Where Have All the Flowers Gone: Choosing Civility in Medicine

It is no news that civility and trust in America are under attack, with lots of polarization based on political and social views.  Civility is closely associated with the ability to empathize with others.  In his 2002 book Choosing Civility: The Twenty-five Rules of Considerate Conduct, author P.M. Forni states that civility is largely “our ability to identify with others and – at least to a certain extent – to feel what they feel.”  The author goes on to say that civility permits us to relate and connect to others and fosters a happy life.

In a special series on NPR called Civility Wars, journalist Hanna Rosin talks in the episode titled “The End of Empathy” about waning civility in society through the lens of a growing brand of selective empathy reserved for those you like, people whom you consider to be on your team, and not extended to your enemies. Rosin states, “That can lead to a very strong empathy and too strong polarization with something you can only see this one side and not the other side any longer.”

Social media is full of vitriol, where opposing views become personal attacks and vile commentary. It happens with regard to health care, be it opinions on the strength of evidence that vaccinations are safe, the evidence (or lack thereof) for vitamin supplements or, on a subject close to this author, the strength of the evidence for maintenance of certification by physicians.

Often, public discourse on these issues doesn’t focus on science or evidence, but on the speaker’s political leaning when it comes to individual freedom and governmental or other regulations.

Perhaps the focus of our attention should be on finding common ground about what the real issues are and understanding each other’s fears about the balance between freedom and regulation.  A discussion can begin with: where should trust start and end?

A lack of civility and collaboration is on display in communities where competition among health systems makes them overly interested in revenues and market share over the health of the population.  For example, when a health system makes a business decision to exclude patients based on who provides their insurance coverage, thus separating patients from their physicians, the health of the community suffers.  When will we see all the health care stakeholders in communities coming together to really advance population health?

The dialogue has to start with the assumption that all parties have good intentions and the belief that most people are reasonable most of the time.  Understanding each other’s perspectives brings civility and builds trust.

Efforts like 100 Million Healthier Lives attempt to work with communities to do just that. The movement, led by the Institute for Healthcare Improvement, collaborates across organizations to improve the health of the community, wellbeing of individuals and equity throughout health care.  They employ trust practices such as Habits of the Heart, a phrase coined by Alexis de Tocqueville that was amplified decades later by Parker Palmer in his book Healing the Heart of Democracy.

Carried forward by the Center for Courage and Renewal, one of the most important Habits of the Heart is the trust-building practice of appreciating the value of “otherness,” not us versus them but us and them.  Additional trust practices are understanding that we are all in this together, holding tension in life-affirming ways and with respect for personal voice and agency.

If we choose civility over fear and mistrust, and couple that with Habits of the Heart, we would have a more effective, more affordable health care system.  As the Pete Seeger song goes, “where have all the flowers gone … when will we ever learn” – about the importance of trust and respectful relationships?

Daniel B. Wolfson
EVP & COO, ABIM Foundation