Get 20M+ Full-Text Papers For Less Than $1.50/day. Start a 14-Day Trial for You or Your Team.

Learn More →

Tolerance and Integrity

Tolerance and Integrity We have reached an impasse. Through the westward-facing window of the hospital room, a shaft of late afternoon sunlight illuminates the space between me and the parents of the child lying in the bed. The air, teeming with the tiny flotsam that usually goes unnoticed, appears agitated and alive. We have been discussing what the best therapeutic course of action is for this young patient; we have shared information and considered the pros and cons at length; we understand each other’s views and have conducted our dialogue with great respect. But we clearly, and perhaps irrevocably, disagree. Perhaps we diverge regarding whether invasive life-extending interventions are still in the child’s best interest, whether to give a blood transfusion or withhold it for religious reasons, whether to use a complementary-alternative approach in lieu of a standard allopathic remedy, whether to perform a particular diagnostic test, or whether to administer a specific drug or immunization to the child. But as I sit in the room and consider the thoughts and emotions swirling in my mind, the precise issue on which we differ is not the critical point. Certainly, the clinical or cultural, scientific or social details that constitute the issue are not irrelevant, but these aspects, if elaborated in full, weave a dense and intriguing veil of details that in this case would merely shroud the naked reality of our disagreement. Disputes abound in medicine. Incomplete understanding, incommensurate worldviews, and incompatible values combine to make clinical decision-making ripe for disagreements large and small. We encounter them so frequently and in so many guises that only the most fractious arguments or aggressive confrontations stand out: acts of quiet dissension are typically drowned out in the hubbub of hospital practice. Once attuned to the soft discordant notes of disagreement, though, each interaction with patient and family transforms into a clinic in deliberative communication, converging or diverging, attempting to formulate pragmatic pathways forward: a medical encounter marked not only by acts of prognosis, diagnosis, and therapeutics, but by politics and poetics as well. In the corner of the room, a pile of clothes and a stack of magazines, with toiletries tucked in between, testify to the realities of camping out at a child’s bedside for 3 weeks. I admire the voracious love and unyielding devotion that these parents exhibit toward their child. Regarding the decision we confront, however, we are stuck. I pause, breathe, collect my wits—and then confess (for what I say feels at the outset like a confession, almost an admission of weakness): “Well, we don’t agree. And yet I respect your dedication to your child tremendously, and even though we view key aspects of this decision differently, and even though we believe in different courses of action, we need to figure out some way to move forward. And I think together we will.” What the parents think of me at this point—a friend or foe—I’m not exactly sure, but they nod in concert. In the ensuing silence, the prospect of formulating some compromise weighs heavy in the air. During this momentary yet crucial pause in my dialogue with the parents, I turn my attention inward, trying to calibrate within myself the interplay of tolerance and integrity. To do so, I must quiet my mind, turning down the volume on our society’s incessant 24-7-365 chatter that valorizes competition: competitive sports, competitive health care markets, even competitive parenting. The great cultural vortex of competition bends myriad aspects of being human—cheering for others, writing poetry, possessing beauty—into contests, prizes, and pageants. In diverse ways, our engagement with other human beings gets distorted when viewed through the ubiquitous competitive lens. I am tempted to conceive of my current predicament both egoistically (as stemming from my inability to convince these well-meaning parents of the rightness of my view) and metaphorically (as a tug-of-war or perhaps a Sisyphean toil of pushing hard truth uphill). Yet these metaphorical notions, besides aggrandizing me while demeaning others, have proven repeatedly to be unhelpful. A contrasting perspective and approach, I believe, is required—and possible. If disputes abound, so do choices: not only regarding what test or treatment to pursue, but also the choices that influence the process by which we decide. While few tasks are more demanding than to adjudicate between competing worthy principles, the challenges presented by conflicting principles suggest that acts of deliberation, not principles per se, are the essential firmament of collective moral action. And so, while these parents debate with me the proper course of action on behalf of their child, I struggle inwardly to maintain the disposition of respectful deliberation. At the core of this struggle are the apparently competing principles of tolerance and integrity. The first commands an active regard for the value of others, manifested by a conscientious accommodation to their beliefs and behaviors; the latter demands the exercise of regard for oneself, through adherence in one’s behavior to self-valued principles. I have come to believe, however, that these 2 titan principles are best conceived not as competitors but as collaborators: tolerance and integrity are crucial prerequisites for deliberative dialogue, providing requisite flexibility and backbone. The child stirs in the bed. I glance across the room at the couple, seated side by side and holding hands, their fingers interlaced. Swayed by the power of metaphors, I have nurtured alternative images of my inward struggle that focus on the complementary nature of tolerance and