Sometimes it seems that I am a member of a dying profession. Increasingly stripped of my autonomy to govern my own affairs and no longer the keeper of “medical secrets,” my profession of medicine is under siege, some might even say defeated. Overrun by financial and bureaucratic interlopers, the sacred space between physician and patient has become crowded with agendas that seem to have little to do with the process of healing. Along with my fellow physicians, I have decried the emergence of a medicine that has become devoid of meaning. This essay describes my journey toward rediscovering the meaning in medicine—and what lessons the dying and the long-since dead have held for me.

At first blush, it all seems very strange. Why this pessimism? Why this sense of professional impotence? One survey after the next describes demoralized and dispirited physicians eager to find an early backdoor into their retirement. How did this happen? Are we not part of the scientific miracle of medicine? Are we not living through the golden age of medical advancement? The human genome has been mapped and our genetic “dirty laundry” will soon be laid bare for spring cleaning with the promise of future generations of perfect babies born without the original sin of genetic time bombs waiting to explode. We have the technology to combat infections, transplant organs, elevate moods—the possibilities seems unending. So why the pessimism, the nagging sense of disease, the deep desire of so many of my colleagues to escape this future life of apparent scientific omnipotence? Why during this gilded age of science have our patients so little faith in our intentions? Can they not see what we have delivered them? Or can they?

To paraphrase Joseph Campbell, it seems as though we have climbed to the top of our medical ladder and discovered that it is resting against the wrong philosophical wall. Sherwin Nuland put it well in an article in the New York Times when he wrote: “These are heady days for those who devote their lives to the study of human biology, and for the many who may benefit from those studies. There is intelligence enough, and some brilliance too, in this new era of medicine. What about wisdom?”

But you know, despite the problems, I do not want to give up the practice of medicine. Each time I think of giving up, or giving in, I remember that day I graduated from medical school, when my world changed in some deep sense … because I felt in some mysterious way that I had entered a very special place … had been given an opportunity to make some kind of difference … to leave the world a little better place. It's hard to remember those feelings … there seems to be little space for meaning in the corporate bottom line.

So confused, bitter, angry, and sometimes despairing I have searched for the old wisdom of my profession. The old teachings that I believed would make sense of my confusion and plot the course for a way back to meaning. At first my medical elders informed me that medical ethics would hold the key. I read about autonomy, beneficence, justice, and nonmalfeasance. All a well-constructed moral template for my work … it left me empty … safe but empty. For what I found in the modern bioethics was not the deeper meaning of my work but rather a recipe for the management of anxious situations. It is not that these concepts are wrong … they are just not enough.

So, confused and angry I have sought teachers and found them. Long dead, dying and dead. They were not what I expected.

What I hope to be able to do in this brief essay is share with you my own way back to a forgotten ethics of experience. To the foundations of the healing art. To the development of an ethics that is capable of sustaining the art of medicine and providing a framework of meaning capable of containing the power of the science we are unleashing.

What I am suggesting is not some new school of ethics but rather a return to its beginnings. We are, I believe, in the center of a perennial dilemma and one that has been at the center of ethics since its beginnings.

Early in his life, Socrates had been an enthusiastic scientist, immersing himself in the natural sciences of his day. Soon however, he became disillusioned with the mere acquisition of knowledge. Rather, Socrates searched for the experience of universal truth and a deep knowledge that transcends mere opinion. Socrates searched for the morality of experience, not conviction—for the experience of the sublime in the ordinary. Socrates believed that the intellectual pursuit in itself could provide a doorway to the experience of good and ultimately to the human soul. For Socrates, philosophy was less with knowing the right answers than with the strenuous attempt to discover these answers. Through his method, Socrates brought about the synthesis of Eros and logos—of passion and mind. As Cicero said some three centuries later, Socrates had “called down philosophy from the skies and implanted it in the cities and homes of men.” Through his method of intellectual discourse Socrates had discovered the contemplative act of the intellect that was capable of transforming the ordinary into the sublime.

The depth of Socrates' dedication to the view that experience paves the way of the individual path to the soul was such that he was willing to sacrifice himself to hemlock rather than compromise himself to the Sophist doctrine that knowledge (like medicine today) was a commodity that could be owned—the stuff of commerce.

Socrates was the next evolutionary step in the developing modern mind. His philosophy melded together the fragments of the archaic that had been torn apart by the naturalists, the rationalists, the atomists, and the skeptics. Rather than devaluing each of these schools, Socrates stated that they were in themselves inadequate—that true understanding of the world could only be achieved through the experience of their particular inadequacies and the philosopher's practice of self-reflection. “The unexamined life is not worth living.” Dogma is not enough, stated Socrates—experience is the stuff of true enlightenment. But perhaps what was most important about the Socratic philosophy was its fundamental belief in the nobility of man—the belief that man held within himself the potential for grace. Rather than believing in man's fall from grace, Socrates and his intellectual progeny envisioned man as moving toward grace. This belief in the grace of man, rather than a preoccupation with his potential for sin, has perhaps become the central theme of our ethics and its relationship to science.

