Tag Archives: Medical Activism

Medical Activism & Professional Identity

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It seems that now, more than ever, it is important for physicians and health care workers and professionals to have a sense of professional identity that involves engagement and activism in the world to protect and promote human health. Human health cannot be attained in isolation from other humans and the community. This means that if any suffer, all suffer. Human health can also not be attained in isolation of environmental and ecological health. The word “health” has its roots in “wholeness” which situates the individual within the ecological.

If you are interested in health, the environment, and the medical humanities, consider joining the Doctor as a Humanist for our 2nd Annual Offering on Nature & Medicine a webinar on Saturday, November 5th, 2022 – register for free here.

Here is some background on my evolving work on the concept of medical activism and its relationship with professional identity – from a University of Washington-Idaho Psychiatry Grand Rounds 1/20/22.

Nature, Medical Humanities & Medical Activism

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Jonathan McFarland, President of Doctor as Humanist, and I recently had the honor of presenting at the University of Washington Nature & Health conference on Thursday, October 14th, 2021. Our overall talk was Nature, Medical Humanities, and Medical Activism. Jonathan presented on Nature & Medical Humanities and I presented on Nature & Medical Activism. Here is the powerpoint from my talk.

Thanks so much to Josh Lawler, Star Berry, and the whole conference team from the University of Washington Nature & Health program. It all ran very smoothly and professionally and brought together great speakers from around the globe. There is a groundswell of interest in looking at the bi-directional effects of Nature & Health – we, at Doctor as Humanist, are planning a free, virtual symposium next month. Register for free for our Nature & Medicine: Restoring the Balance Between Earth & Health – we hope to see you next month!

Interview with Robert Jay Lifton

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This interview was conducted by telephone on 5/28/21, recorded, transcribed, and reviewed by Dr. Lifton.

Robert Jay Lifton, MD – photo from his website

David R. Kopacz: I’d like to start by thanking you today for your time and tremendous body of work over the years. There are many ways that your work has influenced my work that I’d love to talk about, but I’m going to focus in, today, on the concept of the witnessing professional. I wonder if you could start by talking about this concept of the scholar-activist, the witnessing professional.

Robert Jay Lifton: I came to the idea of the witnessing professional in connection with a companion term of malignant normality. Malignant normality being the imposition on a society of a set of expectations that are highly destructive but are rendered ordinary and legal. Of course, the most grievous and extreme example of malignant normality is in connection with my work on Nazi doctors. In that sense, the German physician at the ramp in Auschwitz and other camps, sending Jews and others to their deaths was functioning in a kind of malignant normality. That is what he was supposed to do. That was his job, so to speak.

RJL: Within malignant normality we professionals have the capacity for exposing it, identifying it, and combating it, and that is the development or evolution of the witnessing professional. He or she is witness to the malignance of the claimed normality and not diminishing one’s professional knowledge but actually calling it forth as a means of creating one’s particular witness.

DRK: I wonder, how does this relate to our normal or historical concepts of professionalism, and how professionalism is taught today, in the health professions, with this tight focus on evidence-based medicine and protocols?

RJL: I became interested in the history of what we now call professionalism and the professions and, as you may know, it begins with profession as a profession of faith, of religious faith or commitment to a religious order. Over time, especially as we developed and moved into more of modern society, the idea of a profession became more associated with skills and increasingly technical skills. So, the idea of the professional or the profession became, what I would call technized, and the moral element of it was, in a sense, neglected or denied. In its most extreme form, the technized professional is a kind of hired gun for anybody who will pay him or her for professional knowledge. So, the witnessing professional, then, is a return to the inclusion of an ethical dimension in professional work. If you or I carry out some form of psychiatric or medical healing―that can be seen quite easily as a moral or ethical act. We shouldn’t lose the ethical dimension of being a professional. It is true that sometimes, as a professional, we have to  step back and not experience fully another’s pain, or even the pain that we cause others, such as with a surgeon making a delicate operation or even a psychiatrist taking care of a very disturbed patient. But, at the same time we need to maintain, within the concept of the professional, that ethical or moral dimension and our own openness to some of that pain.

DRK: I am very interested in this idea of professionalism―in my writing I have contrasted the disconnection of the technician and the connection of the healer. I think this goes back, in a way, to the art and science of medicine. My first book was called Re-humanizing Medicine because I was concerned that people could develop that capacity―the psychic numbing or the splitting or selective professional numbing, which you write about―and that they would idealize that, and come to think that is what being a professional is: to be disconnected.

RJL: I think what you are referring to is the danger of what I call the technization of professions and considerable psychic numbing on the part of professionals, with diminished capacity or inclination for feeling―and that is dangerous. We see it is dangerous in different ways in every possible profession, I would say. So, in a way, the idea of the witnessing professional is an effort to recall a dimension of ethical involvement and limit psychic numbing on the part of professionals.

DRK: I suppose the difference is in being able to use psychic numbing as a conscious tool or technique rather than unconsciously assuming that identity of disconnection.

In thinking about the witnessing professional, there is often a narrative―and I just finished your autobiography, Witness to an Extreme Century―I’ve been really interested in reading the narratives of medical activists, people who take on this identity as a witnessing professional. The narrative goes, “I was minding my own business and just trying to be a good doctor when [X] happened, and I felt my training wasn’t adequate for [X], this experience in the world.” Is a witnessing professional―is it something that only happens in exceptional situations or is it something we can impart or teach to residents and students?

RJL: Yes, there are two questions there. One about exceptional situations and the other the capacity to teach residents or other young medical or psychological professionals the idea of the witnessing professional. A good example for me is the doctor’s antinuclear movement, which led to the formation of the International Physicians for the Prevention of Nuclear War, and perhaps you are referring to that. I have been quite active in it over the years and especially early on. What happened was, there was the capacity of first physicists, and then doctors in general, to recognize that they have something to say about nuclear danger. It began with the idea that doctors would be unable to carry out their traditional tasks in disaster, that is to help the living and provide some kind of healing. I used to talk and say the reason why this doesn’t work is because you’ll probably be dead, and we’ll probably be dead and there will be no medical facilities available for this. It is a recognition that one’s usual training can’t cover the extraordinary revolution in destructive weaponry that we’ve undergone and even the ethics of a particular profession are very inadequate because they would talk about being a kind therapist or bringing the latest knowledge to one’s work as a psychiatrist or physician but that’s not adequate for the problems that confront us. So, there can be these large threats, like nuclear threat, that awaken people to a realization that there needs to be a new, broader ethic that has to do with humanity in general.

RJL: All this can be taught, to a degree. One reason why the term ethical professional is useful is that it gives one a concept with which to connect one’s work and one can see oneself clearly as remaining a professional, not leaving the professional orbit, but using professional knowledge in a broader context.

So, there can be lots of discussion and teaching and dialogue in relation to exactly this. It is already beginning to take place. You may know of a recent issue of Dædalus, which ordinarily is a highly professionalized journal, but they were able, they decided to devote one issue, which was edited by Nancy Rosenblum (who happens to be my partner), about witnessing professionals in relation to climate. I have an essay [“On Becoming Witnessing Professionals”] in it describing the witnessing professional which is the basis for the ideas of the issue. There always has to be a kind of development and commitment by individual people, and that development and commitment is enhanced by a collective expression of this kind of witnessing professional.

DRK: Thank you, I wasn’t aware of that issue. I will look that up. One thing I was wondering, in trying to teach this, how, how would you go about it? Is it a skill set that people can learn, that we can impart and measure? So much of medical education now is focused on objective learning goals. Or is it like a different dimension, like cultivating the heart and compassion and human connection. In other words, does one go into the work having been trained as a witnessing professional, or does one become a witnessing professional because one is open to human suffering and to look at that human suffering in a broader context than just being held within an individual in front of you in the clinic?

RJL: Well, it can be taught, what you are describing after all, with physicians in particular, is ostensibly a healing profession.

RJL: A healing profession, or a professional who attempts to heal, has to take in pain and share the pain with patients, with others. Once one considers, early on, one’s work to be an ethical enterprise, it’s not too difficult for the witnessing professional to take root. I’ve mentioned in my work, observing very young physicians who were not clear about these matters, had some issues about them, but once they committed themselves to joining the physicians’ anti-nuclear movement, they themselves could evolve, become more articulate, and become more clear about who they were. In a strange way, I, in my own experience, as I think others did too, in the physicians’ anti-nuclear movement, felt myself more a healer than ever before in connection with this commitment. It is bound up with healing, for physicians.

Of course, in my case, I had direct knowledge of the Hiroshima experience of people exposed to the first use an atomic weapon on a human population and what that caused and what that resulted in. I could talk about that, as together with Nagasaki, the only record we have of the human impact of, what is by present standards, a very small bomb. But even outside of what we consider directly healing professions, even professions that have to do with other forms of knowledge, including the humanities, can evoke their knowledge to confront the malignant normality that is put before us.

Of course, I’ve made use of the idea of malignant normality repeatedly and strongly in relation to Trump and Trumpism―it is not a single individual matter, but it is a collective form of behavior which pursues and seeks to render lying and deception and attacks, personal attacks on anyone who questions the “Big Lie,” render this the norm, the malignant normality of our own society and we are at the present time very much in the process of seeking to confront that malignant normality as witnessing professionals in our own society.

