EP. 166: WHAT IS MEDICINE FOR?
WITH DEVAN STAHL, PHD
A bioethicist explores how Silicon Valley’s pursuit of the beyond-healthy human raises questions about the purpose of medicine — and explains how disability ethics can keep doctors on track.
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In recent years, Silicon Valley has imagined for us a new way of life – one where almost anyone can be a twenty or thirty-something-year-old with a supernatural glow, toned physique, understated intelligence, and a superabundance of vitality. This is not reality for most people, even for the twenty or thirty-something-year-olds, but medicine and technology originally intended to help people achieve baseline health are increasingly being leveraged to close the gap. This raises the question: what is medicine for? Is medicine about restoring people to some definition of “normal” health? And if so, what about all the people contentedly living in bodies considered medically abnormal?
Our guest is Devan Stahl, author, clinical ethicist, and professor of bioethics and religion at Baylor University. Professor Stahl received her PhD in Health Care Ethics from St. Louis University, before completing her Master of Divinity at Vanderbilt University. Her scholarship focuses on disability theology and bioethics, and her most recent books include Disability's Challenge to Theology (2022) and Bioenhancement Technologies and the Vulnerable Body (2023). In addition to her scholarly work, Stahl volunteers as a clinical ethicist with the Supportive and Palliative Care Team at her local hospital.
Over the course of our conversation, we discuss whether it is the role of a clinical ethicist to determine what is “right” in a given situation – and if so, how that is accomplished. We explore how Silicon Valley’s promotion of the “optimized” human raises questions about the purpose of medicine, and the various ways medicine defines the idea of “normal” health. Stahl shares her experience in the healthcare system as someone with multiple sclerosis, cautioning that some providers are more comfortable focusing on the digitized version of someone’s disability than on the person themselves. Together, we imagine a doctor’s role not just in restoring patients to normality, but guiding them to flourish.
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Devan Stahl is a professor, author, clinical ethicist, and podcast host. She currently resides in Waco, Texas with her family.
Dr. Stahl is a bioethicist and religion scholar with experience teaching bioethics, disability ethics, and medical humanities to undergraduates and graduate students as well as medical students and residents. Dr. Stahl also works as a clinical ethicist for Baylor Scott and White Hillcrest hospital, where she is a faculty member for the Supportive and Palliative Care Fellowship. She also runs a clinical ethics internship for graduate students at Baylor University.
Dr. Stahl received her Ph.D. in Health Care Ethics from Saint Louis University and her M.Div. from Vanderbilt Divinity School. Her research interests include disability ethics, medicine and the visual arts, and theological bioethics.
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In this episode, you’ll hear about:
3:19 - The questions that have driven Stahl’s academic career as a professor of bioethics and religion.
5:00 - The types of requests Stahl receives as a bioethicist at her local hospital.
12:51 - How Silicon Valley is skewing public perception of “health” — and the questions this raises about the purpose of medicine.
20:12 - Stahl’s experience navigating uncomfortable and confusing medical encounters as a person with disability herself.
25:24 - Stahl’s take on the “purpose” of modern medicine.
29:48 - Ways in which our society tends to value certain kinds of bodies over others.
39:36 - Imagining the role of physicians in helping patients flourish.
44:55 - How health care professionals can find deeper meaning in their work and lives.
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Henry Bair: [00:00:01] Hi, I'm Henry Bair.
Tyler Johnson: [00:00:03] And I'm Tyler Johnson.
Henry Bair: [00:00:04] And you're listening to The Doctor's Art, a podcast that explores meaning in medicine. Throughout our medical training and career, we have pondered what makes medicine meaningful. Can a stronger understanding of this meaning create better doctors? How can we build healthcare institutions that nurture the doctor patient connection? What can we learn about the human condition from accompanying our patients in times of suffering?
Tyler Johnson: [00:00:27] In seeking answers to these questions, we meet with deep thinkers working across healthcare, from doctors and nurses to patients and healthcare executives those who have collected a career's worth of hard earned wisdom probing the moral heart that beats at the core of medicine, we will hear stories that are by turns heartbreaking, amusing, inspiring, challenging, and enlightening. We welcome anyone curious about why doctors do what they do. Join us as we think out loud about what illness and healing can teach us about some of life's biggest questions.
Tyler Johnson: [00:01:02] In recent years, Silicon Valley has imagined for us a new way of life, one where almost anyone can be a 20 or 30 something year old with a supernatural glow, toned physique, understated intelligence and a superabundance of vitality. This is not reality for most people, even for the 20 or 30 something year olds. But medicine and technology, originally intended to help people achieve baseline health, are increasingly being leveraged to close the gap. This raises the question what is medicine for? Is medicine about restoring health to some definition of normal health? And if so, what about all the people contentedly living in bodies considered medically abnormal? Our guest is Dr. Devan Stahl, author, clinical ethicist, and professor of bioethics and religion at Baylor University.
Tyler Johnson: [00:01:54] Devan received her PhD in health care ethics from Saint Louis University before completing her Master of Divinity at Vanderbilt University. Her scholarship focuses on disability theology and bioethics, and her most recent books include Disabilities Challenge to Theology and Bioenhancement technologies and The Vulnerable Body. In addition to her scholarly work, Devan volunteers as a clinical ethicist with the supportive and palliative care team at her local hospitals. Over the course of our conversation, we discuss whether it is the role of a clinical ethicist to determine what is right in a given situation, and if so, how is that accomplished? We explore how Silicon Valley's promotion of the Beyond Healthy Human raises questions about the purpose of medicine and the various ways medicine defines the idea of normal health. Devan shares her experience in the health care system as someone with multiple sclerosis, cautioning that some providers are more comfortable focusing on the digitalized version of someone's One's disability than on the person themself. We touch on how society values some bodies more than others, and how not all people with disabilities consider themselves disabled. Together, we imagine a doctor's role not as restoring patients to normality, but helping to remove impediments to flourishing. Devan, thanks so much for being here and welcome to the show.