The modern dialogue on bioethics can probably be traced to 1836 when the young Charles Darwin—then just 27 years old and returning from the Galapagos in the HMS Beagle—began to record in his notebooks his radical new ideas about the evolution of species. Darwin unleashed many debates but the one most pertinent to this discussion was the controversy his work ignited around the earlier work of Thomas Hobbes and his book Leviathan. In his polemic, Hobbes argued that man is in a constant struggle between his animal nature and his higher moral sense. Hobbes argued that political and social systems must be constructed to protect society against the base nature of man and that man's moral sense is what separates him from animals. What Hobbes was suggesting was that at his core man is driven by hostile intent and is constantly caught up in a conflict of nature versus nature. According to the Hobbesian view, ethics is necessary to “save us from ourselves.”

Darwin's theory of natural selection appears at first blush to support the Hobbesian worldview for it suggests that through the survival of the fittest modern man was the product of some pretty nasty behavior. Brother, it seems, must have been forced to turn against brother to insure the survival of the fittest. Building on this position, later philosophers and scientists, including Thomas Huxley and Richard Dawkins, suggest that ethics cannot be founded on human nature because of the unbridgeable gap between the selfishness of our natural inclinations and the necessary selflessness of our moral duties. This philosophy suggests that our intuition is not to be trusted and, since it cannot be trusted, what becomes trustworthy is not what we experience but what we construct with our thoughts. The “cynical school of philosophy” has remained constant in its distrust of nature and experience.

The beginnings of modern science gave new impetus to the Hobbesian worldview. Provided with an increasing avalanche of scientific data, the Enlightenment philosopher began the dissection and reconstruction of the human experience. What had been Galen's life force became oxygenated red corpuscles. What had been the mystery of conception became a fertilized ovum. As Jung put it, “The gods have become diseases: Zeus no longer rules Olympus but rather the solar plexus, and produces curious specimens for the doctor's consulting rooms.” Unlike Socrates, the modern scientist/philosopher had not brought the gods into the lives of men, he had slaughtered them—and replaced them with a code of ethics and a manual. Each new discovery became both a gift that improved the lifestyle but also a potential problem, even weapon.

Frightened by this piecemeal dissection and fragmentation of the human experience and harking back to a Socratic worldview, the Romanticists, including Rousseau, Shlegels, Schiller, Coleridge, Keats, Wordsworth, and Whitman, sought refuge in the irrational—in intense feeling and a sense of union with nature. In what Wordsworth called “the spontaneous overflow of powerful feelings.” Whereas for the Enlightened scientific mind nature was an object for observation, for the Romantic it was the live vessel of the spirit, the playground of the irrational.

But the Romantics made one fatal mistake. Through their attempts to move backward to the primal experience of life they had lost sight of the fact that Darwin was right—evolution continues. You cannot turn back the hands of time. Any philosophy must be capable of embracing this change.

Now into this modern era came a school that appeared to appreciate this fundamental fact. The belief that man is evolving and that all his scientific discoveries bring us potentially closer, not further, from God. Toward the summum bonum, the ens perfectissimus, homo sapientissimus. The Idealists, whose school was founded on the work of Schlegel and Hegel, suggested that there could be “no going back,” no “return to nature.” What they suggested was that the answer lay in combining the prerational approach of the Romantics with the rational materialism of the Enlightenment school. This was, it seemed, a remarkable insight and a way through perhaps to a future where science, the arts, and ethics could all become lovers in the same philosophical bed.

However, within just a few years of Hegel's death, the Idealist philosophy had withered on its intellectual vine. So what had happened? How could such an intuitively satisfying philosophy have perished? The simple fact is that the Idealists just could not deliver the goods. Although they spoke of a unifying vision, a transpersonal experience that unified both the intellect and the spirit, the Idealist had no practical means of proof. Unlike the Romanticists, who found validation in their experience of the brief ecstasy found in ritual chants and potions, the Idealists had no contemplative practice capable of bringing forth the sublime. As Ken Wilber points out, they lacked a technology … “yoga” capable of penetrating the depths and heights of their philosophy. They became a system without a means of verification—mere metaphysics and easy cannon fodder for the rational scientific mind.

And all this time the rational materialists marched on. Marched on to the wasteland of postmodernism where reality is not universal but constructed. A postmodern world in which there is no objective reality … just interpretation. A world where, as Alice said in Wonderland, “everyone's a winner and everyone gets a prize.” A philosophy that massacres meaning and leaves us each to fend for ourselves in a world where nothing stays the same.

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When I reached this point in my readings it seemed my optimism collapsed. I had been searching for meaning only to be told that it could not be found. It seemed that I would have to construct the meaning for my work out of the context of my managed care contracts, treatment algorithms, and the inconstancy of a neuroscience that changed with each new research report.

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And then I met my teachers. I had met them before but had not recognized them. Like little Yoda in Star Wars our real teachers come in the most unexpected packages waiting for the student's eyes to recognize them.