DRK: I’m glad you brought this up. You wrote the foreword [“Our Witness to Malignant Normality”] to The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess the President. Like many people I was very concerned with, it seemed like many of the things that were happening were the things that happen in fascist or pre-fascist political movements. Dr. Bandy Lee brought that edited volume together, and brought you in for the foreword, and now she has been fired from Yale, ostensibly for violating the American Psychiatric Association’s Goldwater Rule. What are some of your thoughts on Bandy Lee’s work, her dismissal and also the warning this sends to professionals to “stay in your lane?”

RJL: Bandy Lee has been an extraordinary leader in speaking out about what I am calling malignant normality and encouraging psychological professionals to do the same. Nobody should be fired in relation to the Goldwater Rule, which is quite confused, and complicated with the resistance on the part of the American Psychiatric Association to a more thoughtful approach to psychiatrists speaking out, which could contain freedom to speak out while not making hands on diagnoses. I haven’t been working with Bandy Lee for several years and although the Goldwater Rule was mentioned by the Yale department, I am in no way clear about the whole Yale situation.

DRK: For myself, I went through this phase of feeling―“this is wrong, somebody should say something, somebody should do something.” I felt that collective psychology overlaps with my professional domain, and, additionally, I’ve also studied the literature outside of psychiatry, on fascism and history and the genocides of the last century. I felt a need to do something, on the one hand, but I wasn’t quite sure what to do. On the other hand, I had a fear of going beyond my profession if I were to speak out and point out similarities in current psychology to past fascist movements―and yet I was also aware of the “by-stander effect,” where people do not act when something is obviously wrong. I worry with Bandy Lee that this is a cautionary tale of―can you go too far as a witnessing professional, or is the ethical and moral right with the individual, even if they end up getting punished by the institutions?

RJL: What you are describing is a very human concern that witnessing professionals experience which has to do with how much one can say from the standpoint of one’s profession and how far one should go in saying it. There is, as you know, an interaction of psychology and politics that is inevitable. I think, in my own work, and there are others who do it a different way, I invoke what I know from professional experience, or what I think I know from professional experience, and bring it forward in relation to what I say publicly. In my case, of course, I’ve studied Hiroshima survivors and Nazi doctors and I’ve seen in the latter, in Nazi doctors, the very opposite of the witnessing professional. What I’ve called the “killing professional.” I think we have to speak out from what we have seen and recognized and then look at what we believe we know, or have learned, as a professional. Of course, in addition to that, we are also citizens who have ethical concerns about political issues. People have to give their own perspectives on this and there is no, how shall I say, there is no perfect model of how to go about it.

RJL: But I think there is an increasing recognition on the part of many professionals that what they are doing and thinking is not enough and there is a hunger among professionals that I have encountered for entertaining or including an ethical or moral perspective in their professional work and I think that is increasingly available to people.

So, yes, I believe that a witnessing professional should have discipline, one should say what one thinks one has learned as a professional, and not just speak randomly, and that’s really what defines the idea of the witnessing professional.

DRK: It feels like there is a sense in many witnessing professionals’ narratives of this being out on a limb by yourself, of not having been prepared by your education or profession, unless you have gone out of the way and read about different people who have taken on roles as witnessing professionals. So, I guess I go back again to this idea of―what would be the ideal way to teach this to medical students and residents and other health professionals?

RJL: I agree, it can and should be taught and should be discussed. You don’t have to have experienced an extreme situation in order to gravitate toward becoming a witnessing professional, after all, as you say, we undergo residency or training procedures of some kind and we experience all kinds of pain and have access to a lot of confusion on the part of both patient and healer. If we can look at a concept such as the witnessing professional that doesn’t automatically solve everything, but at least can provide a beginning in one’s sense of one’s self, one’s own identity as both a professional who is committed to learning, yes even the techniques of the profession, on the one hand, but is also committed to applying one’s professional knowledge in a broader way that enhances human behavior on a larger scale―that’s what the doctors anti-nuclear movement was about, there is also Physicians for Human Rights. These organizations then constitute a banding together of witnessing professionals who are always, or can always be, at the edge of activism.

The teaching that you emphasize, and discussion during residency, and even in medical school before that, I think could be very important. What happens, as you know, is that there is so much to learn in the training procedure that one is overwhelmed with memorization and details and the broader ethical dimension can readily be lost, but if it is considered early, it may never disappear entirely, and becomes part of, at least a possible, direction that starts early in psychological and medical professionals.

DRK: There are the studies that show that idealism goes down during medical student years and residency training and burnout starts to increase. I always wonder if somehow that idealism―maybe we should look at idealism as a precious resource rather than kind of a naïve, friendly fire incident with medical training where it is lost, where we could right from the very beginning come up with ways to help students preserve their idealism as they are learning that tight, technical focus to also be able to broaden out to the bigger picture.

RJL: Yes, what you say about idealism is important because, on the one hand, medical practice can be a business―it is in a way, but there is a certain element of idealism even a small one, that is likely to go into anyone’s decision to become a physician or a healer. As you say, it is readily lost in the training procedure which is demanding and dominates everything. If one can reconnect with the idealism, the earlier idealism, even a small element of it, that was a factor in that choice of profession, that could inform the witnessing professional.

RJL: Or, to put it another way, if one has the concept of the witnessing professional that one has discussed early on in training, there is a place to recover and extend one’s idealism that is available in one’s mind because it has been placed there, as at least a possibility, early in one’s medical or psychological life.

So, yes, in that way, the teaching of it, the discussion of it early would be very beneficial and students are very sensitive, as you know, and they are very responsive to what they perceive as authenticity and equally critical of what they perceive as less than authentic, the inauthentic. So, if the discussion is initiated with some sense of authenticity, coming from the experience of the initiator of the discussion, if he or she can tell about experiences that cry out for an element of idealism or of moral or ethical behavior in the professional, that will be responded to by students given their sensitivity and capacity to differentiate between what seems authentic to them or not.

DRK: I wonder whether we should institute practices, like some type of idealism practice and some type of suffering practice? A practice of being able to hold on to these ideals and recapture or regenerate them if they are lost. And a practice of being able to accept and embrace the suffering inherent in our professions and our work with people who are suffering and to be able to have a framework to metabolize and grow from that suffering―to turn the suffering into commitment to action in the world or re-dedication.

RJL: Yes, in recent work I have been talking about issues of death anxiety and death guilt and what I call an animating relationship to guilt or an animating relationship to death anxiety. These are forms of suffering which people we treat, or try to help, undergo and which we, ourselves, are hardly immune to and the animating relationship is the capacity to transform death anxiety or mea culpa guilt into what I call the anxiety of responsibility. The responsibility toward something in the way of healing or life-affirming behavior or contribution to the human future. So, these are very real matters. I think they are immediate and practical, but they are also very much aspects of what we call idealism.

DRK: I developed this idea of a counter-curriculum of re-humanization in medical school. I developed it in myself, by being connected to arts and poetry and literature and meditation, from a feeling that I needed to somehow push back against the ever-present scientific curriculum, to save some part of myself that was more than just memorizing biochemistry. I know you have written about the comparison between totalitarian thought reform and psychoanalytic training and I wonder if what is needed in medical education is some emphasis on this ability to be able to resist the brainwashing of technicism or thought reform of becoming an uncaring or unfeeling physician.

RJL: Well, there is a lot of pressure in medical training in the direction of psychic numbing, starting with the introduction to the cadaver. And I think that another way of saying what I think you are suggesting is that medical training involves diminution of feeling in the service of learning techniques.

Now, there is a reaction, getting to psychoanalysis―I’ve been in touch with some psychoanalytic groups in the last few years and there is a considerable movement away from the direction of totalism that I described which can inhabit psychoanalytic training, (which I myself partly underwent and then left). The American Psychoanalytic Association invited me to give their plenary address in 2020 and published it―a paper that specifically confronted thought reform and totalism. I talked about, in that plenary address, the imposition of ideas in a systematic way: criticism, self-criticism, and confession―which characterized Chinese thought reform and I talked about ways of avoiding this kind of totalism and combating it. The fact that I was invited to do so by the leading American Psychoanalytic Association suggests that they too are hungry for ethical directions. That doesn’t mean that much of medical or psychoanalytic training can still be questioned, but it does mean that there is a hunger for this broadening direction that I summarize in the form of witnessing professionals. I also talk about what I call the Protean style or capacity for individual change and transformation and that being associated with our tendency toward symbolism, not just one thing equals another, pen equal penis, or something like that, but rather a whole symbolizing tradition in philosophy and psychology, within which we must recreate everything we encounter, in order to take in anything at all. We are symbolizers, in that sense, and that opens us toward what I call a Protean Self or multiple Self. We have that capacity for combatting controls of the mind and we are also vulnerable to such a kind of process to a degree, but we also have inclinations within us toward rejecting it and opposing it―we can go either way.

Robert Jay Lifton, MD – photo from his website

You can learn more about Robert Jay Lifton & his work at his website and his latest book, Losing Reality: On Cults, Cultism, and the Mindset of Political and Religious Zealotry is a summary of some of his most important books. This interview is also published at The-POV and is reprinted with permission.

Medical Activism: A Foundational Element of Professional Identity

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David R. Kopacz, MD

The “first task of the doctor is therefore political: the struggle against disease must begin with a war against bad government,” (Foucault).[1]

The idea of medical activism has been criticized lately, from both inside[2] and outside[3] of the medical field. However, medical activism is a foundational element of professional identity – it defines who we are as professionals as opposed to being technicians, prescribers, protocol managers, or employees.

