Hope in Medicine: Hudson Baker - A Defense of Relationship Centered Perfectionism
What does it mean to flourish when illness changes our abilities? Medical student Hudson Baker explores how relationships shape human well-being and why this matters for medicine. Through philosophy and clinical examples, he considers disability, dementia, end-of-life care, and the patient–physician relationship, offering a vision of care grounded in connection, dignity, and accompaniment.
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Hi, and welcome to the Hippocratic Society Podcast. In this series of episodes, we break
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from our usual content to share presentations from the second annual Hippocratic Society
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Conference, during which physicians, trainees, and students from across our chapters came
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together to reflect on what it means to live out the virtue of hope in medicine. We hope
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you enjoy.
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Our next speaker today is Hudson Baker. Hudson is a third year med student at Baylor College of Medicine. And prior to med school, he studied philosophy, medical humanities, and Great Texts as an undergrad at Baylor University.
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And then he did a theology, medicine, and culture fellowship at Duke Divinity School. And Hudson is interested in bioethics, especially focused on end of life care and disability. And I am not going to trust my paper for talk titles, so I'll look at the PowerPoint instead. Today Hudson is going to talk to us about a defense of relationship-centered perfectionism and its implications for the practice of medicine. And I have to add here Hudson is following the lead of a brilliant and undervalued, underappreciated young philosopher.
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as you'll see from his talk with Relationship Center Perfectionism, and I'm sure he's going to do that much better than that boring old philosopher did. So welcome, welcome Hudson. Thank you.
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Hi, I'm Hudson. I'm a third year medical student here in Houston and this talk will be first a defensive relationship center perfectionism, which I'll explain, and then secondly a discussion of some of the implications this would have for the practice of medicine. And yeah, before I start, I got to give thanks to Dr. Shea, who wrote a really good paper on relationship center perfectionism, which inspired this presentation. But any egregious errors in judgment are entirely my own.
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In good hip sock fashion, we'll start off with a case study. And we've got an elderly man with advanced Alzheimer's dementia who undergoes surgery for hip fracture, subsequently develops pneumonia, sorry, and requires intubation. So during a goals of care conversation with his daughter, who's his MPOA, she says she's not sure what her father would have wanted. So in this case, how should the team proceed?
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And typically with like incapacitated patients, they, you start off with like, you know, advanced directives, previously stated wishes, things like that. If you don't have that, then you move on to substituted judgment where you try to figure out what they would have wanted based off their values and other decisions they've made. And then sort of as a last resort, you go to the best interest standard. And this is a case where the best interest standard may actually come into play, assuming the daughter really doesn't know what her father would have wanted.
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And so how do we use the best interest standard? Well, it requires some sort of benefit burden analysis, which sounds very straightforward and mathematical. But in order to do that, we need to know what a benefit is. And I think we can say it's that which makes our life go well. So ultimately, we need a theory of well-being. And I think that's what this case demonstrates. And that's what this presentation will hopefully offer. And we'll return to the case as well.
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So here are some common theories of well-being. think probably some of the most common would be like hedonism and desire satisfaction, which basically equate well-being just to pleasure or to the fulfillment of our desires.
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These could be said to be like subjective views in so far as on these accounts, well-being is purely a or a function of our mental states. And then in contrast, you've got a thoroughly objective view called perfectionism, which basically equates well-being to flourishing.
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and therefore ties it to the fulfillment of human nature. And this typically requires exercising the characteristic human capacities. And depending on what we view those characteristic human capacities to be, we arrive at either a classical Aristotelian perfectionism or a relationship center perfectionism.
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So classical Aristotelian perfectionism holds that the characteristic human capacity is like reason or intellect or rational capacities. This has its origins in the man himself, Aristotle, who said in Nicomachean Ethics, the function of man is the exercise of the soul's faculties and activities in association with rational principle. Therefore, according to this view, living well essentially requires exercising reason, and those who cannot exercise reason in any capacity lack well-being.
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Contrast this with relationship-centered perfectionism, which holds that the characteristic human capacity is like social relational life. It's our relationships that ultimately constitute our well-being to the greatest degree. So in this view, those who have good relationships ultimately may be said to have good quality of life or have well-being, and those who lack such relationships generally lack well-being.