Devan Stahl: [00:03:18] Yeah, thank you for having me.
Tyler Johnson: [00:03:19] A lot of the people that we talk with, just by nature, of the kinds of conversations that we're having, the primary thing they do is they are active healthcare professionals, many of them doctors, although some of them nurses and other professionals as well. So I thought I would just start out by having you tell us what is your day job? What do you do?
Devan Stahl: [00:03:38] Yeah. So I might be a little bit different than your average interviewee. I am a professor of bioethics and religion at Baylor University. I teach undergraduates, graduate students and medical students. Bioethics and disability ethics. And I volunteer as a clinical ethics consultant at our local hospital. So I also take calls from clinicians and families when there are ethics issues that arise in the hospital. So that is a small subset of my job, but the majority of my job is spent researching and teaching.
Tyler Johnson: [00:04:10] So when you say that you are a professor of bioethics and a professor of religion, and you mentioned also also specifically disability ethics, but give us a little bit of an idea. What are the principal questions that have animated your academic career?
Devan Stahl: [00:04:29] Yeah. So I'm really interested in how we think ethically in clinical spaces. Um, this comes from experiences I've had as a patient, just sort of flummoxed by the way that I've been treated in medicine. And a lot of that is animating this idea that, you know, how is it that physicians, nurses, clinicians of all sorts should relate to their patients in ethical ways, and I'm particularly interested in disability as a disabled person. How is it that we might have biases in medicine around disability that can disadvantage people with disabilities in those clinical encounters?
Tyler Johnson: [00:05:05] So we'll come back to some of those things more in a minute, because questions arising out of that part of both your own biography and also your academic work are where I want to spend the bulk of our time. But before we get to that, can you just tell us a little bit? You mentioned that you are sometimes sort of on call for the local hospital as a person who can be called with bioethics questions. You know, I think that a lot of especially younger clinicians, at least in my I've worked in our our hospital here for many years. And in my experience, calling the bioethicist is one of those things that's like way off at the very end of the algorithmic tree, right? Like once you've done everything else you can think of to do, if you're just totally grasping at straws and have no other options, then that's when you call the bioethicist. So can you can you just talk to us a little bit about what does that part of your job look like? Like what are the kinds of calls that you normally get, and what do you do when you receive these difficult inquiries?
Devan Stahl: [00:06:01] Well, let me start off by saying, please don't wait until the problem that you've run into is terrible and intractable before you call me, because that like, you just set me up for impossible situations. So part of the way that I make sure that that doesn't happen is that I regularly round with my supportive and palliative care team. And so I'm hearing a lot of those cases really like as they arise, rather than when they become issues or problems. So I'm there like kind of just hearing how things are going with patients more generally. And so that's one way I can enter a conversation where maybe there's ethical issues that are arising that people aren't necessarily aware of. So I can step in and say, oh, that's really interesting about that patient. I wonder if you've tried contacting their surrogate yet. I wonder if we know who the person is to call. I wonder if we've talked with them about how that goal might end up this way, and are we foreseeing a conflict in that? So trying to catch things on the front end so that they don't become huge problems on the back end? So some of that's just experience, knowing how to see a trajectory that is common in some patient populations, that I can try to sort of guide people to, where there might not ever be an ethics conflict, because we've done all the good work on the front end. So that's one thing I do. But then the other thing I do is when there is an issue and people call me, sometimes that looks like, well, it always looks like looking at the chart and sort of seeing the bigger picture, because I know that one clinician's perspective on a case is not the entirety of the picture.
Devan Stahl: [00:07:32] So I look in, I see the kinds of notes that people are leaving. Sometimes that means I need to talk to a family or a patient directly and just say, hey, how are things going? Can you tell me about this? A lot of the calls I get are something like, we want to do this as a clinical team, but the patient or their family is really resistant. And so how do we get them to just see our side of it. So it's like how do we convince them to do what we know is right, which is not always my job, but thinking through how conflicts might arise in either providing care that is unnecessary or burdensome or even not beneficial to a patient. How do we say no to that? Or alternatively, sometimes it's the opposite. They don't want this, but we know it would really help them. And how can we force it on them? And of course, it's never said like that, but how can we just convince them that this is the right thing to do? Sometimes it's. Do we have a policy about this? Can you look it up for us? Sometimes it's does public health have something to say about this? So sometimes it's a lot of background kind of work to help fill in a situation. Sometimes it's mediating direct conflicts. So sometimes it's even sitting in a family meeting and trying to mediate parties that are disagreeing to the point where, like, nothing good is happening for the patient because of that disagreement.
Tyler Johnson: [00:08:42] And just as a philosophical question, I'm curious. You know, sometimes it sounds like what you're really faced with is a policy question, right? What does the hospital or the state or whatever say that we have to do about ABC, XYZ thing? And to the degree that that's true, that is fair enough and likely in some ways. I'm not saying that policies are always straightforward, but at least you can sort of look it up and just relay what the policy is, right? But what about in cases where there is not a policy or where maybe there are multiple different parts of multiple different policies that could apply to different parts of a case. And the question is what to do at this very painful place where the policies are overlapping and maybe contravening one another to some degree. One question that is fascinating to me is that, you know, we had a bioethicist on the show a very long time ago. I said to the bioethicist who also did clinical consults, as you do. I said, you know, some version of well, when my team and I ask a bioethicist to weigh in, in effect, what we're trying to ask is what is the right thing to do here? And this bioethicist really bristled at that suggestion and said, no, no, no, we would never, you know, we would never be so audacious as to tell you what is, quote, right, unquote.