Activism can take many forms, but its essence is when professional responsibility extends beyond the individual to the community, the country, and the world. Medical activism occurs when we look up from our computer screens and electronic medical records and look outside the four walls of the clinic to be moral agents promoting health & wellness in the world. Medical activism is what Dr. Berwick is encouraging in his recent article, “The Moral Determinants of Health,” where he argues for an expansion of the role of professionals to include societal reform. “Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it. The moral law within insists so.”[4]

Medical activism is always needed, but sometimes it is needed more than others. The times of the Covid-19 pandemic demand that we take a fresh look at ourselves as physicians and professionals to determine the scope of our responsibilities. With political attacks, anti-public health measures, and anti-science propaganda during the pandemic, physicians and health care professionals need to speak up now more than ever. If we do not use our voices, we may lose them.

Two broad categories of medical activism are: 1) the reform of health care delivery systems, and 2) action in the political, cultural, legal, relational, and natural environments. These can also be conceptualized as internal (delivery of care in the clinic & hospital) and external (medicine in the world).

Deprofessionalization

The practice of medicine has changed greatly over the last 75 years, shifting from a practice of largely general practitioners who knew their patients over their whole lives to a fragmentation into sub-specialties, and the proliferation of multiple profit-deriving entities: the pharmaceutical industry, the insurance industry, and for-profit hospital and medical industry. During this time, doctors’ roles have shifted from independent healers engaged and embedded in communities to interchangeable and expendable bit-workers on ever more “efficient” medical assembly lines. Medicine has shifted from a focus on long-term healing relationships to a transactional, technician-based delivery system in which doctors are protocol-managers and data entry clerks.

With the rise of productivity medicine we have seen the deprofessionalization[5] and dehumanization[6] of physicians and health care professionals. Corporate medicine is not interested in moral agents or medical activists, but rather what Foucault called “docile bodies,” to play limited roles within the institution. Moral agents and medical activists function independently or semi-autonomously, rather than as interchangeable technicians who dispense the same, generic, non-individualized treatment interventions. While corporate medicine pushes propaganda of customer service – true caring, compassion, and patient-centered care can only be given human being to human being. Individuality and humanity are extraneous and problematic variables to corporate, machine medicine. 

The idea of medical activism encompasses the role of the physician as a moral agent, a member of a profession who answers to a higher calling. A professional has a moral calling that goes beyond the marketplace of the exchange of money or the influence of power.

What it Means to be a Professional

To be a professional means that one is constantly professing – similarly if one is a profess-or. The roots of the word “profession” have to do with taking vows and declaring openly and to make public statement. The etymology of the word is related to “profess” and “prophet” going back to the ancient Proto-Indo-European root, *bha-, meaning “to speak, tell, say.”[7] What we are doing as professionals is continual professing – to declare openly and to speak, tell, say.

Our job as professionals is to be prophets of health (which is different than the profits of the health). The industry, the organization, the institution is not an inherently moral creation, it is more like a machine than a holder of morality, and it is the job of professionals within the system to be the moral leadership of the institution. To become moral agents in our world, we need to tear ourselves away from the never-ending demands of the Electronic Medical Records system, and raise our gaze from the computer screen to the world we all live in. To be a professional is to be more than a technician blindly following orders. To be professional means that we answer to a higher calling and we engage our hearts as well as our minds to become moral agents for public health. This is what psychiatrist Carl Bell called, “getting rid of the rats.”[8] He learned that a good doctor won’t just treat a rat bite, but will help to get rid of the rats in the neighborhood. He thus saw the role of the doctor and psychiatrist as not a technician in an office, but as an engaged professional intervening in the world.

Witnessing Professional

Throughout his career, Robert Jay Lifton has written about the idea of the witnessing professional. He describes the shift toward “malignant normality,” “the imposition of a norm of destructive or violent behavior, so that such behavior is expected or required of people.”[9]

As citizens, and especially as professionals, we need to bear witness to malignant normality and expose it. We then become what I call “witnessing professionals,” who draw upon their knowledge and experience to reveal the danger of that malignant normality and actively oppose it. That inevitably includes entering into social and political struggles against expressions of malignant normality. (Lifton) [10]

The New Professional

In order to teach the next generation of doctors, healers, and clinicians, we need to provide good role models for students to emulate. This is the transmission of knowledge and wisdom that happens from one generation to the next. Without medical professionalism, students may become technically proficient and yet not be true professionals and healers. We teach students science, but we do not teach them to use what Stevan Weine calls “the witnessing imagination.”[11]

Author and educator, Parker Palmer speaks of the new professional, “a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards.”[12]

Palmer states that “the very institutions in which we practice our crafts pose some of the gravest threats to professional standards and personal integrity. Yet higher education does little if anything, to prepare students to confront, challenge, and help change the institutional conditions under which they will soon be working.”[13]           

The notion of a “new professional” revives the root meaning of the word. This person can say, ‘In the midst of the powerful force-field of institutional life, where so much conspires to compromise the core values of my work, I have found firm ground on which to stand―the ground of personal and professional identity and integrity―and from which I can call myself, my colleagues, and my profession back to our true mission. (Palmer) [14]

An Abbreviated History of Medical Activism

Wash your hands – this seems obvious to us now – but in 1850 Semmelweis tried to convince doctors that they should wash their hands after leaving off doing autopsies and before examining mothers who had just given birth. He was ridiculed, lost his appointment, and died in a mental institution.[15]

In the late 1800s, Virchow was tasked by the Prussian government to research an outbreak of typhus. His prescription was social and political: elimination of social inequality.[16] He came back with recommendations regarding poverty, services, and even political recommendations. He was fired and later wrote, “Medicine is a social science and politics is nothing more than medicine on a large scale,”[17] and that doctors “are the natural attorneys of the poor.”[18]

In 2015, pediatrician Mona Hanna-Attisha noticed that the children in her practice in Flint, Michigan, had high levels of lead. She wrote about her work as a medical activist in her book, What the Eyes Don’t See.[19]

“This is a story of resistance, of activism, of citizen action, of waking up and opening your eyes and making a difference in our community…I wrote this book to share the terrible lessons that happened in Flint, but more importantly, I wrote this book to share the incredible work that we did, hand in hand with our community, to make our community care about our children.” (Hanna-Attisha) [i]

Dr. Fauci.

Examples of Health Care Critique & Reform

There are many different levels of health care reform – from the way a doctor is present with a patient, to how clinics are structured, to how reimbursement occurs, and to how we, as a society, value (or de-value) health care as a human right as all other modern democracies do. An ongoing critique of the contemporary practice of medicine is a moral duty of physicians. It is up to us, as professionals, to hold true to the mission and purpose of health care: caring for people who are suffering. Institutions may have vision and mission statements but they are incapable of moral agency and compassion because those are human traits, not bureaucratic functions.

I have written about dehumanization in medicine and the need for re-humanizing ourselves, our practices, and the culture of medicine – calling for a compassion revolution and a counter-curriculum of re-humanization in my book Re-humanizing Medicine.[20] Many others have called for bringing caring back into health care: Robin Youngson,[21] Victor Montori,[22] Arthur Kleinman,[23] Mukta Panda,[24] and Rana Awdish,[25] to name a few.

Other levels of health care reform can be found in the work of L. Gordon Moore’s idea of the micropractice,[26] and Dr. Quentin Young’s work with Physicians for a National Health Program.[27]

Medicine in the World

Samuel Shem, in his essay, “Fiction as Resistance,” writes of turning to fiction writing as a resistance to “brutality and inhumanity, to isolation and disconnection.” His recommendations on how to resist “the inhumanities in medicine” are four suggestions:

1) “Learn our trade, in the world” to be aware that “Medicine is part of life, not vice versa”

2) “Beware of isolation. Isolation is deadly; connection heals”

3) “Speak up…speaking up is essential for our survival as human beings”

4) “Resist self-centeredness…learn empathy”[28]

There are many kinds of medical activism needed for our current ills, here are just a few examples:

  • Culture, Diversity, Religious Tolerance – addressing racism and intolerance
  • Human rights medicine and international trauma work
  • LGBTQ rights
  • Women’s rights & reproductive rights
  • Immigration policy
  • Public health
  • International Physicians for the Prevention of Nuclear War
  • Peace work, recovery from war and violence
  • Gun violence as a public health issue
  • Social, Climate, Environment
  • Medical student education: preserving idealism and preventing cynicism
  • Burnout and moral injury in physicians and health care workers
  • Public Safety & the Duty to Warn

Meanwhile, back at the pandemic, we just topped 160,000 new cases in one day and the United States of America has no coordinated national policy to control the pandemic. The president has come out against science,[29] has accused doctors of profiting from the pandemic by diagnosing Covid-19 to make money,[30] and there have been many coordinated political propaganda campaigns by the president and one political party to discourage people from following basic public health measures (masking and social distancing)[31],[32],[33] and have actively encouraged unhealthy behavior (large gatherings without masks or social distancing).[34] The activist response by individual physicians through social media as well as of professional medical and scientific organizations has been swift and strong.[35],[36],[37]

Conclusion

We stand at a unique time in history – a global pandemic, smear campaigns against public health experts, attempts to silence or manipulate science for political ends, and the politicization of basic, scientific principles of public health. Now, more than ever, we as physicians, we as clinicians, need to re-claim activism as a core identity. We need to speak, tell, say, to speak openly, to speak publicly about the public health threats of this time in history. We have guidance of those physicians and clinicians who have gone before us and how they have spoken up for the health of the people and the public. Lifton’s witnessing professional and Palmer’s new professional give us a framework for social, moral, and political involvement of professionals as part of the practice of medicine and health care. We are called to become moral agents for social change as we diagnosis and treat the moral determinants of health and the public health threats of the day.

