The question of Being, to return to philosophy — because the first question of philosophy is: What is it “to Be”? What is Being? The question of being is itself always already divided between “the who and the what.” Is Being “someone or something”?
—Jacques Derrida (2002)There are many challenges that face clinicians who choose to work or train for a career in palliative medicine. There is of course the challenge of mastering various medical diagnostic and treatment skills. There is a growing body of evidence based medicine in the field of palliative care, and most training programs in palliative medicine spend an appropriately significant amount of time teaching trainees to become expert diagnosticians and clinicians. It soon becomes obvious, with clinical experience, that skills in sensitive, empathic and effective communication with patients and families also are extraordinary vital to master if one is to have a career in palliative medicine. Goals of care, and how a clinician measures “success, or failure” are also critical to an understanding of one's identity as a palliative care clinician. Often, a conscious dedication to minimizing avoidable suffering rather than prolonging life at the cost of suffering becomes the mark of provision of “good care.” In this way patient deaths are not the metric of meaningful and significant work, but rather the manner of death and one's ability to ameliorate suffering is the measure of the quality of one's skills. These are all such complex and challenging skills and attitudes necessary to master in the process of training as a palliative care clinician, but we haven't yet even mentioned the problem of how palliative care clinicians manage their own death anxiety and their grief while bearing constant witness to death day in and day out.
It was these latter problems of dealing with the impact of confronting death daily, and its impact on palliative care trainees, that the palliative medicine fellowship training program director asked me to try to find some way to help our trainees with these issues. What we started out with was a series of individual meetings (or debriefings as we called them unofficially) between the palliative medicine clinical fellows and myself, in my office at the cancer center. I recently completed the first series of such meetings, which are planned quarterly, and I find myself reflecting on these meetings with a sense that while I may have been of some help to these trainees, I left with the gift of a new understanding of the “creative” process. By that I mean the process by which we as human beings respond to our existing by creating a life and becoming who we aspire to become in the world.
Invariably, in addition to discussions of personal death anxiety, managing the experience of grief over patient deaths, and the notion of existential guilt related to perceptions of a good clinical outcome, our discussions touched on the question of why the trainee chose palliative medicine as a career, and how that choice fit into their notion of the trajectory of the lives that they were creating. What became clear rather quickly was that most of the trainees were focused on becoming a “good palliative care clinician.” They had great difficulty in even grasping the idea of the notion of becoming a person with a set of values and passions that did palliative care medicine as their work, but also held creating a family, or dedicating their lives to some greater cause. This was too abstract for them at first. Jacques Derrida (Reference Kamuf1991) would often discuss the importance of the distinction between “the who and the what” (le Qui et le Quoi). Do you aspire to become a “who” or a “someone” in the world, or do you aspire to become a “what” or a “something” in the world. Derrida found the notion of “qui ou quoi” (who or what) especially important when it came to the concepts of ‘Love” and of “Being.” In the documentary film Derrida (2002) he speaks of Love and Being in the following way:
One of the first questions one could pose … I'm just searching a bit … is the question of the difference between the who and the what. Is love the love of someone or the love of something? Okay, supposing I loved someone. Do I love someone for the absolute singularity of who they are? I love you because you are you. Or do I love your qualities, your beauty, your intelligence? Does one love someone, or does one love something about someone? The difference between the who and the what at the heart of love, separates the heart. It is often said that love is the movement of the heart. Does my heart move because I love someone who is an absolute singularity, or because I love the way that someone is? Often love starts with some type of seduction. One is attracted because the other is like this or that. Inversely, love is disappointed and dies when one comes to realize the other person doesn't merit our love. The other person isn't like this or that. So at the death of love, it appears that one stops loving another not because of who they are, but because they are such and such. That is to say, the history of love, the heart of love, is divided between the who and the what.
The question of Being, to return to philosophy — because the first question of philosophy is: What is it “to Be”? What is Being? The question of being is itself always already divided between the who and what. Is “Being” someone or something?
So in reflecting on my discussions with the trainees, I noticed how many of our young and brightest, those who in fact choose the amelioration of suffering as their life's work, find it so much more comfortable to talk about becoming a “Something” than a “Someone.” One of the trainees, after realizing this, bemoaned the usual party chatter or ritual that takes place when we first meet someone; we ask “what” do you do? We don't ask “who” are you? Although several trainees laughed that that is in fact what they really want to know ultimately. Perhaps it is a culturally induced myopia of some type; quite paradoxical when it is occurring at a time of unprecedented personal freedom in the history of man. But it does seem to be ubiquitous. Media bombards us with images of attainment and “goals of life” that are primarily materialistic and representative of what we are supposed to have and look like and drive, etc.
It is ironic that when we speak of “end of life care goals” for our patients we are much more focused on preserving the “who” of the patient, preserving the someone who that patient has been in life and allow that to be what is most meaningful and significant as they face death. Those of us who are responsible for the training of young palliative care clinician would serve them well to help them understand that their “Life Goals” should also incorporate the who, the someone they want to become and create, not merely the what, the type of clinician they want become. This requires an opportunity for trainees to reflect on who they are becoming as human beings in this world and how palliative medicine is just one important expression of who they are becoming through the process of training. Perhaps such an understanding would help our trainees become more comfortable with communicating with patient on a human level, with the knowledge that we are all in the same existential boat, both mortal human beings. The main difference being that we as palliative care clinicians have knowledge, skills, and experience that we can share that may ultimately relieve suffering. After all, that is “who” we are.