integrity. Two buckets of water suspended from either end of a pole that is balanced across my shoulders: the one cannot exist in full measure without the other. Two sides of a pane of glass with opposing forces pushing on each side: imbalance shatters. Two towers from which a suspension bridge hangs: both are necessary to go the distance. These images point up the interdependence of tolerance and integrity, a pair of necessarily entwined values. Tolerance without integrity degenerates into political correctness, a callow wet-noodle capitulation to the view of others to avoid conflict and the consequences of dissent. Conversely, integrity without tolerance devolves into self-righteous partisanship, a narcissistic embrace of one’s own values (and unacknowledged self-interests) with myopic high-mindedness. Indeed, because these 2 values need each other to shape their meaning, tolerance and integrity are not only principles but also personal or public practices. The arduous practice of tolerance requires a magnanimous, open-minded attitude toward others that is matched by correspondingly respectful and accommodating behavior. Putting up with conduct or views differing from our own in merely unobjectionable ways is an anemic form of tolerance. For the practice of tolerance to have any life blood, it should make us feel uncomfortable. And yet, capitulating to objectionable views out of fear, or kowtowing to them because such is the trend, is not tolerance so much as cowardice or opportunism with an attractive label—a practice lacking integrity and thus not performing the deeper work of tolerance. Integrity is likewise a practice, one that keeps us a coherent whole. I must maintain some degree of integrity to my own fundamental beliefs: that the interest of the child should be paramount, placed above other considerations; that scientific evidence is better than anecdotal evidence; that one cannot avoid all risks in life, and prudent risk-taking is necessary to maximize the safety of individuals and groups; and that as much as I love what technology offers humans, adding additional days to our lives would be an empty accomplishment if we did not embrace relationships, contribute to others, contemplate spiritual mysteries. Yet at the same time, whatever my personal beliefs in these realms, my integrity demands—because I value other people as ends unto themselves—that I be tolerant of views that diverge from mine. To be intolerant of alternative beliefs or preferences is tantamount to treating others as means to the ends that I happen to embrace: abdication of the practice of tolerance is the stepping stone to the arrogance of overweening integrity and from there to xenophobic rigidity. As the child’s respiratory monitor issues a brief alarm, I am pulled out of my seat and back to the bedside, to the physical realities of my hand now rising and falling gently on the chest of another human being breathing slowly in sleep. As concrete as much of medical practice is, though, the more ephemeral issues of deliberation play out equally tangibly in my everyday professional life whenever patients or their family members ask for tests or treatments that I do not condone (and in my personal life when colleagues or friends espouse social or political views with which I disagree). On such occasions, tolerance and integrity hang in the balance as I consider how to respond. While others might view this task as formulating compromise, I see the effort in broader terms, of using integrity to forge a more resolute habit of tolerance, of using tolerance to temper a stronger habit of integrity. This labor not only responds to the specific issues of that particular situation but also creates a necessary but fragile shared resource, a common space in which disagreements can be aired and addressed, a workshop vital to any diverse society, small or large, hoping to amicably cohabit and flourish. Easy to think, harder to do. I admit to worrying, as I stand next to the parents looking down at their slumbering child: How will I be perceived by my colleagues if I give ground on this issue? Or if I refuse to yield, break off negotiations, leave the room? How will I view myself? These seemingly petty concerns compete with more substantial questions: How much is truly at stake in this decision? What will happen if we do not agree? Are there ways, given the stances we have already taken, to make agreement more palatable to all of us? Can I find our common ground, moving our conversation away from what we have proposed to do, focusing instead on what our fundamental goals are, and perhaps build a workable solution from that stable foundation? At this juncture of conflict and doubt, I’m never sure of the answers to these questions—a cardinal reason, perhaps, that medicine remains an art. “So we need to figure out a way forward,” I say again. “And standing as we are, side by side, I trust we will.” Note: The vignette presented here represents a composite of many different encounters. The ideas expressed reflect concepts emanating from diverse fields, including useful works in ethics,1 linguistics,2 negotiation,3 and political theory.4 Correspondence: Dr Feudtner, The Children’s Hospital of Philadelphia, 3535 Market St, Room 1523, Philadelphia, PA 19104 (feudtner@email.chop.edu). References 1. Pellegrino EDThomasma DC The Virtues in Medical Practice. New York, NY Oxford University Press1993; 2. Lakoff GJohnson M Metaphors We Live By. Chicago, Ill University of Chicago Press1980; 3. Fisher RKopelman ESchneider AK Beyond Machiavelli: Tools for Coping With Conflict. Cambridge, Mass Harvard University Press1994; 4. Gutmann AThompson DF Democracy and Disagreement. Cambridge, Mass Belknap Press of Harvard University Press1996; http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Pediatrics & Adolescent Medicine American Medical Association

Loading next page...
 