This paper only just scratches the surface of the topic of medical activism. We need classes, conferences, and an edited textbook on the topic, written by expert activists and covering the various levels of the work. Bassuk’s 1996, The Doctor-Activist: Physicians Fighting for Social Change, is a great start – but we need to move beyond the idea of medical activism as something that exceptional individuals do, to see it as a normative part of professional identity – something we all do for the health of all.

[1] Foucault M. The Birth of the Clinic. New York: Vintage Books, 1994, 38.

[2] Goldfarb S. Take Two Aspirin and Call Me by My Pronouns: At ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness. Wall Street Journal, 9/12/19.

[3] Haag M. Doctors Revolt After N.R.A. Tells Them to ‘Stay in Their Lane’ on Gun Policy. The New York Times, Nov. 13, 2018. The original criticism was in a Tweet from the NRA, “Someone should tell self-important  anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.” https://twitter.com/NRA/status/1060256567914909702

[4] Berwick DM. The Moral Determinants of Health. JAMA. 2020;324(3):225–226. doi:10.1001/jama.2020.11129.

[5] http://www.professionalsaustralia.org.au/blog/deprofessionalisation-matter/

[6] Kopacz, D. Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. Washington DC: Ayni Books, 2014.

[7] Online Etymology Dictionary for “profession,” “profess,” “prophet.” https://www.etymonline.com/search?q=profession

[8] https://beingfullyhuman.com/2020/07/18/carl-bell-md-medical-activist-human-rights-champion-with-an-indomitable-fighting-spirit/. Bell C. The Sanity of Survival: Reflections on Community Mental Health and Wellness. Chicago: Third World Press, 2004, xx.

[9] Lifton RJ. Losing Reality: On Cults, Cultism, and the Mindset of Political and Religious Zealotry. New York: The New Press, 2019, 189.

[10] Lifton RJ. Losing Reality: On Cults, Cultism, and the Mindset of Political and Religious Zealotry. New York: The New Press, 2019, 190.

[11] Weine S. (1996). The Witnessing Imagination: Social Trauma, Creative Artists, and Witnessing Professionals. Literature and Medicine, 15, 167 – 182.

[12] Palmer P. The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life. San Francisco: Jossey-Bass, 2007, 202.

[13] Palmer P. The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life. San Francisco: Jossey-Bass, 2007, 199.

[14] Palmer P. A New Professional: The Aims of Education Revisited. Change, Vol. 39, No. 6 (Nov-Dec, 2007), 6-12.

[15] https://www.pbs.org/newshour/health/ignaz-semmelweis-doctor-prescribed-hand-washing

[16] Mackenbach J. (2009). Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. Journal of Epidemiology and Community Health (1979-), 63(3), 181-184. Retrieved August 8, 2020, from http://www.jstor.org/stable/20720916

[17] Quoted in Vicente Navarro. What we mean by social determinants of health. Global Health Promotion Vol. 16 (1):5-16; 2009. Original reference: Virchow R. Die medizinische Reform, 2 in Henry Ernest Sigerist, Medicine and Human Welfare 1941:93.

[18] Mackenbach J. (2009). Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. Journal of Epidemiology and Community Health (1979-), 63(3), 181-184. Retrieved August 8, 2020, from http://www.jstor.org/stable/20720916

[19] https://www.npr.org/sections/health-shots/2018/06/25/623126968/pediatrician-who-exposed-flint-water-crisis-shares-her-story-of-resistance

[20] Kopacz D. Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. Washington DC: Ayni Books, 2014.

[21] Youngson R. Time to Care: How to Love Your Patients and Your Job. Raglan: RebelHeart, 2012.

[22] Montori V. Why We Revolt: A Patient Revolution of Careful and Kind Care. Rochester: Patient Revolution, 2017.

[23] Kleinman A. The Soul of Care: The Moral Education of a Husband and a Doctor. New York: Viking, 2019.

[24] Panda M. Resilient Threads: Weaving Joy and Meaning into Well-Being. Palisade: Creative Courage Press, 2020.

[25] Awdish R. In Shock: My Journey from Death to Recovery and the Redemptive Power of Hope. New York: Picador, 2018.

[26] Moore LG. ‘Going Solo: Making the Leap,’ Family Practice Management. February 2002, American Academy ofFamily Physicians website, accessed April 7, 2012.http://www.aafp.org/fpm/2002/0200/p29.html .

[27] https://pnhp.org/news/dr-quentin-young-selected-obituaries-stories/

[28] Shem S. Fiction as Resistance. Annals of Internal Medicine. Vol 37(11):934-937; 2002.

[29] https://www.scientificamerican.com/article/trumps-5-most-ldquo-anti-science-rdquo-moves/

[30] https://www.forbes.com/sites/brucelee/2020/10/27/trump-claims-doctors-overcounting-covid-19-coronavirus-deaths-to-make-more-money/?sh=7439b2836cb9

[31] https://www.reddit.com/r/SeattleWA/comments/jduz3x/culp_antimask_propaganda/

[32] https://www.vox.com/the-goods/2020/8/7/21357400/anti-mask-protest-rallies-donald-trump-covid-19

[33] https://www.vox.com/2020/6/20/21297693/trump-rally-tulsa-masks

[34] https://apnews.com/article/donald-trump-rallies-virus-surges-50e79fabd46472c51ecc1444184082de

[35] https://www.forbes.com/sites/brucelee/2020/10/27/trump-claims-doctors-overcounting-covid-19-coronavirus-deaths-to-make-more-money/?sh=7439b2836cb9

[36] https://www.scientificamerican.com/article/leading-scientists-urge-voters-to-dump-trump/

[37] https://www.medicalnewstoday.com/articles/respected-scientific-journals-publicly-oppose-trump

The End of E pluribus Unum? The De-evolution of “Out of Many, One,” to ME First

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Medical Activism Series.2

Doctors Against Fascism Series.2

Article originally published in the online magazine The Badger, 2017, Year 3, Volume 2.

My concerns of the risk to our Union are even greater now than they were in 2017. This article was inspired by the removal of the motto of the United States from the presidential coin as described in the Washington Post article by David Nakamura & Lisa Reinin in the Dec 22, 2017 article, “It’s ‘very gold’: The presidential coin undergoes a Trumpian makeover.”

“The presidential seal has been replaced by an eagle bearing President Trump’s signature. The eagle’s head faces right, not left, as on the seal. The 13 arrows representing the original states have disappeared. And the national motto, “E pluribus unum” — a Latin phrase that means “Out of many, one” — is gone.”

Instead, both sides of the coin feature Trump’s campaign slogan, “Make America Great Again.”

The Great Seal of the United States, Public Domain, Wikipedia

The motto of the United States is E pluribus unum, which is Latin for “Out of many, one.” Joseph Rael (Beautiful Painted Arrow) and I have written about the importance of this motto in our book, Walking the Medicine Wheel: Healing Trauma & PTSD. This motto is of crucial importance for helping veterans return home after war and reconnect to their own hearts and to society, which is why Joseph and I wrote about it, but it is also crucial for all of us and the very fabric of democracy―in the United States as well as in the rest of the world. The ability to see our similarities rather than our differences allows us to see that the suffering of others suffering is our suffering and that others joy is our joy. When we view other human beings as “other,” this sense of separation makes violence possible. Peace comes from a sense of unity, not a sense of “otherness.” “The heart of violence is the divided and separated heart,” we write, the heart of violence is “the heart that cannot see other hearts as interrelated and interconnected.”

“Violence has its roots in the false idea of separation. Physically we appear separate, but even physically we are in a complex web of life with animals, plants, and the earth. When we begin to speak about human realities beyond the physical: emotion, heart, intuition, and spirit, the idea of ourselves as separate beings no longer makes sense. One can only be violent against someone or something seen as ‘other,'” (Kopacz & Rael, Walking the Medicine Wheel: Healing Trauma & PTSD, 214).

Currently in the world, we are seeing more division and separation than coming together in unity. The recent order by the president of the United States banning all international refugees and also citizens of Iran, Iraq, Libya, Somalia, Sudan, Syria, and Yemen from entering our Nation of Immigrants is the latest and most extreme example of this. This breaks my heart and it breaks the heart of democracy. I worry for the future because, through my work with Joseph, I know that peace depends upon unity and similarity and that the current mania for separation and division is very dangerous. The rise of nationalism has historically been associated with violence and the rise of totalitarian regimes for the very fact that an over-emphasis on “me first” leads to seeing “others” as getting in my way. We teach our little children, “Don’t rush to the front of the line, don’t push others aside.” We teach our children to respect others, and yet respect has been one of the first casualties in the current national and world-wide Me First Movement. In a very, very short time, the public dialogue has shifted so far toward disrespect and hatefulness that people feel justified in hate speech and separation speech.

We are seeing the rise of nationalism world-wide: Brexit, throughout Europe, the Philippines, the United States, Russia, and Turkey. Nationalism very easily leads to violence against “others” and once the mad dog of nationalism is let off leash, even a country’s own people can all too easily be labeled as “others.” The media, which often serves as a watch dog to power, is often the first to be vilified and silenced.

Our institutions of unity and collectivism are being seen as obsolete, holding us back, ineffective. The institution of democracy, the United Nations, NATO, the European Union―these are the organizations that we have created to moderate human selfishness in order to promote peace and equality. Parker Palmer, in his book Healing the Heart of Democracy, writes that democracy is one of the ways that we, as human beings, seek to civilize ourselves. Palmer sees democracy as one of our best tools of civilization and that these tools “constitute the core self-hood called the human heart” (Palmer, 81).