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This is just kind of recapping what I covered so far, but sometimes we have to know what's in somebody's best interest. This is true in medicine. It's also just true in life. In order to do so, we have to know what sort of things benefit us. We have to have a theory of well-being. If we adopt an objective perfectionist view, we want to know how do humans flourish or how do we fulfill our human nature. And this typically is understood to involve exercising the characteristic human capacities, which could be either intellectual or social or some third option.
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but we'll be kind of covering those too. And so I'll be arguing for relationship-centered perfectionism against this classical Aristotelian view, which is admittedly kind of bold, and I'm not an Aristotelian scholar in any way, so forgive me. But I think first it's helpful to look at kind of Aristotle's argument for the intellect being the characteristic human capacity.
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In early in Nicomachean ethics, he says, may be held that the good of man resides in the function of man, and we're looking for the function peculiar to man. This is, think, known as his function argument or his Aragon argument. And then he pretty quickly narrows this down to rational life, suggesting that humans have both vital activity and sentient life in common with animals.
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However, I think there's two things worth noting here. First of all, there may be other things which are peculiar to man. I listed a few here. Resability or the ability to laugh, language and relationality. Language may be falling under the category of both reason and relationality, but maybe its own thing as well.
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Interestingly, I had a college professor who argued that visibility is what really made us human and he subsequently got fired for making an inappropriate joke. Not sure he would still say that that contributes to our living well. And then, yeah, secondly, I think we're all tired of talking about AI, but I think in the age of AI,
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We might question whether or not it's truly our reason or our rationality that makes us unique as humans and is what our human nature centers on. And of course, AI is artificial. It's not true. It has no true rational capacities. But I think, nonetheless, we're feeling more and more that maybe it's not our intellect that is what fulfills us.
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So looking at why I think relational capacities would be primary, Aristotle himself understands human nature as involving a relational activity. In politics, he says, he who is unable to live in society or who has no need because he is sufficient for himself must be either a beast or a god. A social instinct is implanted in all men by nature.
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And later he says something similar to the same effect. But the point is, even for Aristotle, our social capacities are characteristically human. So I think the question we need to ask isn't just what is peculiar to humans, but what really fulfills us in our human nature. And here are a bunch of quotes to argue my point. But Aristotle kind of sets up his argument saying, what is the end at which all actions aim?
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And because if we can know what that end is then the actions that allow us to get there are likely to be the ones that really fulfill us as humans. So Aquinas answers this exact question saying it's the union of man with God and the perfect enjoyment in which happiness exists. So for him our relationships, our relational capacities ultimately fulfill us.
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He also says to love God is something greater than to know him. So these two quotes, I think, suggest that Aquinas would hold the view that our relationships fulfill us as humans. Granted, you could also find other quotes from Aquinas that would argue kind of the opposite. But Augustine opens his confession saying, thou hast made us for thyself, and our hearts are restless till they rest in thee.
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I think this is sort of a poetic expression of the primacy of relationships, specifically relationship with God, being the only sort of thing that can really fulfill us as humans. Later on in Confessions, he says, after losing one of his close friends, he says, I became a great enigma to myself and was forever asking my soul why it was sad and why it disquieted me sorely.
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To a similar effect, JP2 says, man cannot live without love. He remains a being that is incomprehensible for himself. His life is senseless if love is not revealed to him. I think taken together, these suggest that it's really our relationships that ultimately fulfill us as humans, at least from like a religious or a Catholic perspective. The question is whether or not this really stands true from a secular perspective as well. And I think the argument looks a little bit different, but it's no less strong.
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If man invented God, as a non-believing perspective would have to say, then he did so not only as an explanation for the existence of the universe, he created a personal God with whom he dares to have a personal relationship.
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And I think the ubiquity of religion and the fact that I think over 85 % of people who are religious throughout the world believe in a personal God suggests that humans ultimately find fulfillment in relationships. Yeah.
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And then finally, I think the way we just talk about humans now, we place, like if we describe a moment as particularly human or something like that, we're not meaning that everybody was exercising their rational capacities to the utmost. I think what we mean is that there is an element of genuine human connection. My second kind of argument is that this classical view fails to account for the flourishing of those with impaired cognition.
