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Warren Kinghorn: Asking broader questions of medicine

Medicine needs physicians who can call on the Christian tradition to offer another way of thinking about human flourishing, sickness and health, says a physician-theologian.

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March 26, 2013

A knowledge of theology, whether acquired through formal education or life in Christian community, can bring much to the practice of medicine, said Dr. Warren Kinghorn, a theologian and physician at Duke University.

“Medicine -- and perhaps other professions as well -- needs people who are able to explore deeply the Christian tradition and make it relevant to medical practice,” Kinghorn said. “Someone with formal theological education can call on the Christian tradition to challenge certain assumptions within medicine.”

Warren KinghornKinghorn, an assistant professor of psychiatry and pastoral and moral theology, said those assumptions include the notion that illness, indeed all life, is simply a matter of which technique or technology people need to get the results they want.

“Medicine is much less adept in asking broader questions about what it actually means to flourish or to be healthy,” he said.

With its long history of asking difficult questions about human flourishing, health and illness, Christian theology can give practitioners the ability to challenge those assumptions, Kinghorn said.

Trained in both medicine and theology, Kinghorn has joint appointments at Duke Divinity School and the Department of Psychiatry and Behavioral Sciences at Duke University Medical Center. He has a B.S. from Furman University, an M.D. from Harvard, and M.T.S. and Th.D. degrees from Duke.

Kinghorn spoke with Faith & Leadership about medicine and theology and the role that Christianity can play in shaping the practice of medicine. The following is an edited transcript.

Q: During medical school at Harvard, you took a couple of years and came to Duke to complete a master of theological studies degree. Why?

I started medical school in the fall of 1997 with a great deal of enthusiasm for medicine. As someone who grew up in the church, I also had a strong desire to think theologically -- but little training in how to do so.

As a first-year medical student, I was mostly learning about how to read medical literature and the kinds of issues that physicians deal with. But I also did some shadowing at an alcohol detox facility in Boston and met people who were struggling with addiction.

I wondered how to make sense of that as a Christian. Is alcoholism a sickness? Even then I understood the medical literature around alcoholism.

Or is it sin? And if sin, then in what way, and what do I mean by sin anyway?

I realized that I didn’t have any categories to make sense of how to think about alcoholism in relationship to the moral agency of a Christian.

I needed to know more. So I went to the Harvard Divinity School library and for the first time in my life read about the fourth-century debate between Augustine and the Pelagians. I realized that there was this deep, rich conversation around the nature of sin and the degree to which humans are bound or not by sin.

Although I didn’t understand how to make sense of the question of alcoholism, I realized that the Christian tradition has this 2000-year history of asking difficult questions about human agency, flourishing and illness, about how humans die and how humans live. I wanted to know more.

Q: So this ancient conversation you stumbled upon had relevance for modern medicine?

Absolutely. The questions that Augustine and the Pelagians argued about are absolutely relevant to questions around the disease concept of alcoholism. Are humans bound in sin? Can we pull ourselves up by our bootstraps? To what extent can we be caught in structures that limit our agency?

Later, I read about the disease concept of alcoholism and learned that alcoholism has a particular social history in the United States. It went from being seen predominantly as a moral, spiritual, religious and, sometimes, criminal issue to being seen in the 20th century as a medical issue.

Yet it’s complicated. Alcoholics Anonymous itself has a religious logic. These concepts of sickness and sin are still with us and still affect the way that culture relates to people with addictions, and how physicians relate to people with addictions or with mental or physical illness. I wanted to learn more about how Christians had thought about these questions as a way to then do so as a practicing physician.

Q: After you completed your M.T.S., you finished med school, returned to Duke to do a residency in psychiatry and then decided to get a Th.D. Why? What made you want to come back and do a Th.D.?

When I did the M.T.S., I didn’t plan to do a doctorate in theology. I wanted to be a practicing physician who was theologically trained.

But several faculty encouraged me to think about how my vocation could be of service to the church. I realized that I wanted to be involved in scholarship and teaching at a university level, and in pastoral formation, teaching in a divinity school. So to do that kind of work, I decided to get a Th.D.

Q: What does a theological education bring to the practice of medicine? In what ways can it help prepare a physician?

Every Christian physician needs to have a theological view or context in which they practice their vocation -- though not all physicians need to have formal theological education or training.

But with that said, medicine -- and perhaps other professions as well -- needs people who are able to explore deeply the Christian tradition and make it relevant to medical practice. Someone with formal theological education can call on the Christian tradition to challenge certain assumptions within medicine.

Physicians who are able to engage the Christian tradition can also help medicine recover some of the moral sources that have sustained the care of the sick and dying for centuries. For example, the charity hospital evolved in the Mediterranean in the context of Christian monastic institutions in the fourth century.

Christians have long sustained those forms of care, and that’s what’s sometimes in danger of being lost in our modern, business-oriented practice of medicine.

Q: So theological training can help a physician to see and to name the assumptions that otherwise go unseen in medicine?

Yes. Training in medicine is a distinct process of moral formation and formation of the imagination. Like any process of disciplined training, it both creates new possibilities for imagination and constrains the imagination.