/lp/american-medical-association/tolerance-and-integrity-lCIzyPkQfJ
Publisher
American Medical Association
Copyright
Copyright © 2005 American Medical Association. All Rights Reserved.
ISSN
1072-4710
eISSN
1538-3628
DOI
10.1001/archpedi.159.1.8
Publisher site
See Article on Publisher Site

Abstract

We have reached an impasse. Through the westward-facing window of the hospital room, a shaft of late afternoon sunlight illuminates the space between me and the parents of the child lying in the bed. The air, teeming with the tiny flotsam that usually goes unnoticed, appears agitated and alive. We have been discussing what the best therapeutic course of action is for this young patient; we have shared information and considered the pros and cons at length; we understand each other’s views and have conducted our dialogue with great respect. But we clearly, and perhaps irrevocably, disagree. Perhaps we diverge regarding whether invasive life-extending interventions are still in the child’s best interest, whether to give a blood transfusion or withhold it for religious reasons, whether to use a complementary-alternative approach in lieu of a standard allopathic remedy, whether to perform a particular diagnostic test, or whether to administer a specific drug or immunization to the child. But as I sit in the room and consider the thoughts and emotions swirling in my mind, the precise issue on which we differ is not the critical point. Certainly, the clinical or cultural, scientific or social details that constitute the issue are not irrelevant, but these aspects, if elaborated in full, weave a dense and intriguing veil of details that in this case would merely shroud the naked reality of our disagreement. Disputes abound in medicine. Incomplete understanding, incommensurate worldviews, and incompatible values combine to make clinical decision-making ripe for disagreements large and small. We encounter them so frequently and in so many guises that only the most fractious arguments or aggressive confrontations stand out: acts of quiet dissension are typically drowned out in the hubbub of hospital practice. Once attuned to the soft discordant notes of disagreement, though, each interaction with patient and family transforms into a clinic in deliberative communication, converging or diverging, attempting to formulate pragmatic pathways forward: a medical encounter marked not only by acts of prognosis, diagnosis, and therapeutics, but by politics and poetics as well. In the corner of the room, a pile of clothes and a stack of magazines, with toiletries tucked in between, testify to the realities of camping out at a child’s bedside for 3 weeks. I admire the voracious love and unyielding devotion that these parents exhibit toward their child. Regarding the decision we confront, however, we are stuck. I pause, breathe, collect my wits—and then confess (for what I say feels at the outset like a confession, almost an admission of weakness): “Well, we don’t agree. And yet I respect your dedication to your child tremendously, and even though we view key aspects of this decision differently, and even though we believe in different courses of action, we need to figure out some way to move forward. And I think together we will.” What the parents think of me at this point—a friend or foe—I’m not exactly sure, but they nod in concert. In the ensuing silence, the prospect of formulating some compromise weighs heavy in the air. During this momentary yet crucial pause in my dialogue with the parents, I turn my attention inward, trying to calibrate within myself the interplay of tolerance and integrity. To do so, I must quiet my mind, turning down the volume on our society’s incessant 24-7-365 chatter that valorizes competition: competitive sports, competitive health care markets, even competitive parenting. The great cultural vortex of competition bends myriad aspects of being human—cheering for others, writing poetry, possessing beauty—into contests, prizes, and pageants. In diverse ways, our engagement with other human beings gets distorted when viewed through the ubiquitous competitive lens. I am tempted to conceive of my current predicament both egoistically (as stemming from my inability to convince these well-meaning parents of the rightness of my view) and metaphorically (as a tug-of-war or perhaps a Sisyphean toil of pushing hard truth uphill). Yet these metaphorical notions, besides aggrandizing me while demeaning others, have proven repeatedly to be unhelpful. A contrasting perspective and approach, I believe, is required—and possible. If disputes abound, so do choices: not only regarding what test or treatment to pursue, but also the choices that influence the process by which we decide. While few tasks are more demanding than to adjudicate between competing worthy principles, the challenges presented by conflicting principles suggest that acts of deliberation, not principles per se, are the essential firmament of collective moral action. And so, while these parents debate with me the proper course of action on behalf of their child, I struggle inwardly to maintain the disposition of respectful deliberation. At the core of this struggle are the apparently competing principles of tolerance and integrity. The first commands an active regard for the value of others, manifested by a conscientious accommodation to their beliefs and behaviors; the latter demands the exercise of regard for oneself, through adherence in one’s behavior to self-valued principles. I have come to believe, however, that these 2 titan principles are best conceived not as competitors but as collaborators: tolerance and integrity are crucial prerequisites for deliberative dialogue, providing requisite flexibility and backbone. The child stirs in the bed. I glance across the room at the couple, seated side by side and holding hands, their fingers interlaced. Swayed by the power of metaphors, I have nurtured alternative images