Tyler Johnson: [00:10:01] Right. We that that's not our job. Rather, we give different frameworks and we suggest ways that things can be thought about and whatever. On the one hand, I totally get what that person was saying. But on the other hand, it does seem to sort of beg a deeper question, which is, I mean by its nature, ethics is the study of, in effect, how to do what's right, right, or how to show up in the best way in the world. And so I guess my my sort of philosophical question here is if at least some version of that kind of question beats at the heart of the kinds of questions that you're asking, how do you know? Like whose ethics are the right ethics. Like, how do you even know which framework within which to operate? And how does that decision get made?
Devan Stahl: [00:10:48] Yeah. I'm so glad that you told me ahead of time that this would be the singular three hour podcast. Um, because that's how long it's going to take to answer that. I think you're right. I think it would be dishonest for most clinical ethicists to say that all they're doing is mediating or trying to get people on the same page or following policy. There is a deeper sense in which we have taken sides, although most of that work we've done before we ever enter this space. So there are kind of principles and ideas around ethics within bioethics in particular, that most of us do carry with us into the encounter. So, for instance, and this is it's going to sound so boring, but it's only boring because we've all kind of agreed on the outset that this is probably true, that like, we care what patients think and want, right? That's an ethical position to say that something like autonomy is important, and it's not always the most important thing, but it is awfully important. It's not my role to, like, force things on people who don't want it, to the point where we've actually said people can say no to stuff, even if it's ill informed, as long as you know they have a certain basic understanding and they are in their right mind, they have decisional capacity.
Devan Stahl: [00:12:00] They can say no to stuff that then leads to their death. Like that's a huge sort of position we've staked out. It's just that I think most of us actually agree that that's probably the right way to go about things. So I do think that we've made kind of choices on the front end that they're like goods of medicine that we should pursue, and there are wrongs that we can commit against people. And our role then is to like, sort of fulfill that in the clinical space. And so it's maybe not to say like, oh, your ethics are right, your ethics are wrong. But on on some level, we have said that because there might be people who think differently about something like autonomy or our obligations to benefit people and not hurt them, or we have different ideas of justice. If you have a radically different way of thinking about any of those things, then you probably won't have your ethics upheld in a clinical space.
Tyler Johnson: [00:12:51] Okay, well, I actually think that can be a good transition point to what I want to talk about for most of today's encounter, which is. So we mentioned briefly the idea of disability ethics. And I want to sort of come around to this, but I want to do it in what might seem like a little bit of a roundabout way, but just to sort of set up a framing. So I live in Silicon Valley and, you know, living in Silicon Valley can be a kind of weird experience for a person like me because I'm, if anything, probably kind of tech pessimistic. I'm much more likely to, you know, be found reading Wendell Berry than I am to be, you know, cheering on. I don't know Sam Altman or whatever. And also Silicon Valley, it's just it's strange for me to recognize what an outsize impact people in Silicon Valley have on the rest of the world, because people like Mark Zuckerberg and Sam Altman and whatever, control these companies that literally over time, are becoming to a degree that is much greater than I think we often appreciate, are coming to control both what we think and how we think, in the sense that they control algorithms, that control feeds, that people give, in many cases, pretty unfettered access to their both conscious and subconscious selves. Right. And certainly the thing that Silicon Valley is most known for is those direct kind of tech companies, right? Both the social media companies and computer hardware and software companies that are kind of the generation that I would argue is kind of passing in a sense.
Tyler Johnson: [00:14:37] And the AI companies that are the generation of tech companies that are sort of really coming into power now. Right. But one of the the kind of ancillary technologies that goes along with that is that there is also this very particular kind of health culture that has a very strong basis in Silicon Valley. And that, I would argue, also has a lot of connection to many of those tech companies that I was just talking about. And I want to argue that the tech culture here has this very specific way of thinking about, ostensibly, of thinking about human health. But I would argue that also kind of less obviously, it is also a way of thinking about human dignity and even about what it means to be human. Right. So there is this very specific way in Silicon Valley of thinking that there is, quote, the ideal human unquote. Right. And this person looks like someone who's probably in their maybe late 20s to mid 30s. They have a certain particular kind of look about them. Right. They have a sort of a almost supernatural glow. They have very toned physique. They are kind of smart, but without being ostentatiously intelligent.
Tyler Johnson: [00:16:01] They are kind of effortlessly strong. They eat and drink a certain kind of thing that lends them a certain kind of at least vitality, if not virility, honestly. And I would argue that what they never quite exactly say, but the very strong subconscious message is this is the peak of what it means to be human. Right? And so then if you look at all sorts of advertising and messaging both about and within, for example, the apps and the algorithms and whatever it is targeted towards convincing people that that is the ideal. And to the degree that you as a person in the world differ from this ideal, then the point of, you know everything from supplements to your AI avatar to social media algorithms, all of it. It is meant to close the gap, and that if you could get the gap to zero, if you could in effect, become this perfectly chiseled avatar of a mid 30s tech bro or whatever, then you would have fulfilled the measure of your creation and you would be happy, right? So then one kind of weird side effect of that culture is that then the entire health care industry is effectively meant as a vehicle for closing that gap in people's individual lives, right? For delivering them across the breach so that wherever they are now, they can get as close to possible as being that sort of Adonis, you know, whatever stereotype.