“For those of us who want to see democracy survive and thrive―and we are legion―the heart is where everything begins: that grounded place in each of us where we can overcome fear, rediscover that we are members of one another, and embrace the conflicts that threaten democracy as openings to new life and for our nation,” (Palmer, 10).

How much are we the people of the United States of America making decisions from the heart? To what extent are our current elected officials leading from the heart? What will happen to us if we give up on unity, if we glorify everything falling apart? Louis Ferdinand Céline, writing about World War I, wrote that people had become “madder than mad dogs” because dogs don’t worship their madness.       

“Could I, I thought, be the last coward on earth? How terrifying! … All alone with two million stark raving heroic madmen, armed to the eyeballs? With and without helmets, without horses, on motorcycles, bellowing, in cars, screeching, shooting, plotting, flying, kneeling, digging, taking cover, bounding over trails, root-toot-tooting, shut up on earth as if it were a loony bin ready to demolish everything on it, Germany, France, whole continents, everything that breathes, destroy, destroy,  madder than mad dogs, worshipping their madness (which dogs don’t) a hundred, a thousand times madder than a thousand dogs, and a lot more vicious! A pretty mess we’re in!” (Céline, Journey to the End of the Night).

Céline bore witness to the brutality of World War I and he calls himself a “coward” because he doesn’t want to join in the blood bath of killing “others.” However, non-violence has been raised to a spiritual virtue and political power by people like Martin Luther King Jr. and Gandhi. (Céline did succumb to his own madness and cowardice in turning against the Jewish people in the lead-up to World War II, and citing him here in regard to World War I in no way condones his later anti-Semitism). I choose to quote Céline because his phrase “madder than mad dogs, worshipping their madness (which dogs don’t)” keeps echoing in my mind recently. There is something very scary about the Me First Movement in U.S. politics that is worshipping madness, division, and hatred. This is happening in the United States of America―right now, yet it has roots going back over the past decades, and honestly back to the history of the European colonization of this land.

Going back to the early days of the U.S. “war on terror,” journalist, Andrew Cohen, wrote “Our journey toward Abu Ghraib began in earnest with a single document — written and signed without the knowledge of the American people” (The Atlantic, “The Torture Memos, 10 Years Later,” February 6, 2012). Cohen continues:

“On February 7, 2002…President George W. Bush signed a brief memorandum titled ‘Humane Treatment of Taliban and al Qaeda Detainees.’ The caption was a cruel irony, an Orwellian bit of business, because what the memo authorized and directed was the formal abandonment of America’s commitment to key provisions of the Geneva Convention. This was the day, a milestone on the road to Abu Ghraib: that marked our descent into torture — the day, many would still say, that we lost part of our soul.”

White House Counsel, Alberto Gonzales wrote that the Geneva Conventions should not restrain the United States any longer in how we treat prisoners. “In my judgment, this new paradigm renders obsolete Geneva’s strict limitations on questioning of enemy prisoners and renders quaint some of its provisions,” he wrote. I remember this as a very disturbing philosophical position our government took as it eroded the work of many countries and peoples work to prevent war crimes. When we stop appealing to our higher humanity and to our collective sense of ourselves as brothers and sisters―even while temporarily enemies―we not only take away what makes others human, but we lose our humanity as well. This is because humanity is a two-way street of interaction and of unity. Humanity is a state of interactive being and when we take away this human state of being from others (whether they be Muslims, women, African-Americans, American Indians, people with different sexual orientations or identities, or anyone who disagrees with us), we lose our own humanity as well and we risk becoming mad dogs worshipping our madness as we have let ourselves of the leash of humanity. It is difficult to understand the current anti-immigrant sentiment in the U.S. because anyone who is not a full-blooded American Indian is an immigrant to the United States. The current president of the United States is an immigrant, as are most of us who have come together as one people in the United States.

It breaks my heart to see the people of the world turn our backs on the institutions we have worked so hard to create that call forth our higher humanity and work to promote peace. What we are witnessing is a kind of war of the many against the One. William Butler Yeats, writing in the aftermath of WWI, in 1919 captured this spirit in his poem, “The Second Coming,” which includes the lines:

             “Things fall apart; the centre cannot hold;

             Mere anarchy is loosed upon the world,

             The blood-dimmed tide is loosed, and everywhere

             The ceremony of innocence is drowned;

             The best lack all conviction, while the worst

             Are full of passionate intensity.”

The loss of central cohesion, the centripetal force of humanity, leads to the break-down of our sense of shared humanity paves the way for dangerous economic and social policies and paves the way for violence against “others” whose humanity we have taken away, thereby losing our own humanity.

By Edward Moran – Museum of the City of New York, Public Domain, https://commons.wikimedia.org/w/index.php?curid=229787

Under the new administration, many career diplomats at the US State Department have been asked to leave. One such career diplomat is Tom Countryman who, in his retirement speech said:

“And we want Americans to know that the torch borne by the Statue of Liberty is not just a magnet for immigrants, it is a projector, shining the promise of democracy around the world.  The United States is the world’s greatest economic power, the world’s greatest military power, and with your vigilance, it always will be.  But the greatest power we project is hope, the promise that people can establish liberty in their own country without leaving it.”

In an interview with Steve Inskeep on NPR on February 1st 2017, he further expanded on this idea of the Statue of Liberty as a projector.

“I mean that the promise of America is not just that people can come here and build a better life, a free life. But I’ve been overseas in countries where the American model of democracy has been a powerful inspiration for people to build democracy at home without the need to immigrate to the United States. And if we build walls between ourselves and other countries, we will dim that light forever.”

By Source (WP:NFCC#4), Fair use, https://en.wikipedia.org/w/index.php?curid=39992533

One of our primary global institutions of peace is the United Nations. The United Nations, formed in 1945 in the aftermath of World War II, includes 193 states and serves as the earth’s only inclusive organization that promotes peace between countries and condemns violence. The newly appointed U.S. Ambassador to the U.N., Nikki Haley threatened the organization in her first speech, saying that “we are taking names” and repeating that “this is a time of strength” (Somini Senguptajan, “Nikki Haley Puts U.N. on Notice: U.S. Is ‘Taking Names,’” The New York Times online, January 27, 2017). The speeches and positions coming out of the current administration sound more like those of school-yard bullies than of elected democratic officials. “War is peace, freedom is slavery, ignorance is strength,” this motto of George Orwell’s dystopian society in his book, 1984, warns us about the kind of rhetoric we are now hearing from the Nation of Immigrants. The ME First Movement does not play well with others and it distorts facts and reality to suit its needs. The only thing more dangerous than a bully is a group of people blindly following a bully.

Joseph Rael (Beautiful Painted Arrow) was recognized by the United Nations in a 2/20/89 letter for his work promoting peace through building Peace Chambers on four different continents. What Joseph has taught me is that the work of peace is spiritual work, and spiritual work is what makes us true human beings. Peace requires us to be seekers of our common goodness, our common shared humanity. The place that we find this common goodness and unity is in our hearts.

“If we remember E pluribus unum on the Great Seal of the United States, we will remember that we are called to work toward an ideal that moves us from our many individual identities into a larger Union. E pluribus unum is Latin for ‘Out of many, one.’ This identity is not just the social body of peacemakers, it is also the mystical and spiritual identity of visionaries and mystics. This is the realm of unity that Joseph is familiar with as a visionary and healer,” (Kopacz & Rael, 215).

If we focus on separation and division, we not only destroy peace, we promote violence. This is why Joseph and I say that we all must move from seeing each other as “other” and move toward seeing each other as brother and sister. This is why we cannot give up on E pluribus unum―within the myriad of forms, we must always be seeking the spiritual unity of humanity and the cosmos.

You can access The Badger, 2017, Year 3, Volume 2 for the articles by other authors.

Medical Activism: A Draft of a Working Paper

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Activism: A Foundational Element of Professional Identity

Over the past year I have been thinking about the idea of medical activism. I started drafting a paper and have wanted to pursue some of the sub-topics in greater depth and breadth, but I have lacked the time to put this together due to numerous other projects. Still, I believe that these ideas should be circulating at this particular time in history. I do not mean this as a definitive statement on medical activism, but rather I mean it to open a conversation.

Abstract:

The idea of medical activism has been criticized lately, from both inside[1] and outside[2] of the medical field. This paper takes the position that medical activism is a foundational element of professional identity – it defines who we are as professionals as opposed to being technicians or employees of institutions. Medical activism prioritizes caring and advocacy in the face of competing priorities of productivity and profit. Activism can take many forms, but its essence is when caring and healing extend  beyond the internal biochemistry and inner thoughts of the client to include all the factors that we know influence individual and public health: childhood history, trauma, relationships, human rights, toxin exposures, environmental influences, and access to education and self-care. Two broad categories of medical activism are: 1) the reform of health care delivery systems, and 2) action in the political, cultural, legal, relational, and natural environments. These can also be conceptualized as internal (medicine in the clinic & hospital: having to do with the practice and delivery of health care) and external (medicine in the world: addressing public health issues outside the clinic or hospital). Examples of health care reform that will be considered are the movements of holistic and integrative medicine, Whole Health at the VA, the recovery movement in mental health, trauma-informed care, and addressing physician and health care worker burnout and suicide. Medical activism is born, again and again, when circumstances demand, from the identity of the physician/clinician as a professional and a moral agent in society whose “lane” is to treat disease, alleviate suffering, and to promote population health and well-being at local, national, and global levels. We need to make sure that the practice of medicine remains focused on healing and not just on making healthy profits or meeting institutional needs. Since the original conceptualization of this paper, new threats have arisen to the professionalism of medicine: fascism and political attacks on science. These political events, more than ever, remind us that if we do not use our voices we may lose them. Nourishing medical activism keeps the focus on care and compassion in health care and society. We must all adopt identities of what Parker Palmer calls “the new professional” and Robert Jay Lifton calls the “witnessing professional” in which we become moral agents within our world, tearing ourselves away from the never-ending demands of the Electronic Medical Records system, raising our gaze from the computer screen to the world we all live in.