of my inward struggle that focus on the complementary nature of tolerance and integrity. Two buckets of water suspended from either end of a pole that is balanced across my shoulders: the one cannot exist in full measure without the other. Two sides of a pane of glass with opposing forces pushing on each side: imbalance shatters. Two towers from which a suspension bridge hangs: both are necessary to go the distance. These images point up the interdependence of tolerance and integrity, a pair of necessarily entwined values. Tolerance without integrity degenerates into political correctness, a callow wet-noodle capitulation to the view of others to avoid conflict and the consequences of dissent. Conversely, integrity without tolerance devolves into self-righteous partisanship, a narcissistic embrace of one’s own values (and unacknowledged self-interests) with myopic high-mindedness. Indeed, because these 2 values need each other to shape their meaning, tolerance and integrity are not only principles but also personal or public practices. The arduous practice of tolerance requires a magnanimous, open-minded attitude toward others that is matched by correspondingly respectful and accommodating behavior. Putting up with conduct or views differing from our own in merely unobjectionable ways is an anemic form of tolerance. For the practice of tolerance to have any life blood, it should make us feel uncomfortable. And yet, capitulating to objectionable views out of fear, or kowtowing to them because such is the trend, is not tolerance so much as cowardice or opportunism with an attractive label—a practice lacking integrity and thus not performing the deeper work of tolerance. Integrity is likewise a practice, one that keeps us a coherent whole. I must maintain some degree of integrity to my own fundamental beliefs: that the interest of the child should be paramount, placed above other considerations; that scientific evidence is better than anecdotal evidence; that one cannot avoid all risks in life, and prudent risk-taking is necessary to maximize the safety of individuals and groups; and that as much as I love what technology offers humans, adding additional days to our lives would be an empty accomplishment if we did not embrace relationships, contribute to others, contemplate spiritual mysteries. Yet at the same time, whatever my personal beliefs in these realms, my integrity demands—because I value other people as ends unto themselves—that I be tolerant of views that diverge from mine. To be intolerant of alternative beliefs or preferences is tantamount to treating others as means to the ends that I happen to embrace: abdication of the practice of tolerance is the stepping stone to the arrogance of overweening integrity and from there to xenophobic rigidity. As the child’s respiratory monitor issues a brief alarm, I am pulled out of my seat and back to the bedside, to the physical realities of my hand now rising and falling gently on the chest of another human being breathing slowly in sleep. As concrete as much of medical practice is, though, the more ephemeral issues of deliberation play out equally tangibly in my everyday professional life whenever patients or their family members ask for tests or treatments that I do not condone (and in my personal life when colleagues or friends espouse social or political views with which I disagree). On such occasions, tolerance and integrity hang in the balance as I consider how to respond. While others might view this task as formulating compromise, I see the effort in broader terms, of using integrity to forge a more resolute habit of tolerance, of using tolerance to temper a stronger habit of integrity. This labor not only responds to the specific issues of that particular situation but also creates a necessary but fragile shared resource, a common space in which disagreements can be aired and addressed, a workshop vital to any diverse society, small or large, hoping to amicably cohabit and flourish. Easy to think, harder to do. I admit to worrying, as I stand next to the parents looking down at their slumbering child: How will I be perceived by my colleagues if I give ground on this issue? Or if I refuse to yield, break off negotiations, leave the room? How will I view myself? These seemingly petty concerns compete with more substantial questions: How much is truly at stake in this decision? What will happen if we do not agree? Are there ways, given the stances we have already taken, to make agreement more palatable to all of us? Can I find our common ground, moving our conversation away from what we have proposed to do, focusing instead on what our fundamental goals are, and perhaps build a workable solution from that stable foundation? At this juncture of conflict and doubt, I’m never sure of the answers to these questions—a cardinal reason, perhaps, that medicine remains an art. “So we need to figure out a way forward,” I say again. “And standing as we are, side by side, I trust we will.” Note: The vignette presented here represents a composite of many different encounters. The ideas expressed reflect concepts emanating from diverse fields, including useful works in ethics,1 linguistics,2 negotiation,3 and political theory.4 Correspondence: Dr Feudtner, The Children’s Hospital of Philadelphia, 3535 Market St, Room 1523, Philadelphia, PA 19104 (feudtner@email.chop.edu). References 1. Pellegrino EDThomasma DC The Virtues in Medical Practice. New York, NY Oxford University Press1993; 2. Lakoff GJohnson M Metaphors We Live By. Chicago, Ill University of Chicago Press1980; 3. Fisher RKopelman ESchneider AK Beyond Machiavelli: Tools for Coping With Conflict. Cambridge, Mass Harvard University Press1994; 4. Gutmann AThompson DF Democracy and Disagreement. Cambridge, Mass Belknap Press of Harvard University Press1996;

Journal

Archives of Pediatrics & Adolescent MedicineAmerican Medical Association

Published: Jan 1, 2005

References