과정이 얼마나 고된 것인지 정확히 가늠해야만 깨달을 수 있습니다. 

품위 있는 겸손함 갖출 수 있다는 것은 값진 선물입니다."

It is thus not surprising that the virtue of humility has been appreciated as essential to good practice since the inception of the modern era of medicine. In 1892, during an address to medical students at the University of Minnesota, Sir William

Osler urged his audience, “at the outset of your journey take the reed of humility in your hands, in token that you appreciate the length of the way, the difficulties to overcome, and the fallibility of the faculties upon which you depend.”2(p38) In words that describe our current context surprisingly well, he adds: 

In these days of aggressive self-assertion, when the stress of competition is so keen and the desire to make the most of oneself so universal, it may seem a little old-fashioned to preach the necessity of virtue but I insist of its own sake … since with it comes not only reverence for truth, but also proper estimation of the difficulties encountered in our search for it…. This grace of humility is a precious gift.2(p38)

겸손함에 필요한 세 자질 (Three qualities required for humility)

Coulehan은 겸손함을 갖추는데 필요한 세 가지 요건들을 언급하였다.

A contemporary understanding of humility has been offered by Coulehan,41 who proposes that humility requires three qualities:

스스로의 한계를 인지하는데 위축되지 않는 것 : 자신의 강점 뿐만 아니라 약점도 마주할 수 있는 능력

• “Unflinching self-awareness”—an ability to know your own strengths as well as a willingness to confront your weaknesses.

다른 사람에 대한 공감 : 잘 듣는 기술과 다른 사람이 무엇을 필요로 하는지 알아채는 능력

• “Empathetic openness to others,” manifested by good listening skills and the ability to be present to the needs of others.

아픈 이를 돌보아줄 수 있는 권리에 대해 감사하는 마음

• “A keen appreciation of, and gratitude for, the privilege of caring for sick persons.”

첫 번째 두 개는 자기 고양적 편견을 줄이기 위한 습관이며, 우리가 의사결정을 하는 과정에서, 자기 성찰을 하는 과정에서 흔히 빠지는 편견을 인정하는 것이라 할 수 있다. 

The first two of these qualities clearly support the very habits we recommend as a remedy for the self-serving bias that has called the very possibility of virtue into question: acknowledging our tendency toward biased decision making, practicing reflection, and soliciting input from respected others precisely in order to ensure that we protect our commitment to serving patients before ourselves. 

세 번째 자질은 더 근본적인 것으로서, 바로 의학의 근본적 목표를 인지하는 것이다. 앞서 언급된 것처럼 Pellegrino와 Thomasma는 전문직이 갖춰야 하는 선(善)이란 그 직업의 목표를 달성할 수 있는 기질이라고 했다. 어떤 전략이나 습관도 의사의 기본적 임무를 저버리는 의사를 도울 수는 없다. 의학에 있어서 근본적인 목표는 예방, 치료, 완화에 초점을 두는 것이다.

The third quality suggests an even more fundamental habit: Recalling the fundamental goals of medicine. As noted above, according to Pellegrino and Thomasma3,4 the virtues of a profession are those traits of character that enable individuals to achieve the goals of the profession. No strategies or habits—such as taking time-outs or consulting with others—will serve to support virtue if a professional is not first committed to the primary goals of the profession. In medicine, the primary goal is patient care focused on prevention, healing, and palliation (with personal or corporate profit and prestige as merely secondary goals).42

한계점

Limitations to Our Solutions

전문직의 선(善)이 가져야 하는 핵심적 역할과 관련해서, Goodpaster는 teleopathy를 그 목표를 불균형적으로 추구하는 것이라고 했다. 사업을 예로 들면, 이는 '좋은 제품이 무엇인가'에 대한 고민 없이 이익만 창출해내고자 하는 자세라고 할 수 있다.

Engaging the central role of goals in professional virtue, Goodpaster43 defines teleopathy as the unbalanced pursuit of purpose or goals. In business, this may manifest as a pursuit of profits without proper consideration of means or other important purposes such as providing a good product. 