They were Dolores—the woman who had built a life around her strength only to find it being corroded by the cancer in her breast. Tim—the man in torment, beaten down by the intractable pain of his gastroparesis … the man who had become the medical pariah because his pain would not relent. The man who called me to his deathbed … simply to hold his hand. Steve—the man whose intractable depression I had cured only to find that after years of expensive treatment he was destitute and estranged from life. Who killed himself not because he was depressed but because the clarity of his suffering had only increased with the cure of his disease.

Dolores taught me about the nature of suffering. That suffering is not about disease but about our disconnection from the things that are important to us. That each of us infuses our life with some metaphor that makes sense of all of this. That for Dolores, child of a broken home from a minority group, what gave her life meaning was a sense of being important, of being the foundation stone of something larger than herself. She had built around her a community identity as the rock upon which they launched their ships. When the cancer came it seemed it crippled her belief in her invincibility and exposed the raw nerve of her inner experience that she was vulnerable and insecure. Left her feeling shamed by her illness and unable to accept help from those she had always helped. Led her to destroy all the connections that had given meaning to her life. Led to a lonely painful death where she would not accept even my help. Dolores taught me that healing is about being allowed to travel together along a journey to places that are most frightening to us. That healing is about the process of becoming whole through a transformation of our self to something complete, not better, just complete. Dolores never healed for she could take on the challenge of accepting herself—the strong and the frightened she believed could not co-exist in the temple of her life.

Tim taught me the power of myself, and not my medicine, to relieve suffering. Taught me that it as at those times when I feel most helpless as a physician that I become most powerful as a healer. Forced me to conclude that perhaps Hippocrates had been wrong when he had taught that medicine should be the silent profession founded on scientific observation. When he asked me to hold his hand, not provide analgesic relief, Tim brought us back to the sacred lineage of healing that binds us to that first caress between a mother and her distressed child. Brought us back to the courtyard of Aescalipius where the statue of Venus stood.

Steve taught me that healing is a frightening and painful experience for both the healer and the healed. That disease is not the same as illness. That disease sucks up meaning from our lives and that it is the healer's task to find that meaning and the transformation it demands. That there are no guarantees and that if I am to take on the task of healing I must be willing to experience my patients' pain and travel with them to the dark places … the dark night of the soul. Steve opened me to the experience that in the process of healing both the healer and the healed are inevitably transformed. I cured Steve's disease and he killed himself. It shattered my belief in the ultimate power of medicine. It humbled me, it frightened me, but eventually it freed me from my irrational belief that medical science could ever be omnipotent.

It was no coincidence that my three greatest teachers were each dying. As a physician, death was the only thing that I felt truly helpless about—the only part of the human machine that I couldn't fix. These dying patients forced me to move from doing to being. Forced me to enter their experience, not observe their disease.

And so I had these and many other great teachers who forced me through experience, not knowledge, to confront my practice of medicine and to search for further wisdom that could make sense of these experiences. I found that wisdom in Joseph Campbell's mythological quest for the Hero whose story is told in every language and culture. I learned that the art of medicine represents the hero's journey of awakening to the calling, a journey to the unknown, painful transformation and a return to service in the community.

But perhaps the greatest lesson I learned from my teachers was the power of compassion. That what makes healing possible is the capacity for empathy that awakens us to the subjective experience of our patients and not the observation of their disease. That empathy is not the same as compassion, for compassion requires action. Through compassion the patient's suffering becomes the healer's suffering and the motivation for action. Compassion makes it impossible for us to abandon our patients in their deathbeds. Compassion demands that even if we cannot cure … we can always care. Compassion demands advocacy, activism, and passion for the work of healing … in short, compassion demands that medicine become a calling not a profession. Compassion demands sacrifice, but also promises to bring meaning to this work of medicine.

My dying teachers taught me that Socrates was right. In order to find meaning in our work as physicians we must once again begin to experience (Eros) the art of healing and not retreat to a world of sterile scientific fact (logos). Simply stated, I believe physicians must begin to ask themselves “What should we do for our patients and community” rather than “What could we do with our scientific knowledge.”

I believe that the care of the dying patient, as a moral crawl space where issues of meaning, virtue, and calling cannot be disregarded, will become the philosophical battleground for the future of allopathic medicine. The HIV epidemic is now ripening in Africa and the world will soon witness death in numbers never seen before. Like other plagues this one will not leave society as it found it. I wonder what ethical position we will construct to sanitize our horror as we watch on television as a continent dies of neglect—bereft of scientific miracles too expensive to share. Will we retreat into “heady” scientific explanations and economic justifications, or will we be motivated by the experience and search for ways to refocus our intent and steer our science toward compassion rather than dominance.

Palliative medicine with its focus on addressing the patient's experience of suffering offers allopathic medicine an opportunity to rediscover the Socratic ideal. Most importantly, palliative medicine provides the philosophical foundation for a wisdom that is capable of containing the enormous power unleashed by the scientific method. Palliative care has brought me to an appreciation of the “ethics of experience” and a doorway to rediscovering the mystery and meaning that first led me to becoming a physician.