Tyler Johnson: [00:17:41] So the thing that I think is so dangerous and corrosive about what I just described is that it's one thing when I sit here, not that I'm even necessarily doing a good job, but it's one thing when I sit here and sort of articulate like like this, right? It sounds almost a little sort of cringe as young people would say, right. Like you kind of want to roll your eyes when you hear it articulated that way. But of course, nobody ever articulates it that way, right? It's just this kind of like unspoken set of ideals that undergirds so much of advertising and tech and whatever. It just controls our lives in ways that we're not even aware that it's there. We don't even know that it's doing anything, let alone exactly what it's doing. Right. Which I would argue then leads to a whole host of unintended consequences. So I was hoping that we could start by you just telling us based on your research and writing and all the rest of it. First of all, do you think I'm on or off the mark there? And secondly, just in a general way, we'll get to some of the more specifics in a little bit. But what do you make of that sort of cultural milieu?
Devan Stahl: [00:18:41] Yeah, I think you're right on. And it's exactly what I want. Just kidding. Um.
Tyler Johnson: [00:18:46] So that's what you.
Devan Stahl: [00:18:48] Really want to be a mid 30s man in Silicon Valley? Yeah, I think that that's exactly right. So some of the work that I do is in bio enhancement and the ways that we're trying to leverage medical technologies to sort of make ourselves better than. Well. And the line of like where we're talking about therapy then and where we're talking about enhancement gets a little bit blurry, but we're like leveraging all this technology that was once meant to sort of help people get back to a baseline or to sort of be normally healthy, whatever that means. Now it's like we got to push beyond that. We're creating new ideals of what it means to be a normal or healthy person in the world in ways that are like, not at all. I think what medicine was ever intended for, but can be used to achieve those kinds of goals. So this creates kind of new paradigms of what it means to be human, or what it means to be a good human. That I do think, because you're right, that Silicon Valley has like is in a cultural milieu that allows for this. But also, like people have billions of dollars that they're pouring into this kind of stuff. Like, does shape the way that the rest of the culture feels about or sees what it means to be good or healthy. And I think that that's shaping sort of our cultural imaginations about what it means to be good and healthy and in ways that are actually deeply moral and ontological. So what does it mean to be? And then what does it mean to be good? Are both being shaped within that discourse?
Tyler Johnson: [00:20:12] So let me ask you a question. You mentioned briefly before that you have had, I think you said, and something like that. As a disabled person yourself, that you have had encounters with healthcare professionals that have just left you totally. Like what? Like what? What was that about? Like what was going on in that? If you're comfortable. Of course. Can you tell us a little bit about the way in which your disability shows up? And then tell us a little bit about one of those encounters that left you just sort of really, genuinely confused?
Devan Stahl: [00:20:47] Yeah, sure. So, um, I have Ms.. So multiple sclerosis and um, so sometimes that means, uh, that I look perfectly able bodied, and sometimes it means that I don't. So that's a part of the nature of a relapsing remitting illness. And I see neurologists quite often. I see lots of health care professionals all the time, and most are perfectly lovely. And I have great encounters. And sometimes it looks a little bit like a neurologist who's like, super comfortable looking at an MRI and talking to an MRI and then like, can I manage to turn around and look at me? There's a kind of techno vision that comes with my illness that I just notice a lot of physicians being super comfortable, kind of like with the numbers and with the image. The medicalized images. And just like, really uncomfortable in real conversation in like sort of turning around, acknowledging me, acknowledging my feelings, asking about things that would be related to my illness but aren't directly sort of about like, are you experiencing this checklist of things at this moment? Sometimes that feels a little dehumanizing, right? Like, I'm a person who has a story, and all you can do is like, look at the progression of bright spots on an MRI.
Tyler Johnson: [00:22:02] You know, it's I've referenced this before on the podcast, but one of the most important essays for my own moral development as a physician is one that Abraham Verghese wrote. Now, probably, gosh, it's been like 17, 16, 17 years ago. But he had been at a hospital in Texas for much of his career and then was recruited to come to Stanford. And shortly after he came to Stanford, he was attending on the wards. And this was kind of right at a time when hospital systems were starting to really make the wholesale jump to electronic medical records and sort of to the point I was making earlier about unintended consequences of tech. One of the things that that has done for healthcare professionals is that it creates this strange world where you end up spending so much time interfacing with the electronic medical record that it starts to take away from the time that you actually spend with your embodied patients, right. And he wrote this piece called Culture Shock, where he talks about how for him, both as a trainee and as an attending, attending on the wards had always meant the attending with the teams, with the patients. And you would do that for, you know, 4 or 5, six uninterrupted hours. It was literally just you and your medical trainees interacting with the bodies, hearts, and minds of the patients that you were taking care of and learning, as he likes to say, learning to read the body like a text.
Tyler Johnson: [00:23:24] To see the physical exam findings that would suggest what was going on, and all the rest. But then he goes to attend on the wards at this, you know, very fancy famous hospital, Stanford Hospital, and finds that it was often only with great difficulty that he could peel the trainees away from the rooms that had computers in them to go see the actual patients in the rooms. Right. And further subsequent research actually outfitted trainees with trackers and demonstrated that, in fact, you know, this wasn't just some sort of, you know, elder statesman clinician who was imagining things. It really was true that most of the trainees time was spent in front of the computers, and relatively little of it was spent with the actual patients. And to your point, you know, there is a way, a pretty easy way in 2026 of starting to believe that your patient can basically be reduced to CT scan findings and lab values. It's almost as. And he says this in the essay. It's like the avatar has become the patient and the patient has become the avatar. Right. The digital representation of the patient has, in some ways, the culture seems to suggest, is almost more important than the person in the bed. Him or herself?
