Michelle Munyikwa // One of the first pieces I ever wrote about the practice of medicine was about vulnerability. At the time, I was concerned with how understanding vulnerability as intrinsic to care might help us communicate more effectively with patients. We might imagine how, if physicians found it easier to embody vulnerability, they could to come into relation with their patients in a way that honored the potential for mutual acknowledgment and recognition. The capacity to acknowledge, rather than disavow, their imperfection is important for physicians developing the capacity to admit culpability, or to utter those banished words: I don’t know. An adequate exploration of shame, guilt, and vulnerability is vital to being a doctor. It enables us to meet our patients where they are, and it allows for us to think about the consequences of our actions more fully, with open eyes.
Today, I want to talk about how understanding vulnerability, guilt, and shame is vital to enabling the physician to act as an advocate. I believe that one of the primary hurdles that doctors must overcome in the journey to effective advocacy is a tendency to strive for perfection and invulnerability. Thinking through relationships to shame, guilt, culpability, and complicity allows us to consider ourselves more fully as flawed political actors, enabling us to act as advocates for a different world for our patients and ourselves alike.
In recent months, there has been a renewed recognition of interpersonal and structural racism in the United States sparked by the disproportionate impact of COVID-19 in Black and Brown communities and state-sanctioned violence against Black and Brown people. I cannot do justice to the scope of this ongoing revolution, which has been fueled by the courage of activists around the country, particularly those who have been working in the background between each spectacular crisis.
During this time of more intense reflection about racism, inequality, and complicity in America, I’ve had many conversations with friends in medicine who express an uncertainty about what to do. They don’t know the right answers for this moment. They dwell, uneasily, in the uncertainty.
For many, this uncertainty is profoundly awkward. Coupled with the tenuousness that is inherent in living through a life-transforming epidemic, it unsettles a sense of permanence. In addition, medical culture encourages perfectionism and the performance of confidence. To not have the answers is unsettling for those inculcated into a culture which punishes uncertainty. Finally, after years of focus on medicine to the exclusion of everything else, often including sleep, eating, and basic self-care, people in medicine often feel ill-equipped to address non-clinical aspects of care and advocacy for our patients.
So, what is a doctor to do? Of course, they can – and should – read, watch, and listen. There have been many reading lists specifically geared towards physicians with recommendations that address racism and discrimination in medicine, the colonial character of medicine, and medicine’s participation in coercive structures of sexual violence and gender construction, to name a few. Physicians must, of course, do the work of educating themselves about the systems that they participate in. If we are among the many stewards of the health of our communities, it’s imperative that we educate ourselves about all the issues that face our patients.
That said, cognitive transformation alone is not enough to change the world we live in. If it were simply a case of knowing better, our society would look much different than it does. If all we needed was an encyclopedic knowledge of the disparities associated with the social determinants of health, or the fundamental understanding that the racialized and gendered distribution of resources is at the core of most of the suffering we see, then we would have “solved” our problems years ago. Injustice is at once structural and individual, and it is fueled, in part, by our investments in our lives as they are currently structured. Changing our world requires us all to engage in personal ethical transformation, and understanding how to do this work is much trickier and complex to understand. Calls for introspection can easily slip into solipsism, and we must be very careful about how we turn inward. Questions we might ask ourselves include: How do I do the work of inner transformation necessary to make myself a more effective agent of social change, especially in small, less spectacular ways? How do I show up more effectively in the spaces I am in? How do I develop my courage? How do I resist the pull of the quick fix?
One of the primary impediments to this transformation is the deep desire to disavow our connection to suffering. We live in a world saturated with violence and despair, and many of us desperately wish it were not so. We also often desperately wish we had nothing to do with it. The notion of the “good person” who isn’t racist, shops ethically, and follows the right people on social media is extremely seductive. At the same time, simply living in the United States and purchasing anything puts us into relation with structures of domination.
Here, Alexis Shotwell’s work on politics, purity, and guilt is helpful for thinking about accountability and a more livable future. She suggests, drawing from the work of many others, that a major impediment to justice is the drive to purity, for example through norms around ethical consumption and the desire to use products that promise to be pure of suffering and toxins at the same time. Shotwell also frames shame as a recognition that your life is inescapably entangled with the harm that has been done to others, and that this has something to do with who you are in pervasive and surprising ways. This recognition is inescapable; it permeates everyday aspects of life in places like the United States and Canada, settler colonies whose very existence is dependent upon genocide. Her work is an attempt to think about how to reckon with that every day in ways that don’t involve disavowing or attempting to cleanse or avoid that stain through individual practices.
She urges a turn toward collective action rather than individual culpability. Of course, Black feminists and queer activists have long urged us away from the tendency to valorize individuals at the expense of community. They remind us that the hard work is in collective solidarity, and the ethical struggles and interpersonal quandaries that such struggles entail. These movements teach us to think with complexity about matrices of domination that apply to us in ways that are different but which leave none of us untouched by their machinations. Doctors and other health professionals must continue to think about how, in the wake of this devastation that has again laid bare persistent inequalities, they can explore with vulnerability what that means.
Ultimately, advocacy as a physician is less about certainty, expertise, and perfection than it is about the inevitability of complexity, complicity, and vulnerability. Apart from our basic personal complicity as humans in a world whose suffering is not separate from us, we have a particular complicity as physicians. There are few of us who are not implicated in institutions whose actions in their communities are ambivalent at best and deeply violent at worst. Rather than cleansing ourselves of that imbrication through disavowal, we must continually acknowledge that complexity. We should remember that, as affiliates of violent institutions, there is no reason for communities to trust us. Further, many of us maintain emotionally-laden professional attachments to the benefits of these institutions even as we decry them and their actions.
Finally, I believe that a recognition of physicians as entangled in the worlds we operate in includes aligning ourselves with the struggles of other workers. Specifically, this involves the development of class consciousness among physicians and a sense of our interdependence with other healthcare workers without which the American healthcare system would not function. It involves understanding that there are many possible futures, but all the just ones involve us relinquishing much of what we hold dear. It involves performing a kind of radical uncertainty and openness to change, challenge, and calling-in that is frankly uncommon in medical culture.
That isn’t everything, but it’s a start.