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This is because if flourishing requires exercising reason, then clearly those without reason can't flourish. And I think this is not super debatable, but maybe what's more debatable is whether or not this is a problem. And so I listed a few consequences of this view that I think most of us would take issue with at least one of them. So first of all, such a view justifies the termination of children with disabilities. Aristotle himself said, let there be a law that no deformed child shall be reared.
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And this isn't just a theoretical consequence, this is done in practice with many of those who elect to terminate their children with Down syndrome, citing poor quality of life as the reason for doing so. Secondly, it promotes the societal exclusion of the disabled. This has been going on forever and it's still going on today
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Finally, I think it shapes discourse around advanced dementia. When.
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when dementia obviously robs us of our cognitive capacities in some way. And I think the way we talk about it reflects how we view that. And we often hear people talk about those with Alzheimer's as if they're no longer who they once were, or if they're a shadow of their former selves. And we even hear people suggest that for them to die would be somehow a mercy to themself and to their family.
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On the other hand, I would argue that relationship-centered perfectionism does account for the flourishing of those with impaired cognition. This may not be immediately evident as...
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as we might think that those who can't communicate can't really be in relationships. So I think it's helpful to give sort of a definition of what I mean by human relationship. And first of all, I don't mean any of these things. It's different from that which exists between objects, obviously. It's also different from a relationship between two animals, which may be marked by affection, codependence, even communication. Lastly, it's different from what exists between us and our pets. As much as we love our animals, man's
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best friend is ultimately man. So what is a human relationship? This is my best attempt at a positive definition and it's admittedly not very good but I would say it's a mutual orientation between subjects or persons not objects characterized by union in which neither party is regarded as a means. In other words it's an I-thou not an I-it relationship and I think by this view those with profound disability clearly can be included.
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as these individuals demand to be treated as subjects and not objects. And I think one of the more poignant examples of this, at least in literature, is the violent, is the Flannery O'Connor's novel, The Violent Bared Away, which is a really good book if you haven't read it. But throughout this book, it kind of follows two characters who are attempting to reduce a third character who's a child with...
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an intellectual disability, they're trying to reduce them to sort of the status of an object, going to extreme, even violent lengths to do so, only to find themselves ultimately incapable. There's something in the child which demands to be treated as a person.
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And reflecting on his own inexplicable attitudes towards his son, the father says, it was not the kind of love that could be used for the child's improvement or his own. It was love without reason, love for something futureless, love that appeared to exist only to be itself, imperious and all demanding, the kind that would cause him to make a fool of himself in an instant. I think this demonstrates not only that those with profound disability cannot be treated as objects, but also
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that relationships themselves are an end and not merely a means to something else. I'm gonna skip over the objections just for sake of time, come back to that if I can, and go on to the implications this theory would have for the practice of medicine. Firstly, we kind of already covered this, but I think that this view, the relationship-centered view, allows for the flourishing of those with intellectual disabilities insofar as it...
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And as a result, it undermines the justification for aborting children with intellectual disabilities. And it also justifies resources for profound disability. Maybe we'd be willing to take care of these people. Secondly, I think it reshapes end-of-life care discussions by shifting focus from a patient's irreversible impairments to his or her relationships. I think this is one of the more important implications because
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Like the theme of this conference is hope and if a patient lacks well-being in a way that we can't do anything about, then there's nothing to do about it. But if they lack well-being because they're lonely or their relationships are damaged somehow, then that's maybe something we can do, particularly in medicine where we have the opportunity to accompany these patients.
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Secondly, it allows for the prioritization of home-based care. Clearly, if relationships are what matters most, then we should spend the end of our lives surrounded by those we care for and who care for us.
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Revisiting the case. So what would we do for this elderly man with advanced dementia who's intubated? And that goals of care conversation I'll just say the correct answer from from my view is a we should ask about his relationships What may be done to preserve or cultivate relationships for this patient? and then let this inform goals of care and Admittedly, this is not like a simple answer. It doesn't really tell us what to do next
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But I think it's a better approach. And I think we should look at kind of the wrong answers as well and see why they're wrong. we don't have to pursue curative treatment at all costs. Health is an intrinsic good, but it's not the ultimate good. And even though there's no reason to abandon hope on anybody, even if they have advanced dementia, that doesn't mean we have to cling to life. And we also don't have to ignore the diagnosis of Alzheimer's just because those with Alzheimer's can flourish.