Devan Stahl: [00:24:36] Yeah. I think I've experienced that. I know from the research that depending on your specialty, like most physicians, will spend more time in front of their electronic medical record than they will in front of their patient. And for some of them, that's like wildly so. Which is a whole conversation about AI and how it might be helpful there, but. And nobody likes it. I mean, I don't know any physician who's like, yeah, I love sitting in the medical record. It's my favorite thing to do. Right. Like, it's it's a system developed for billing and coding. Right.
Tyler Johnson: [00:25:04] 100%.
Devan Stahl: [00:25:05] I don't know any physician who's like, I went into medicine to find proper billing codes, and that's where I find my passion, right? They want to be helping patients. Nobody wants to be sitting in front of their computer. So it's just, like, bad for everybody. It's bad for patients. It's bad for burnout for clinicians. And I don't we haven't figured out a great way to solve that yet.
Tyler Johnson: [00:25:24] Yeah. So let me ask you, you wrote a book about the ways in which, specifically, some powerful theological ideas can critique the way that not just that modern medicine is practiced, but even that sort of modern medicine, sort of the ideals behind modern medicine or the often unspoken philosophical framework of modern medicine. So I wanted to start by asking this question to sort of help us to think about that together. What do you think the modern medical system, at least in the United States, what do you think it is largely built to do? Like what do you think is the that you use the word telos, but the point of modern medicine as it is currently constituted.
Devan Stahl: [00:26:15] Yeah, I think it's something like curing people or fixing people who have problems that we can fix. That sounds so general, but like, people are vulnerable and fragile and that's bad for us. And if we can fix and correct those things and help people live a better life through being sort of more physically fit or more mentally apt, that those would be goods that everybody would agree with. And so there's a kind of like normalized vision. I think it's not maybe the exact vision of the tech bros that you were describing earlier that might be going beyond kind of what medicine is typically thought of as a normal, healthy person. But there still is a vision of like, what does it mean to be normal and more or less healthy? And how do we get people there through these techniques or these technologies? And I don't think that there's anything necessarily wrong with that vision, except when our vision of what is normal and healthy is not in line with what individuals experience about themselves. And this is sort of where it gets into my thinking around disability. There's ways in which I view some practices of medicine as like wanting to fix things that people think are just fine or normal about themselves. And so there's sometimes can be an overreach into like, that vision of the norm can be placed onto people who have a different idea about, like, what it means for them to live a flourishing life.
Tyler Johnson: [00:27:41] So let me ask you what might seem like a deceptively, I would argue, simple question, but what defines normal? Like if the if the point of medicine is quote to help people get back to normal, unquote. So where does the idea of normal come from?
Devan Stahl: [00:27:59] Yeah, it's a great question. So it came from this Belgian statistician in 1880. I'm sort of joking, but there was like, um, the norm is often depicted as like sort of the if there was a curve of the population. There was actually a Belgian statistician who went around the countryside. And as far as we know, this was the first time this happened and just started like literally measuring people so that the kingdom could know the kind of population that it had. And so there's a way in which some of that is just like statistical norms. And that's a lot of medicine is, you know, you are you have a particular disease or malfunction when you're two standard deviations away from the norm. So there's some norms that are kind of just population statistics norms. But it clearly isn't just that, because if there are maladies that are affecting widespread portions of the population, then we might say, well, just because that's statistically normal doesn't mean it's good. And so there is always in the background this vision of like what it means to have a normal function. So sometimes this is also expressed as like what is normal for the species. So in a kind of pulled back natural science sort of sense of like what would be the norm, the bio typical species norm. And so sometimes the norm is framed that way. But I think actually for most of medicine, it's not explicitly named at all. There's this kind of something in the background around norms that get carried in implicitly into a lot of encounters that I think people are actually not aware of. And so where does that come from? It comes from a culture that sort of values certain kinds of bodies more than other kinds of bodies. It comes from, you know, just sort of all the things in which our social imaginations are built around. Some of that is science, but some of that is also just like the kinds of people that get valued.
Tyler Johnson: [00:29:48] So let's explore this for a minute, because one of the things that has been really interesting over the past, I would say, especially the past 10 to 15 years in the United States, and arguably, well, I think actually, probably inarguably, this has changed somewhat, especially in the last year because of changes in the federal government and other things. But I think there has been a great movement towards generally being more careful about the way that we speak. Right, and trying to speak in a way that at least the stated purpose is in a way that is more inclusive and less likely to offend different kinds of people. And I think that, to be clear, I think that that generally I think we should always try to speak in a way that is kinder and more inclusive and more thoughtful about how it will land for all different sorts of people. I think that, you know, it seems hard to me to question the idea that that is a bad thing on its face. At the same time, though, I do worry sometimes that if the only thing we're doing is creating what amounts to a checklist of words to say and words not to say, and better words to say than these other words that you should try not to say or whatever on some level, if that's the only thing that it is, it can become kind of a game of semantics, right? And and it can even become, in a perverse way, it can even become a sort of a, a status symbol.