Introduction:

The practice of medicine has changed greatly over the last 75 years, shifting from a practice of largely general practitioners who knew their patients over their whole lives to a fragmentation into sub-specialties, and the proliferation of multiple profit-deriving entities: the pharmaceutical industry, the insurance industry, and for-profit hospital and medical industry. During this time, doctors’ roles have shifted from independent healers engaged and embedded in communities to interchangeable and expendable bit-workers on ever more “efficient” medical assembly lines. Medicine has shifted from a focus on long-term healing relationships to a transactional, technician-based delivery system in which doctors are protocol-managers and data entry clerks.

The idea of medical activism encompasses the role of the physician as a moral agent, a member of a profession who answers to a higher calling. A professional has a moral calling that goes beyond the marketplace of the exchange of money or the influence of power. In speaking of medical activism, we wish to ground our discussion in the ancient profession of medicine, however we do also want to be inclusive and also use “medicine” in a larger context of health care professionals. The term, “healthcare activism,”[3] is a much larger term encompassing grass roots and activist/organizer movements. We do not mean to neglect this critical cultural force of health and healing, however for the purposes of this paper we are concerned with the identity of health care professionals as activists and medical activists.

In this paper we will develop the idea of medical activism as a form of moral agency which is a foundational element of professional identity. While there are many different forms of medical activism, we will focus on a few forms, such as, speaking out, bearing witness, critiquing systems and practices that contribute to disease and suffering, developing innovative delivery systems, reformulating philosophies of care and treatment, and advocacy to promote the health and well-being of individuals, local, national communities, and in this ever-more connected world, the global community. More recent public health issues have arisen with the Covid-19 coronavirus pandemic, the politicizing of sound public health measures (such as wearing masks and social distancing). Another growing public health concern is the growing fascist tendencies in the United States and abroad. We have a number of diagnostic manuals on fascism and we know that fascism is a public health issue: first it affects marginalized groups (Muslims, immigrants, Native Americans, African Americans, the LGBTQ community), then it affects those deemed dangerous to the regime (the “liberal” press, intellectuals, teachers, scientists, “liberal” politicians), and then it starts infecting more and more people with side effects of racism, xenophobia, hate speech toward the above groups, and eventually violence toward the above groups. To the end of cautioning the public about the public health risks of fascism, the formation of the professional organization, Doctors Against Fascism is proposed.

What it Means to be a Professional

To be a professional means that one is constantly professing – similarly if one is a profess-or. The roots of the word “profession” have to do with taking vows and declaring openly and to make public statement. The etymology of the word is related to “profess” and “prophet” going back to the ancient Proto-Indo-European root, *bha-, meaning “to speak, tell, say.”[4] What we are doing as professionals is continual professing – to declare openly and to speak, tell, say.

            Our job as professionals it to profess, to declare openly, to speak, tell, say, to be prophets of health (which is different than focusing on the profits of the health care industry). The industry, the organization, the institution is not an inherently moral creation, it is more like a machine than a holder of morality, and it is the jobs of those professionals within the system to be the moral authority, the moral leadership of the institution.

De-professionalism

            With the rise of economic and productivity medicine we have seen a deprofessionalization[5] and dehumanization[6] of physicians and health care professionals. Corporate medicine is not interested in moral agents or medical activists, but rather what Foucault called “docile bodies,” to play limited roles within the institution. Moral agents and medical activists function independently or semi-autonomously, rather than as interchangeable technicians who dispense the same, generic, non-individualized treatment interventions. While corporate medicine pushes propaganda of customer service, true caring, compassion, and patient-centered care can only be given by individuals to individuals in the context of human relationships. Individuality and humanity are extraneous and problematic variables to corporate, machine medicine. 

Witnessing Professional

            Throughout his career, Robert Jay Lifton has written about the idea of the witnessing professional. He describes the shift toward “malignant normality,” “the imposition of a norm of destructive or violent behavior, so that such behavior is expected or required of people”.[7]

As citizens, and especially as professionals, we need to bear witness to malignant normality and expose it. We then become what I call “witnessing professionals,” who draw upon their knowledge and experience to reveal the danger of that malignant normality and actively oppose it. That inevitably includes entering into social and political struggles against expressions of malignant normality.[8]

The New Professional

In order to teach the next generation of doctors, healers, and clinicians, we need to provide good role models for students to emulate. This is the transmission of knowledge and wisdom that happens from one generation to the next. Without medical professionalism, medical ethics, medical morals, students are left morally adrift. Author and educator, Parker Palmer speaks of the new professional, “a person who not only is competent in his or her discipline but also has the skill and the will to resist and help transform the institutional pathologies that threaten the profession’s highest standards.”[9]

Palmer states that “the very institutions in which we practice our crafts pose some of the gravest threats to professional standards and personal integrity. Yet higher education does little if anything, to prepare students to confront, challenge, and help change the institutional conditions under which they will soon be working.”[10]      

“The notion of a ‘new professional’ revives the root meaning of the word. This person can say, ‘In the midst of the powerful force- field of institutional life, where so much conspires to compromise the core values of my work, I have found firm ground on which to stand―the ground of personal and professional identity and integrity―and from which I can call myself, my colleagues, and my profession back to our true mission.’”[11]

Science presents itself as “value-free” but the practice of medicine is one of moral agency.

Medical students enter the profession of medicine with idealism (which we know our medical education system diminishes) and yet they also enter having cultural biases. Research has been done on medical student attitudes toward homosexuality,[12] AIDS,[13] abortion,[14] the homeless,[15] immigrants,[16] and torture[17],[18] and how those attitudes might shape clinical care decision.

The Practice of Medicine as Continual Revolution & Reform

The beginning of Western Medicine is often said to have begun with Hippocrates who, rejected supernatural causes of illness, establishing the beginning of the scientific method and initiating a revolution of the truth which vanquished the other, competing, schools of medicine. The choice of Hippocrates as the “Father of Medicine” is somewhat arbitrary, as the study of nature, health, illness, and healing is ancient and has been practiced by all cultures. Hippocrates stands out as a medical activist in the musings of writers of history, as a medical activist championing science, rationalism, empiricism, and materialism.

The Structure of Scientific Revolutions

Thomas Kuhn, in The Structure of Scientific Revolutions, describes the stages of progress in science, starting with “normal science,” which mainly consists of technical puzzle solving. There comes a time when enough anomalies accumulate which do not fit the current scientific paradigm, which eventually leads to a crisis point. At the crisis point, the majority of scientists continue to adhere to a paradigm which is no longer as helpful as it once was, while a smaller group of scientists begin exploring new paradigms. Scientific revolution occurs when a new viable paradigm arises and there is conflict between the old and the new.

Semmelweis

Before the acceptance of germ theory, in the mid-1800s, Semmelweis tried to convince doctors that they should wash their hands after leaving off doing autopsies and before examining mothers who had just given birth. Although this seems common sense to us from our vantage point, Semmelweis was ridiculed, lost his appointment, and died in a mental institution. The concept of invisible pathogens was not part of the existing paradigm of understanding disease. We can consider Semmelweis as a medical activist who tried to protect the well-being of his patients and challenged the medical establishment.

Virchow

In the late 1800s, Virchow was tasked by the Prussian government to research an outbreak of typhus, in Upper Silesia, which had a large minority of Polish people living in poverty. His prescription was social and political: elimination of social inequality.[19] He came back with recommendations regarding poverty, services, and even political recommendations. This resulted in him losing his job. He wrote, “Medicine is a social science and politics is nothing more than medicine on a large scale,”[20] and that doctors “are the natural attorneys of the poor.”[21]

Social Determinants of Health

In addressing social determinants of health, Vicente Navarro writes that “we need to broaden health strategies to include political, social and cultural interventions that touch on the social (as distinct from the individual) determinants of health,” (15).[22]

Moral Determinants of Health

Berwick’s recent article, “The Moral Determinants of Health,” argues for an expansion of the role of professionals to include societal reform. “Healers are called to heal. When the fabric of communities upon which health depends is torn, then healers are called to mend it. The moral law within insists so.”[23]

Refounding: Reinvigorating the Founding Principles of Health Care

Another line of support for viewing medical activism as a core element of medical professionalism comes from anthropologist Gerald Arbuckle’s work on the concept of “refounding” in organizations. Arbuckle has observed that, over time, organizations and institutions lose touch with their original founding vision. A crisis-time comes and a “refounding individual” arises who challenges the status quo and seeks to revitalize the institution by bringing it back in line with the original, founding vision. The new state is a hybrid integration, though, of the new state of the surrounding culture and the original vision. This is to say it is not simply a return to the historic founding rules of the institution, but is a creative adaptation of the founding vision with a modern re-interpretation. An opposite way of trying to resolve the institutional crisis is a literal and rigid return to the past, which Arbuckle describes as the root of fundamentalism. Fundamentalism is reactionary and resists any change, growth, or adaptation. Refounding is a hybrid, bringing the spirit of the old into a new formulation within a new time and place. Arbuckle’s descriptions of the “refounding person” are consistent with the idea of the medical activist that we are discussing.