이 논문은 teleopathy를 가진 의사에게는 별로 도움이 되지 않을 것이다. 우리는 의사가 다양한 목적을 추구할 수 있다는 것은 인정한다. 하지만 우리는 이러한 여러 목적이 환자를 돌보는 것에 밀려서는 안 된다고 생각한다. 개인의 이익을 우선하는 의사는 위의 습관을 갖춘다고 해도 별로 도움이 되지 않을 것이다. 그러나 환자의 웰빙을 우선시하는 의사라면 이러한 습관들이 도움이 된다는 것을 알게 될 것이다.

This article has little to offer to physicians who suffer from teleopathy. We assume that physicians pursue many purposes through their activities— earning a living, developing medical knowledge, and training new physicians. But we also assume that these goals are secondary to patient care and that the means of achieving these goals matter. Physicians who pursue personal gain as a primary aim of the practice of medicine will not profit from the habits proposed in this article because those habits are all aimed at overcoming self-serving bias. However, physicians who are committed to prioritizing the well-being of their patients in their practice of medicine or their medical research may find that these habits increase the likelihood of acting virtuously. 

적절한 지원이 없는 상황에서 막연하게 스스로 잘 할 것이라고 믿으면서 의사결정을 내리는 것보다 의사로서의 도덕적 가치를 받아들여가면서 의술을 행할 때 더 일관될 수 있을 것이다.

We understand this to mean acting more consistently in accord with the moral values one embraces as a physician rather than out of the unenlightened self-interest that apparently drives much of our decision making when we naively trust ourselves to do the right thing without adequate supports in place. In this discussion, we have not provided an account of how virtues such as prudence originate (e.g., through modeling and character formation) but, rather, an account of how individuals may increase the likelihood of acting in virtuous ways even when the environment poses challenges to their trained character.

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Acad Med. 2013 Jul;88(7):924-928.

A Humble Task: Restoring Virtue in an Age of Conflicted Interests.

Dubois JM, Kraus EM, Mikulec AA, Cruz-Flores S, Bakanas E.

Source

Dr. DuBois is director and Hubert Maeder Professor, Bander Center for Medical Business Ethics, Saint Louis University, St. Louis, Missouri. Ms. Kraus is a seventh-year MD/PhD student and coordinator, Bander Center for Medical Business Ethics, Saint Louis University, St. Louis, Missouri. Dr. Mikulec is professor, Department of Otolaryngology-Head and Neck Surgery, Saint Louis University School of Medicine, St. Louis, Missouri. Dr. Cruz-Flores is professor and interim chair, Department of Neurology and Psychiatry, and director, Souers Stroke Institute, Saint Louis University, St. Louis, Missouri. Dr. Bakanas is associate professor, Department of Internal Medicine, and associate director, Bander Center for Medical Business Ethics, Saint Louis University, St. Louis, Missouri.

Abstract

Virtues define how we behave when no one else is watching; accordingly, they serve as a bedrock for professional self-regulation, particularly at the level of the individual physician. From the time of William Osler through the end of the 20th century, physician virtue was viewed as an important safeguard for patients and research participants. However, the Institute of Medicine, Association of American Medical Colleges, and other policy groups-relying on social science data indicating that ethical decisions often result from unconscious and biased processes, particularly in the face of financial conflicts of interest-have increasingly rejected physician virtue as an important safeguard for patients.The authors argue that virtue is still needed in medicine-at least as a supplement to regulatory solutions (such as mandatory disclosures). For example, although rarely treated as a reportable conflict of interest, standard fee-for-service medicine can present motives to prioritize self-interest or institutional interests over patientinterests. Because conflicts of interest broadly construed are ubiquitous, physician self-regulation (or professional virtue) is still needed. Therefore, the authors explore three strategies that physicians can adopt to minimize the influence of self-serving biases when making medical business ethics decisions. They further argue that humility must serve as a crowning virtue-not a meek humility but, rather, a courageous willingness to recognize one's own limitations and one's need to use "compensating strategies," such as time-outs and consultation with more objective others, when making decisions in the face of conflicting interests.

PMID:

 

23702525

 

[PubMed - as supplied by publisher]