Tyler Johnson: [00:31:15] Like the more up to date you are about the words to say and not to say, then the better you fit in in certain kinds of circles than if you aren't up to date on all of the latest. Which is to say that it can in some ways kind of blind us to the deeper meanings that those things to say and to avoid saying are trying to get at in the first place. Right? So what I'm trying to get at here is one of the things that you mentioned, which I think is a thing that we don't think about very much, is the idea that society values certain kinds of bodies more than other kinds of bodies. Can you talk to us a little bit about what do you mean when you say that? And what are some examples of bodies that society values more than others.
Devan Stahl: [00:32:01] So I'll say that, like a lot of my friends with disabilities have been told various things by even clinicians around like, you know, if I had to live like you, I think I'd rather be dead. So there's a kind of like, very explicit valuing of a good body is an able body is probably the right age. So I think there's a general dis valuing in our culture around aging. People are terrified of aging. People are terrified of things like dementia. So anything that might affect their cognitive ability, and then that carries over to the ways that we treat people. So I've just spent some research in all the nursing homes in my area, and they are overwhelmingly pretty bleak places. It's clear to me that we do not value the elderly based on the ways that we house them. I think that there is in some ways that we talk about newborns. I mean, we all love babies, and yet some babies just seem to be less valued than others based on the projected sort of amount of ability that they might have in the future, or their economic productivity even. There's like ways we subtly talk about how people contribute to society. Who is a drain on society? States of living. We would be aghast to be in such that we might rather be dead. I was just in Canada, talking to folks around their new euthanasia and made laws and the ways in which kind of this narrative around who gets valued and who has dignity have been shaped by that discourse.
Devan Stahl: [00:33:33] So I think that there's ways we do this implicitly, but also explicitly just ask somebody, what's a state of living that you think would be worse than death? And you'll hear all sorts of things. It's funny, like there are studies that show that when you ask an average person that mid-life fully able bodied, they'd say, like, uh, incontinence. If I was ever incontinent, I think I'd rather be dead. And you're like, well, that's that's just not true of people who are incontinent. Like they don't wish they were dead for the most part, like, because of that. But we do sort of have this vision of like, what are the life's worth living? And lots of people fall outside of that. And yet when you ask those people about their own quality of life, who live with the very conditions that many people say would be worse than death, people are remarkably good at living in their bodies. People value their own state of existence for the most part. That's not to say that there might be some states of existence all of us would think are terrible, but I think our barometer for that is like pretty off. Like when you start hanging out with people with disabilities, they have a very different sense of like what makes their life worth living and what is valuable about that life.
Tyler Johnson: [00:34:34] You know, part of what I was trying to get at when I offered my description of how I think Silicon Valley often views these kinds of questions, is that I think there is a sense in which at least popular culture suggests that there is a very A particular kind of life that is, let's say, most worth living. Not to say that others are not worth living at all, but that there is a certain kind that is most worth living, and that we can kind of judge the value of a life based on how close it is to that particular kind. Right. And, and some people, like Elon Musk, for example, is sort of infamous for kind of saying the quiet part out loud about this kind of stuff, in the sense that he can be very sort of crass in voicing some of these ideas that other people might think, but wouldn't, you know, want to say them, at least in a public way. But I guess that the thing that I am trying to think through with you is, I think it is also true that many people would say, okay, maybe it's not that I wouldn't want to live at all if I had this condition or that condition, or if I lacked this function or that function, or if, as you say, I was incontinent.
Tyler Johnson: [00:35:47] But it is also probably true that most people would agree that they would certainly prefer to have certain abilities and not have certain other problems and whatever. And it is also true that much of the medical world is devoted to helping people to try to at least grapple with, if not overcome, some of those lack of function or whatever it is. So I guess the part of what I'm wondering is, as a person who thinks about this a lot, how do you think the medical system can maintain its ability to try to help people address and in many cases, even overcome these various different kinds of problems without simultaneously breeding a culture where there is at least the very strong implicit suggestion that people who conform to a certain physical or mental or cognitive ideal are better or more valued than people who either don't at all or who do to a lesser degree.
Devan Stahl: [00:36:51] It's a great question. So I think part of that's just talking to people about what gives their life meaning and purpose. There's a way in which you yeah, you can hold people to a standard that's like super unfair to like who they are or what they can ever achieve. At the same time, many people I know readily use medicine and value medicine for being able to, like, mitigate symptoms to stave up further disability. Those things are all goods that you know. I might value my disabled life and yet not want to become more disabled than I already am. I think that's an okay position to hold. Like, I can have pride in who I am and still, if there are problems, want to use medicine to mitigate them. I think framing all disabilities as problems might be, in and of itself, an overreach, right? So not everybody experiences their disabilities as problems. I have plenty of deaf and blind friends who would not describe deafness or blindness as a problem in their life, and actually might not want it to be cured, even if a cure were available to them. So I want to, like, hold space for that to be true, that this is like another form of living in which flourishing is completely possible and medicine need not intervene really in any way on those particular embodiments. So I think there's a segment of people for whom that's true, a segment of others like myself who would like I'd happily take a medical cure. I'm not going to invest all my time in that being the sole pursuit of my life, because that's not realistic. And it's not very. It doesn't contribute to my flourishing. There are many things that can, and I just don't think spending all my time worried about medicine fixing me is going to be one of the ways that I flourish.