The ongoing health of institutions requires “refounding persons,” who remember the “original instructions” of the institution, the principles and ideals upon which the organization was founded but periodically loses its way. The refounding person is like the hero or heroine in Joseph Campbell’s hero’s journey – an individual who takes on what seems like an individual challenge that turns out to be healing for the entire community and places the people back in harmony with sacred and with the world. The refounding person is a person whose job it is to declare openly, to speak, say, tell, that we have lost our way, we have gone out of balance, and that we have to work to get ourselves back in balance, internally as individuals, in our relationships, in our community, and within our larger culture and our interrelationships with the world.

Cultural Models of Medicine within Contemporary Health Care

Interestingly, Arbuckle has worked in medical institutions as a consultant and this led to his book, Humanizing Healthcare Reforms. One of the challenges in healthcare reform, he finds, is that there are multiple cultures at play within modern medical settings and that in discussions between various clinical staff, accountants, and leadership, people bring different cultural world views, however these views are not clearly articulated and defined, so they are like invisible walls that impair discussion. He describes different cultural models of healthcare: traditional (indigenous medicine), foundational (Western values of care for the poor, sick, and suffering), biomedical (scientific, evidence-based medicine), social (living environment and inequalities), and economic rationalist (the business model of medicine with a focus on efficiency and productivity). These different cultural models of healthcare inevitably lead to cultural clash and crisis. Medical activism, or refounding,  in healthcare would be a revitalization of some of the models of medicine (e.g. the traditional, foundational, and social) that have been neglected and suffered under the dominance of the economic rationalist and biomedical models. “In healthcare,” Arbuckle writes, “the need to refocus on moral and spiritual ideals means returning to a mission based on founding values such as solidarity, equity, respect and compassion,” (16).

Examples of Health Care Critique & Reform

An ongoing critique of the contemporary practice of medicine is a moral duty of physicians. It is up to us, as professionals, to hold true to the mission and purpose of health care: caring for people who are suffering and ill. Institutions may have vision and mission statements but they are incapable of moral agency and compassion because those are human traits, not bureaucratic functions. Within this critique of contemporary medicine, we will look at several issues: burnout, physician suicide, the pressure on physicians and health care workers to become narrowly defined technicians rather than healers, and the general loss of caring within the practice of health care.

Holistic and Integrative medicine are examples of reform and refounding. Many advocates of holistic and integrative medicine have felt corporate and biological reductionistic medicine have lost touch with the heart and soul of what it means to be a healer. The science of medicine has nearly eclipsed the art of medicine.

The following are some bullet points to be more fully developed:

  • Limits of evidence-based medicine
    • Groopman, How Doctors Think
    • Beahr, The Limits of Scientific Psychiatry
    • Pathological Objectivity
      • Scientism – scientific fundamentalism
      • Defensive mechanism
      • As part of burnout triad – extreme form of emotional distancing
  • Re-humanizing Medicine
    • Healer vs. Technician
    • Counter-curriculum of re-humanization
    • Compassion Revolution
  • Holistic & Integrative Medicine
  • Recovery Model in mental health
  • Physicians for a National Health Program
  • Micropractice, Ideal Medical Practice
    • Work of L. Gordon Moore[24]
  • Burnout
    • Institutional factors
    • Danielle Ofri: “The Business of Healthcare Depends on Exploiting Doctors and Nurses” [25]
  • Physician suicide
    • 300-400 suicides/year, size of three average medical school classes

Medicine in the World – Possible sections

The “first task of the doctor is therefore political: the struggle against disease must begin with a war against bad government,” (Foucault).[30]

Samuel Shem, in his essay, “Fiction as Resistance,” writes:

“We believed that if we saw an injustice, we could organize, take action, and change things for the better…When we entered our internship, we were told to treat our patients in ways that we didn’t think were humane. We ran smack into the conflict between the received wisdom of the medical system and the call of the human heart.”[31] Shem describes turning to fiction writing as a resistance to “brutality and inhumanity, to isolation and disconnection.” His recommendations on how to resist “the inhumanities in medicine” are four suggestions: 1) “Learn our trade, in the world” to be aware that “Medicine is part of life, not vice versa;” 2) “Beware of isolation. Isolation is deadly; connection heals;” 3) “Speak up…speaking up is essential for our survival as human beings;” 4) “Resist self-centeredness…learn empathy.”[32]

Bullet points to more fully develop examples:

  • Human Rights
    • Human Rights Medicine & Psychiatry, e.g. international trauma work
    • LGBT Rights
    • Women’s Rights
    • Culture, Diversity, Religious Tolerance – addressing racism and intolerance
    • Immigration policy and public health
  • Racism
    • Black Lives Matter
  • Trauma-Informed Care
  • Judith Herman’s view of the tendency to forget trauma and the need to for those who work with traumatized populations to bear witness and be moral agents.
  • Peace/Recovery from War & Violence
    • The influence of Buddhism and Mindfulness in Health Care
    • Gun Violence
  • Preserving/Continuing Healing Traditions
    • e.g. Shamanic work, physicians working with indigenous cultures who have written on benefits of incorporating elements into contemporary medicine
    • Lewis Mehl-Madrona, in a study of Indigenous elders, learned that “Healers have to maintain some independence from political structures.”[33]
    • Medical Pluralism[34]
  • Social, Climate, Environment
    • Flint, Michigan – lead in drinking water
    • Poverty
    • Homelessness
    • Promoting the health of the Earth
  • Public Safety

A recent example of professional activism is found in the book, The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts assess the President. Many well-respected researchers and clinicians came together to raise awareness of public health and safety concerns stemming from their view of the dangerousness of the 45th president of the United States. Stephen Soldz and Brandy Lee write that

“Professionals are an important component…helping to provide checks on powerful institutions and alerting the public to wrongs. Professions operate with an implicit social contract with the broader society to contribute their special knowledge and training for the greater good.”[35]

They caution that what “is often missing from [ethics] training is any deep engagement with fundamental ethics principles and ethical thinking.” They see the comments and actions of the 45th President as a risk to public health and safety and feel that the safety risk comprises a duty to warn which overrides the past Goldwater rule which prohibits psychiatrists from diagnosing public figures.

They argue that the ethical principles of justice and universality “direct health professionals to pay attention to the wider world beyond the clinic as they call upon us to serve the broader public, not just those who become our patients. And they direct us toward the world of public policy and of ‘politics,’ broadly defined, as a way of collectively improving public health.”[36]

            Soldz and Lee mention a number of recent examples of health professional activism, including opposing the involvement of psychologists and health professionals in torture under the Bush administration; opposing the use of psychiatrists in the Soviet Union to punish dissidents; physicians against nuclear war; physicians against land mines; and physicians supporting civil rights and health equity; and physicians for a national health plan.[37] They write that these examples illustrate that “activism by health providers is compatible with and even integral to professional responsibility toward society.”[38]

            In this same volume, Robert Jay Lifton writes of the ideal of “witnessing professionals” who combine a “sense of outrage with a disciplined use of our professional knowledge and expertise.”[39] Lifton cautions that if we define ourselves too narrowly, as technicians, we lose our sense of identity as witnessing professionals. This is a caution alongside those who argue that many professions are being deprofessionalized.

  • Doctors Against Fascism
    • Proposed founding of this organization based on the systemic fascism in politics affecting public health
  • Doctors as Public Health Advocates
  • The Institute of Peace Medicine

I have long thought of writing a book called, Re-spiritualizing Medicine. This does not mean going backwards into religious fundamentalism, but rather recognizing that human beings are inherently spiritual creatures. By spirituality I do not mean religion, but rather a sense of aliveness, vitality, connection to other people, connection to the natural world, connection to something larger than our own egos. The spiritual underlies our sense of interconnectivity with humanity and all life.

Since 2016 I have been working with Southern Ute visionary artist and healer, Joseph Rael (Beautiful Painted Arrow). His work since the 1980’s building Sound Peace Chambers around the world led to him being recognized by the United Nations for his work for world peace. Ultimately, peace is a public health issue, although we do not often think of it that way. War, violence, hatred, oppression, racism – all these are the opposite of peace. Perhaps we should found an Institute of Peace Medicine to address the social and moral determinants of health, but also to promote peace, unity, and non-duality as core human principles to protect and nurture human life and the life of the planet.

