I have been reading/listening to Martin Buber’s classic work I and Thou (Ich und Du). I was encouraged to returned to this difficult book after several years by Ezra Klein’s podcast of a conversation with Jaron Lanier, one of the pioneers of virtual reality and the author of several books on the interaction between humans and technology. Klein always ends his interview with the same question, “Name three books that have influenced you.” Lanier struggled with the question. His first choice was James Carse’s Finite and Infinite Games: A Vision of Life as Play and Possibility. It took Lanier several minutes of conversation to produce two more titles. I was very surprised by his second choice which really made a lot of sense in the context of what he had been saying over the last 90 minutes. His second recommendation was Martin Buber’s I and Thou.
While listening to Walter Kaufmann’s translation of “I and Thou” on my daily walks I was being careful to hit the 30 second rewind as often as necessary to get as much understanding as possible out of the wisdom of Buber. One paragraph hit me “full on” like a blind sided open field block that knocks you for a flip. I got the message immediately the first time I heard it. Its wisdom became even more profound for me as I played it over and over again and then as I have read it many times. I am responsible for the bolding in the passage that captured my imagination:
It is said further that the “religious” man steps before God as one who is single, solitary, and detached insofar as he has also transcended the stage of the “ethical” man who still dwells in duty and obligation to the world. The latter is said to be still burdened with responsibility for the actions of agents because he is wholly determined by the tension between is and ought, and into the unbridgeable gap between both he throws, full of grotesquely hopeless sacrificial courage, piece upon piece of his heart.
Buber, Martin. I and Thou, Trans. Kaufmann (p. 156). Kindle Edition.
On most days I do not think of myself as either a religious man or an ethical man, although on everyday the better part of me wishes that I could accept myself in the more generous and wholesome definition of either category. It is sad to imagine that “religion” has become the source of so much pain in the world that if you describe yourself as religious you are quickly into a world of “apologetics” or dissuading others that although you hope, and have faith, that God is not dead, you are not forcing your opinion on them. What stood out for me was Kaufmann’s translation of the last words, especially “the tension between is and ought.”
Buber commends the “moral” or “ethical” man but offers him little hope for success even if he throws his whole heart into his endeavors to fix what “is” that he sees “ought” to be fixed. I commend those of you who are “still involved in duty and obligations to the world.” Buber suggests that your tasks in healthcare are hard because actions required of you exceed your resources. Your labor is hard because you have not been granted the agency that you are due.
The tension between “..is and ought to be…” is Lean thinking. What “is” is imperfect and needs improvement. We call that concept “box 2” of the A3. What “ought to be” is “box 3.” I can see almost all of our concerns as tense relationships “between is and ought to be.” The struggle against gun violence by the students from Marjory Stoneman Douglas High School is a perfect example of such a “tension between what “is and ought to be.” Their efforts are full of heart as they plead for relief from the adults who theoretically have the agency to end gun violence if they would just act together.
The challenge of “is” to “ought” to be is what Buber called the “unbridgeable gap.” The combination of “is and ought” separated by a gap immediately reminds me of the 2001 call to action of Crossing the Quality Chasm. Given the fact that we have not even come close to the realization of the Triple Aim, Kaufmann’s use of “unbridgeable” in his translation rather than the phrase “insatiable gulf” that was the original translation in 1937 seems to fit our experience. A bridge to something better is a strong metaphor. Bridges come in many sizes and modes as is symbolized by the old covered bridge in the header. At their best they take you from where you are to where you need to be.
Once we are sensitized to the power of the concept of what “is” and what “ought” to be and have measured the reality of the unbridgeable gap, which we must believe is eventually bridgeable, we have a construct and language that we can use to think about issues like the ones that the Marjory Stoneman Douglas students are pressing us to address. We should also look at the inequities of our criminal justice system, the role of American policy in the issues of the global environment, our nation’s posture in the world’s affairs, the toxic economic inequities of our society, the confusion in issues of gender, the power that men exercise over women in the workplace, and almost any issue powerful enough to appear in the comments on Twitter and Facebook. The next questions become examinations of appropriate means, the sources of intent, energy and commitment, and finally an examination of the tensions between individual concerns and the creation of an inclusive community. The story of healthcare over the last seventy five years has been about the…tension between is and ought, and…the unbridgeable gap between both…
I often ask people to tell me about their healthcare. More often than my asking is the reality that as soon as someone learns that I am a retired physician I am offered their assessment of what is wrong with their care. The stories are personal and often disturbing but it is not a gross oversimplification to say that the majority of the stories could be filed under the concept of “I am treated like an ‘it’ rather than a ‘you.’”