The medical model in general -- the way that we interpret pain and suffering through the language of pathology, prognosis, epidemiology, treatment and cure -- absolutely dominates modern biomedicine and leads to this heavily instrumentalized understanding of human suffering. It is very hard to even imagine medicine otherwise unless one has a different kind of sustaining community that makes that possible.

You don’t have to have formal theological education, but you do need some alternative community that provides a sense that the logic of biomedicine is not the only way to think about human flourishing and sickness.

Q: You just touched on this some, but what are the challenges in integrating a Christian calling in the world of medicine?

Biomedicine in America is rooted in certain givens that are largely unquestioned. One has to do with how physicians think. Medicine encourages clinicians and patients to think in very instrumentalist ways -- “I have something that’s wrong with me, and I need the right technology, the right technique to cure it.”

It encourages people to see all of life as a question of what technique do I need to get where I want to go. Medicine is much less adept in asking broader questions about what it actually means to flourish or to be healthy.

I was in my third year of psychiatric residency before anyone in an academic setting ever asked, “What is health?” It’s ironic. We’re in this world of health care, and yet the question “What is health?” is rarely asked in any robust way.

That’s partly because if you begin to ask normative questions about what it means to be healthy, then you get into questions of value. You press up against religious and theological conceptions about what it means to live a flourishing human life. And medicine, which sees itself as a neutral institution that doesn’t take sides on these value questions, tends to back off.

That allows individual patients or physicians to set for themselves their own particular ends, and the only focus is on the instrumental questions, the questions of which technique or technology to use.

But that’s unsustainable, because it means that particular conceptions of health can be inserted by anyone who wants to. So advertising, the pharmaceutical industry, various commercial interests that have a stake in the medical system begin to shape what we understand as health and flourishing.

Theology gives us the ability to call that into question.

Another challenge is the way medicine deals with questions of religious faith by bracketing them into the worlds of “spirituality” or “personal commitments” that aren’t allowed to inform the way that medicine is practiced. That is very hard to get outside of if one is in medicine.

How do you think about a theological view of medicine that doesn’t become marginalized through the language of spirituality, that makes a difference for the way that medicine is practiced?

For me, the question of Christian vocation is not tied up in my spirituality. It’s tied up in how I understand excellence in medical care. How do I be an excellent physician? What is excellence?

Christian vocation allows me to see myself as an integrated whole, practicing medicine in a way that seeks the good for my patients and that embodies this sustainable practice for the culture as well.

Q: What are the places, the issues, in health care and medicine that would benefit from this kind of Christian formation?

We have an immensely expensive health care system. No one has any clear idea how to decrease costs or how to set boundaries, in part because we don’t know how to ask questions about the role medicine should play in a good, flourishing life. We don’t have the ability to stand back from medicine and ask those kinds of questions.

Also, within medicine itself, there’s widespread discontent, which I think reflects a moral or even spiritual discontent. A recent survey found that 45 percent of physicians show signs of burnout and 37 percent have symptoms of major depression.

There’s certainly increased dissatisfaction with parts of managed care, with litigation, with increased demands of time efficiency. There’s also a cultural shift, where medicine is increasingly no longer seen as a calling but as a job.

All this dissatisfaction has a number of causes. The Christian tradition would say this is at least partly a problem with theological dimensions. Christians engaged in health care need to remember that the sick need care because Christ is in the sick. The sick person, the dying and the mentally ill are where Christ is. That doesn’t provide all the answers, but it provides a way to go on.

Often, Christian physicians, like other medical practitioners, are so focused on finding the right techniques or technologies to control the body that we forget to ask basic questions about what the body is for and what human life is for, what a well-lived life looks like. Those are the kinds of questions that can be transformative for physicians and for relationships between physicians and patients.

The Christian tradition also has the ability to sustain care of those who aren’t wealthy or pleasant, because Christians recognize that we also stand in need of grace. The person in the emergency room at 2 a.m. who is cursing and malodorous and spitting on clinicians is not ontologically different from us. We have been given grace, and we still need grace.

Christ is in that person, too. So when we care for that person in the ER at 2 a.m., we are caring for Christ. The Christian tradition can illumine all of that in ways that can help sustain medicine as a moral and spiritual practice.

The Christian tradition also is very clear that physicians are not in medicine alone but, like all Christians, are part of a larger body, the church, which has as its mission the reconciliation of the world to God. And so the question is how to help congregations to own that and to support physicians and to sustain medicine as a practice.

Q: How did you work through the process of vocational calling and decide on medicine?

I don’t know that I had a clear sense of call when I entered medical school. For me, it’s been a process where I walk into new opportunities, experience what it’s like to inhabit the role and the practice of medicine, and then see opportunities for beauty within that and pursue them.

I’ve changed course several times. When I came to the Divinity School, I thought I was going to be a primary care physician, and when I left I was interested in psychiatry, because of the kinds of human questions that psychiatrists engage in daily.

Q: Did each of these experiences feed the other? Med school fed divinity, which fed medicine, which fed divinity?

Absolutely. My training as a theologian has always been in the context of my vocation as a physician. And my training as a physician has always been informed by my theological training in ways that are hard to separate out. It’s one integrated whole.

It doesn’t mean that my medical practice is always about theology. But it does mean that my Christian commitment always informs, and motivates, the way that I understand what it means to practice psychiatry well.