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It doesn't mean that they always are. And Alzheimer's is a condition that affects not only our cognition and our bodily health, which are intrinsic goods, but also it affects our relationships in a significant way. And there's no arguing that. I think the important thing here, though, is that we can't assume that these people are living unwell just because they have Alzheimer's.
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Additionally, I would say that this view calls into question the aggressive contraceptive counseling that's often practiced in medicine. It's just a fact of life that having children is in some way detrimental to autonomy. So if we have a view of the world that the intellect and being able to, you know, exercise our autonomy is what really allows us to live well, then I think we might assume that the life of an autonomous worker is going better than that of a stay-at-home parent.
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And as a result, and I think we see this in medicine, that the default recommendation is basically in medicine to avoid having children.
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Contrast that with relationships and imperfectionism, which suggests that the relational bond between parents and children may actually account for the well-being of both. So in this view, parenthood may actually be a good thing.
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Finally, I would say this view reshapes the patient-clinician relationship simply insofar as this relationship becomes an aspect of the patient's well-being and vice versa, part of the physician's well-being.
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In doing so, it protects against two problematic alternatives that we see. First of all, the physician being reduced to a technician. If the patient's autonomy is all that matters, I think we're unlikely to, well, if the patient's autonomy is all that matters, then we have to kind of forsake the goods of the relationship that exists there. In any normal relationship, we have to have the other person's best interests in mind, not merely the optimization of their rational capacities.
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The opposite problem also occurs where patients are sort of reduced to objects. I think this happens most often in hospitals where patients, as the name suggests, assume a very passive role.
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Yeah, I think this passive role sort of reduces them to an object because, and we've got like informed consent, but really that's all it is. It's just consent. so patients are more or less just along for the ride, not really exercising any capacities.
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Whereas physicians become elevated to the status of like the acting agent here. And I think a better view would be that there's a relationship that exists here. And the patients, despite all their bodily suffering, may be able to flourish even in the hospital, as long as we're willing to accompany them.
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Just to conclude with a poem, the last lines here I think are the most relevant. To avoid thy fellow, vain thy plan, all the interests of man is man. That's all I got.
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Yeah, beautifully done, beautifully said.
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and it's a nice extension of back and tire from what I understand about back and tire. I guess one question would be if relations are critical to our perfection.
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For example.
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the other day.
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severely abused as a child and is very afraid and cannot have relations now. I've also seen patients who have profound paranoia about other people.
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them.
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Yeah. Yeah. Yeah, think that's like the probably the most important objection to consider and so I kind of included that in here. The other ones I thought of a lot of forms of autism as well and P relationship formation as well as like schizoid personality which I've never actually seen but theoretically the person that doesn't even have an interest in forming human relationships. Okay.
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But so yeah, the concern here is that relationships enter perfection and just replaces one marginalized group with another, from those who lack cognitive capacities to those who lack relational capacities. And I think we should consider each group within, there's different types of people who are isolated. So there's those who are isolated because they've done things that are toxic to relationships. And this is consistent with a virtue view. We would expect that the
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Those who are treating others poorly would not have flourishing relationships. That's not what you were referring to, obviously. Then there's hermits, or people who self-isolate to better themselves. Typically, these individuals are trying to form relationships with God. So from a religious perspective, I think it still satisfies the relationships in our view. And of course, if we're not religious, we're not really too worried about hermits.
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And then there's those like that you mentioned the non self-imposed these individuals who have difficulty forming relationships. And I think that this is the challenge. But I think the difference here is that there's no reason to give up hope trying to form relationships. And I also think we'd be hard pressed to say that these individuals are living well. I think it's a tragedy that there's people who are isolated or lonely. And that's a call to action. It's not a call to abandon. It's a call to do our best to meet these people.
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Yeah, I think so. think relationships look different for everybody. And I think there's a lot of people who we might be quick to say have like schizoid personality or something, but really it just looks so different. They're not social in the ordinary sense, but they don't not care about others and they don't want to exist in isolation. just looks a lot different.
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All right, thank you Hudson.
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Thank you very much for joining and reflecting with us today.
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we'll see you next time on the Hippocratic Society podcast.