My most consistent recent personal window into the world of the patient has been the medical adventures of my 97 year old father. Not long ago, less than a week after he had been discharged from the local hospital thirteen pounds lighter from a three day admission for dyspnea and leg edema, he was sent back to the EW after a nurse who was filling in for someone else who knew him better had thought that she had heard “crackles” in his lungs. Perhaps his weight was up three pounds. It was hard to know because he is unsteady on his scales. Since his discharge he had been tired and weak. He has been iron deficient and marginally anemic since his four unit GI bleed last fall which was followed a week post discharge by a readmission for aspiration pneumonia. He has gotten most of his nutrition since the aspiration through a G tube, but recently he has been doing better with his swallow tests and has begun to eat more. The progress is the result of the intensive focus of his wife and the attention of the therapist who regularly sees him to coach him on his swallowing.
The picture that I am painting is remarkable because he has been sustained, but never the less the difficulties that he has experienced with care have left him and his wife wondering why things must be so hard. As I have listened to what is described and personally observed much of it, my emotions are mixed. On the one hand I am terrified by the possibility of losing him and very thankful that the sum total of all that has happened has preserved him. I am also pretty sure that his care is a perfect example of overuse and misuse.
His survival is a function of his personal resources, the amazing facilities that are available to a man of his means, and the constant focus on his every need by his devoted wife who patiently suffers and sifts through all of the confusion and ambiguity of the conflicting messages of his care providers who never confer with one another. Not every man is so fortunate.
Many people in the same situation as my father would have died long ago. The knowledge that so many others don’t have the same resources that my Dad has leads me to the conclusion that our current “is” is not what it “ought” to be. It is impossible to make a system that is inefficient and difficult to use work better for just one individual, even a man like my father who has great support. Systems of care are so complex that they must be improved for populations, for everyone every time, or they will be reliable for no one anytime.
Bad systems are not discriminatory. Sure, those that have no access to any care are the ones who stand in greatest need, but cynical house officers have long known that the ultra luxurious hospital rooms reserved for the very rich in some of our most impressive institutions are often so gated from the hoi polloi that their barriers can create a distance from the care that the denizens of those luxurious surroundings really need. The very powerful and the very privileged suffer other people’s inability to be objective about them. The ultra privileged can suffer the unusual burden of too much care.
I have observed that the importance of what “is” and “ought” to be varies across all six domains of quality: patient centeredness, safety, timeliness, efficiency, effectiveness, and equity. Some would say the prime concern is safety. Others are concerned most with cost and value as manifested by variations in efficiency, effectiveness, and timeliness. But, I believe the hardest to achieve components of the six domains of quality, the ones for which the chasm between what “is” and what “ought” to be is greatest, are equity and then patient centeredness. Our ability to relate to our patients as a true “you” in dialogue and reciprocity with our medical “I” is a dramatic example of the gulf between “is” and what “ought” to be.
I believe our ability to cross the chasm from “is” to “ought” is more than a systems issue, but I also believe that the “noise” from our systems issues, and all the other issues that compete with healthcare for the attention of our leaders and the public, make the gap between “is” and “ought” much wider. The dysfunction in our systems generates burnout for our medical professionals and frustration for our patients. We can not build the bridges from “is” to “ought” without focusing on how dysfunctional systems widen our gaps and make it harder to engage all people, as “you.” But above all, we must see everyone, those with access and resources and those denied access and bereft of resources, as “you.”
Dr. Martin Luther King, Jr. was the greatest advocate of our age for treating everyone as a “you” and breaking down the barriers to equity that have existed as far back into antiquity as we can see. Fifty years ago he paid the price that is associated with efforts to lead us from “is” to “ought.” There can be much debate about how far we have moved “is” toward “ought” since Dr. King died on April 4, 1968. There can be no doubt that what “is” is still far from what it “ought” to be. We have not yet crossed the bridge to the other side.