Devan Stahl: [00:38:24] So there's space for both those things. But I think talking to people about like what it is they really want and what it is they really value, which any good physician will do. And in my experience, very few ever can get into those conversations, even when it's important to the medical care itself. Like, why are you here? And what do you want? Should be like the first question. And it's often like week four that anyone bothered to ask. And sometimes the answers are surprising, like, oh no, I thought this person came to the hospital for this, and now I'm realizing they came for something else. Yeah. So not holding everybody to a kind of norm that doesn't make sense for them. Not valuing or suggesting that a life isn't worth living. I think you're right. The most most people are not doing that. They're not running around telling people that they should die because they have disabilities, that even though that does happen to people, I don't think that's how most clinicians are operating. But I do think that there's an implicit assumption that like, yeah, everyone would rather just not be like this. And I actually don't know that that's true. I think that there are people for whom they're just perfectly happy with the ways that they're living and the bodies that they have, and then others that aren't, but also are pretty good at living in those bodies and don't need to spend all their time worried about fitting into some other kind of body.
Tyler Johnson: [00:39:36] So one of the things that Henry and I, my co-host and I have recognized over now a number of years of recording this podcast, is that one of the things that I think has happened to medicine over the past, let's say 30 or 40 years especially, I think, two things that have gone hand in hand. One is that medicine is becoming increasingly more subspecialized and this is often of necessity, right. So I can say as a medical oncologist, a doctor who gives chemotherapy, I of the entire universe of, you know, possible oncologic diagnoses that a person can have. I take care of patients who have about, depending on how you count them, about 7 or 8 different kinds of cancer, even though there are I don't know, it depends on how you count them, but 50 or 60 or 100 or whatever you want to say. Different kinds of cancer, right? I only take care of a small subset. And while there are some community physicians who oncologists who take care of patients with all cancer, even in the community, we're often starting to see people who subspecialize in. The reason for that is because there are just so many advances in oncology that, in my mind, I have the utmost respect for and frankly, kind of bewilderment at people who treat patients with all kinds of cancer because it's hard enough to keep up with just the advances in GI cancer, let alone every kind of cancer.
Tyler Johnson: [00:40:54] And so I think the specialization may be necessary, but regardless, it is just a fact. And then I think a thing that has come up along with that is that because any individual physician's focus has become narrower and narrower and narrower, it is easy to think of oneself as sort of my point as an oncologist is to get rid of GI cancers. That's what I do, right? Or my point as an interventional cardiologist is to open blocked heart arteries or, you know, whatever the thing is. But it becomes almost then entirely a technocratic endeavor, right? It's like being a machinist for very complicated machines. And this is nothing against machinists, but it's just a very different way of thinking about medicine. But the idea that you mentioned is this much broader concept of an idea of human flourishing. And I'm wondering if you can just talk for a minute about what might it look like for a doctor to interact with her or his patients in a way that is, that holds as the final goal, human flourishing rather than as the final goal fixing? Whatever the one particular kind of problem that they happen to specialize in is.
Devan Stahl: [00:42:04] First of all, I want to say that, like, I don't know that it's like the physician's role to facilitate everybody's flourishing. Like, hopefully most of the people that you call patients have lots of other people in their lives that can help facilitate that. So I don't want to put it all in the position to be like, listen, our flourishing is totally dependent on how you use the right words and the right kinds of things to say. No, you're one part of a life whose flourishing might be hampered because of a kind of either, you know, physical or mental challenge that somebody is experiencing and that's an obstacle to their flourishing or might be an obstacle. If I could figure out how to make this part, like if I'm in excruciating pain from this cancer, like it's going to be hard to flourish. And so it might be that you can sort of cure that for me, or it might be that you can, you know, minimize pain, or it might be that you're just like another person to hear that experience. And that in and of itself can facilitate my flourishing. So for me, a person who is flourishing is like, well, I'm a Christian theologian, right? So it's a person who is like able to love themselves, others, their neighbors and God. And so a flourishing life is the one in which we're communing well with ourselves, with our neighbors, and with God. And there's ways in which even the physician can help that to happen, by getting rid of the impediments to that and helping people to sort of see all the relationality that they're already experiencing. I mean, some of the most beautiful things I see in healthcare are when families get together at a bedside and are able to, like, reconcile and say, I love you.
Devan Stahl: [00:43:35] These are like important moments that can happen in a hospital because people realize the gravity of doing that in that moment. And so I think doctors can open up space for that to happen, can help facilitate sort of deep thinking around what is it that I want? What is it that I value? That doesn't mean, like you have an hour long therapy conversation with every patient, but it is sort of how do how do we get the most out of this encounter so that you can live the life that is meaningful to you? And doctors get to have those conversations in ways that, like lots of other professionals, don't get to have those conversations. You don't you don't go to your bank and say, and the banker doesn't say, what is it that you truly I know you love money, but what do you truly value and how can I help facilitate that? So physicians are in this really unique space to help people at the most vulnerable points in their lives, spaces where actually opening up and thinking through meaning and purpose might be like the most acute time that they can do that because we live our lives and we just don't sort of sit around enough thinking about that. But when we have a crisis or when we have trauma, or when we're like thinking through chronic illness, those are potent spaces for connecting our deepest values. And I think physicians, clinicians of all sorts can facilitate that thinking with very little work. I know that you all are very busy, but I think that that you can open space for at least a start to that kind of conversation.
Tyler Johnson: [00:44:55] Yeah, I will say that certainly from my vantage point as a doctor who's been doing this for a number of years, I think those are some of the most beautiful moments that I have had as being a physician come in precisely that way. When we get to enter into that sacred space together with patients to talk about what really matters most to them. I know that our time is almost gone, and so I want to finish by kind of turning our focus a little bit in the following sense. One of the reasons that we launched the podcast a number of years ago was because we wanted to address what is often referred to as the epidemic of physician burnout. Right. Which is this really unfortunate shift that has happened over the last, especially 10 to 15 years, where there's all different kinds of statistics you can look at. But many physicians are will say this way, are thinking seriously of leaving the profession altogether because they feel so professionally unfulfilled. Now, you know, you mentioned a moment ago that you come from a particular theological and religious orientation. And yet I think that regardless of of the particular orientation, you are a person who has spent a large part of your life thinking about the philosophy that underlies, in effect, how to build a flourishing life.