Spiritual Democracy

Joseph and I borrowed the term, spiritual democracy from Steven Herrmann. This idea of spiritual democracy also addresses many of the social and moral determinants of health. It also is an antidote to fascism. Fascism is founded on division and separation of us and them and on the priority of the will of the leader, and a small group of people defined to be like the leader, over the social good of the global community. Here is what Herrmann writes about spiritual democracy:

“Adopting the big idea of Spiritual Democracy, the realization of oneness of humanity with the universe and all its forces, can help people feel joy, peace, and interconnectedness on an individual basis. It can also inspire us to undertake sacred activism, the channeling of such forces into callings that are compassionate, just, and of equitable heart and conscience, and give us some tools to start solving some of these grave global problems, while uniting people on the planet.”[40]

Sacred Activism

            The idea of spiritual democracy is related to the idea of sacred activism. This goes a step beyond professional or medical activism, but grows out of a common love and care for humanity and our environment. Herrmann credits Andrew Harvey for originating this term:

“Each of us, it seems, is guided by such a star and it varies in its fixed orbits, in different fields of sacred action, in every person’s life. A central existential task is to discover what that star is and to make its light, the inner fire of human love, burn brightly against the darkness, as a calling to live by. . . . Sacred activism is a spiritual practice for bringing about planetary changes through a receptivity to, and response to, experiences of a mysterious energy, force, or power, which move through the human body, psyche, and entire cosmos in an effort to bring about alterations of consciousness, cultural transformation, and ultimately: world peace.”[41]

World peace may seem like a big goal, but would that not bring about the greatest improvement in public, global health? The current US administration pulling out of the World Health Organization and the UN Human Rights Council is the opposite of what will heal us – as individuals, as communities, and as a stewards of the global ecosystem. Spiritual democracy, sacred activism, re-spiritualizing medicine and an Institute of Peace Medicine are logical extensions of the doctor and clinician as moral agents and profess-ors of public health.

Conclusion

We stand at a unique time in history – a global pandemic, smear campaigns against public health experts, attempts to silence or manipulate science for political ends, the politicization of basic, scientific principles of public health. We also stand at a time when fascist words are turning into fascist behaviors.[42] We have seen these early symptoms in the 20th Century and they can become fulminant and more deadly than a viral pandemic. Now, more than ever, we as physicians, we as clinicians, need to re-claim activism as a core identity. We need to speak, tell, say, to speak openly, to speak publicly about the public health threats of this time in history. We have guidance of those physicians and clinicians who have gone before us and how they have spoken up for the health of the people and the public.

            We can draw on Robert Jay Lifton’s development of the witnessing professional. We can draw on Parker J. Palmer’s development of the new professional. We can draw on the moral foundations of our professions, to become moral agents for social change as we diagnosis and treat the moral determinants of health and the public health threats of the day.

[1] “Take Two Aspirin and Call Me by My Pronouns: At ‘woke’ medical schools, curricula are increasingly focused on social justice rather than treating illness,” Stanley Goldfarb, Wall Street Journal, 9/12/19

[2] “Doctors Revolt After N.R.A. Tells Them to ‘Stay in Their Lane’ on Gun Policy,” Matthew Haag, The New York Times, Nov. 13, 2018. The original criticism was in a Tweet from the NRA, “Someone should tell self-important  anti-gun doctors to stay in their lane. Half of the articles in Annals of Internal Medicine are pushing for gun control. Most upsetting, however, the medical community seems to have consulted NO ONE but themselves.” https://twitter.com/NRA/status/1060256567914909702

[3] Laverack, Glenn. Health Activism: Foundations and Strategies. Sage: Thousand Oaks, 2013.

[4] Online Etymology Dictionary for “profession,” “profess,” “prophet.” https://www.etymonline.com/search?q=profession

[5] http://www.professionalsaustralia.org.au/blog/deprofessionalisation-matter/

[6] Kopacz, David. Re-humanizing Medicine: A Holistic Framework for Transforming Your Self, Your Practice, and the Culture of Medicine. Washington DC: Ayni Books, 2014.

[7] Lifton, Robert Jay. Losing Reality: On Cults, Cultism, and the Mindset of Political and Religious Zealotry. New York: The New Press, 2019, p. 189.

[8] Lifton, Robert Jay. Losing Reality: On Cults, Cultism, and the Mindset of Political and Religious Zealotry. New York: The New Press, 2019, p. 190.

[9] Palmer, Parker. The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life. San Francisco: Jossey-Bass, 2007, p. 202.

[10] Palmer, Parker. The Courage to Teach: Exploring the Inner Landscape of a Teacher’s Life. San Francisco: Jossey-Bass, 2007, p. 199.

[11] Palmer, Parker. “A New Professional: The Aims of Education Revisited.” Change, Vol. 39, No. 6 (Nov-Dec, 2007), pp. 6-12.

[12] Klamen, D, Grossman, L, and Kopacz, D. (1999). Medical student homophobia. Journal of Homosexuality, 37 (1): 53-63.

[13] Kopacz, D., Klamen, D., & Grossman, L. (1999). Medical students and AIDS: Knowledge, attitudes and implications for education. Health, Education & Research, 14 (1): 1-6.

[14] Klamen, D, Grossman, L, & Kopacz, D. (1996). Attitudes about abortion among second-year medical students. Medical Teacher, 18 (4): 345-346.

[15] Morrison, A., Roman, B. & Borges, N. Psychiatry and Emergency Medicine: Medical Student and Physician Attitudes Toward Homeless Persons. Acad Psychiatry 36,211–215 (2012) doi:10.1176/appi.ap.10080112

[16] Hudelson, P, Perron, NJ, & Perneger, TV. (2010). Measuring Physicians’ and Medical Students’ Attitudes Toward Caring for Immigrant Patients. Evaluation & the Health Professions, 33(4), 452–472. https://doi.org/10.1177/0163278710370157

[17] Dubin K, Milewski AR, Shin J, Kalman TP. Medical Students’ Attitudes toward Torture, Revisited. Health Hum Rights. 2017;19(2):265–277.

[18] Bean J, Ng D, Demirtas H, Guinan P. “Medical students’ attitudes toward torture,” Torture 18/2 (2008) pp. 99–103.

[19] Mackenbach, J. (2009). Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. Journal of Epidemiology and Community Health (1979-), 63(3), 181-184. Retrieved August 8, 2020, from http://www.jstor.org/stable/20720916

[20] Quoted in Vicente Navarro. What we mean by social determinants of health. Global Health Promotion Vol. 16 (1):5-16; 2009. Original reference: Virchow R. Die medizinische Reform, 2 in Henry Ernest Sigerist, Medicine and Human Welfare 1941:93.

[21] Mackenbach, J. (2009). Politics is nothing but medicine at a larger scale: Reflections on public health’s biggest idea. Journal of Epidemiology and Community Health (1979-), 63(3), 181-184. Retrieved August 8, 2020, from http://www.jstor.org/stable/20720916

[22] Vicente Navarro. What we mean by social determinants of health. Global Health Promotion Vol. 16 (1):5-16; 2009

[23] Berwick DM. The Moral Determinants of Health. JAMA. 2020;324(3):225–226. doi:10.1001/jama.2020.11129.

[24] L. Gordon Moore, ‘Going Solo: Making the Leap,’ Family Practice Management. February 2002, American Academy ofFamily Physicians website, accessed April 7, 2012.http://www.aafp.org/fpm/2002/0200/p29.html .

[25] Ofri D. The Business of Healthcare Depends on Exploiting Doctors and Nurses: One resource seems infinite and free: the professionalism of caregivers. The New York Times, June 8, 2019.

[26] Dean W, Talbot S, Dean A. Reframing clinician distress: Moral injury not burnout. [published correction appears in Fed Pract. 2019 Oct;36(10):447]. Fed Pract. 2019;36(9):400-402.

[27] Norman SB. Moral Injury. National Center for PTSD website. https://www.ptsd.va.gov/professional/treat/cooccurring/moral_injury.asp. Accessed April 27, 2020.

[28] ZDoggMD. It’s Not Burnout, It’s Moral Injury. March 18, 2019. https://zdoggmd.com/moral-injury/47 . Accessed July 30, 2020.

[29] Talbot SG, Dean W. Physicians aren’t ‘burning out.’ They’re suffering from moral injury. STAT. July 26, 2018. https://www.statnews.com/2018/07/26/physicians-not-burning-out-they-are-suffering-moral-injury/. Accessed July 30, 2020.

[30] Michel Foucault, The Birth of the Clinic (New York: Vintage Books, 1994), 38.

[31] Shem, Samuel. Fiction as Resistance. Annals of Internal Medicine. Vol 37(11):934-937; 2002.

[32] Shem, Samuel. Fiction as Resistance. Annals of Internal Medicine. Vol 37(11):934-937; 2002.

[33] Mehl-Madrona, L. “What Traditional Indigenous Elders Say About Cross-Cultural Mental Health Training,” Explore, 2009, 5:20-29.

[34] Michael H. Cohen, Healing at the Borderland of Medicine and Religion (Chapel Hill: University of North Carolina Press,2006), 3.

[35] Lee, Brandy X (ed). The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President, Updated and Expanded with New Essays. New York: Thomas Dunne Books; 2019, p. xxviii.

[36]  Lee, Brandy X (ed). The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President, Updated and Expanded with New Essays. New York: Thomas Dunne Books; 2019, p. xxxi.

[37] Lee, Brandy X (ed). The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President, Updated and Expanded with New Essays. New York: Thomas Dunne Books; 2019, p. xxxiv – xxxv.

[38] Lee, Brandy X (ed). The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President, Updated and Expanded with New Essays. New York: Thomas Dunne Books; 2019, p. xxxv.

[39] Lee, Brandy X (ed). The Dangerous Case of Donald Trump: 37 Psychiatrists and Mental Health Experts Assess a President, Updated and Expanded with New Essays. New York: Thomas Dunne Books; 2019, p. xlix.

[40] Steven Herrmann, Spiritual Democracy: The Wisdom of Early American Visionaries for the Journey Forward, xiii.

[41] Herrmann, Spiritual Democracy, xvii–xviii.

[42] I have been writing a series of essay under the heading, “Words Create Worlds,” in the online magazine The Badger, https://beingfullyhuman.com/?s=words+create+worlds&submit=Search.