Tyler Johnson: [00:46:17] And so I'm going to give you these last maybe five minutes to answer this question. If there is a physician who's listening, who is just feels like they're coming apart at the seams, and particularly professionally, they just feel like, good grief, I, I dedicated a decade of my life to training to become a doctor, and either I'm in the middle of that decade or I just finished that decade, or maybe that finished, you know, 20 years ago or whatever. But like, like I thought this was going to be such a beautiful, meaningful, you know, thing that would just fill me up all the time. And yet I just feel totally alienated from myself, from my patients. Like, I just like, this is just not what I signed up for. And if they were to come to you and, I don't know, sit down in your office hours or something and say, like, Doctor Stahl, here's how I feel. This feels like the opposite of flourishing. How do I get from here to where I'm flourishing? What might you say?
Devan Stahl: [00:47:11] So I'm so glad we ended on an easy question. Um.
Tyler Johnson: [00:47:17] That's all we have here is easy questions. Yeah.
Devan Stahl: [00:47:20] One thing I do with my pre-med students is have them write essays to their future selves about why it is they want to go into medicine. I think because I know that one day they might feel just like that, and it's going to be really important to connect with what it is that motivated them to start this whole process to begin with. And so I think some of it's about reflecting on like why we do this thing. Because it's a hard thing. I'm not a physician, but I see my I have many friends who are and I see how difficult it is. So why is it that you wanted to do this? Like what? What were the motivations there? And yeah, it's going to be more you you were a little, maybe overly idealistic as a pre-med student about like what was going to be possible. But you didn't do it for praise, right? You didn't do it because you thought every patient at the end of the day was just going to, like, send you flowers and love you. And unfortunately, they rarely do, even when they feel like you are their hero because you met them at the worst possible moment. So the kind of gratification of like, thanks that I think you're owed, I think you genuinely are owed is probably not going to be felt in those moments because again, you're just entering into a really tough place in somebody's life. So it can't be about praise. It has to be about something else. And it can't escape the bureaucracy of medicine. I think there's ways that Brewer and others are trying to, like, find a better way for medicine to function, to not burn out.
Devan Stahl: [00:48:43] But until we, like, totally reform the system, that's just the life you're going to live. And so in those moments when it's really hard, why are you doing this? Who are the people that have touched you? Like, remember those stories? Probably even write them down. One thing I found for myself is like, unless I start saving the thank you letters, unless I start, like, capturing that writing those moments down, they're easy to forget in tough moments. So going back to the times and and the narratives in which you felt like you really made a difference, that can be really powerful. And then, um, something I know Brewer and I both do is like, connect to the arts, like finding beauty in in In places beyond just the sort of profession like the professional work, like how do we find other ways to fulfill ourselves? It can't just be your job. Your job is going to take up like the majority of your time. I get that, but there has to be other things in your life that give meaning, or else you are definitely going to burn out because it can't be. Your job cannot be everything to you. So what is the community? What are the practices that are going to fill you up in the times when you're not working? Those are going to be as important as sort of finding meaning in the work itself. So why did you do this? Where are the beautiful moments and what can you look forward to outside of the direct job itself that is going to fill you up and give you meaning?
Tyler Johnson: [00:50:04] Yeah, you know, the one the one thing I will add to that or just to really give you a plus one, as a person who is inside the practice of medicine is that I think there is a really, you know, I love the, the poetic quote old a little more and how much it is, oh, the little less. And what worlds away. And I think that one way that I see that play out in medicine is that it is beautiful and wonderful to find meaning in medicine. And yet, one of the things that I think is one of the greatest impediments to finding meaning is to pretend that your life's only meaning is going to be in medicine. Like having a superstructure and a set of roots that are outside of medicine, paradoxically, are one of the most important things to facilitating finding meaning inside of medicine. Because if medicine is the only thing, it can become totalizing in a way that I think is both unhealthy and unproductive. And as you say, having a greater both a moral and a community superstructure outside of medicine, I think, I think really matters. Well, Doctor Stahl, we know you are so busy and have a lot of demands on your time. We want to let you know how much we appreciate the many years of study you've put in to developing the expertise that you have, and we appreciate so much that you would spend an hour of your time to come and be in conversation with us. And we thank you so much and wish you all the best.
Devan Stahl: [00:51:26] Yeah, thank you for having me.
Henry Bair: [00:51:31] Thank you for joining our conversation on this week's episode of The Doctor's Art. You can find program notes and transcripts of all episodes at the doctor's Art.com. If you enjoyed the episode, please subscribe, rate, and review our show, available for free on Spotify, Apple Podcasts, or wherever you get your podcasts.
Tyler Johnson: [00:51:50] We also encourage you to share the podcast with any friends or colleagues who you think might enjoy the program. And if you know of a doctor, patient or anyone working in healthcare who would love to explore meaning in medicine with us on the show, feel free to leave a suggestion in the comments.
Henry Bair: [00:52:04] I'm Henry Bair.
Tyler Johnson: [00:52:05] And I'm Tyler Johnson. We hope you can join us next time. Until then, be well.
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LINKS
Read about Dr. Stahl’s book Bioenhancement Technologies and the Vulnerable Body.
Explore how the ADA is shaping healthcare for people with disabilities.
