A New Ethic for A New Era: Shining a Moral Light on Healthcare
By Thomas P. Forlano, BSN, RN
In what has been called the 3rd Era of health, an era that aims to wisely synthesize technological, organizational, and cultural knowledge, a holistic consciousness is of central importance not only because it devotes proper deference to the human form as unified with natural, relational, and spiritual orders, but also because it creates a rich context in which the art and science of healing are best formulated and administered. By capitalizing on Dr. Donald M. Berwick’s (2016) proposition that the 3rd Era requires a moral appraisal of today’s healthcare apparatus, this article touches on key themes, namely holism and holistic embodiment, systems thinking, and information flow. Grassroots initiatives, integrative care, and coaching are also mentioned.
Mechanisms of disease are an increasingly precision-driven subject. Drug-based interventions predominate and are paired with every pathology. Genomic diagnostic and treatment interventions targeting human DNA denote individualized care. (Nothing is more unique, it is presumed, than a person’s genetic strand.) The agenda for such interventions is driven by a snowball of biomedical and pharmaceutical research funding, which outspends most other industries (Whicher et al., 2018).
Amidst biomedicine's compelling narratives, it may not be apparent that today’s healthcare paradigm struggles to sustain public health. One way to bring this discrepancy to light is in economic terms. When patients encounter a nurse, billions in expenditures (over 17 percent of GDP) converge at the point of care. The product of this exchange is unclear. Despite inordinate funding, positive health outcomes remain elusive (Gunja et al., 2023).
Healthcare's future is determined as much by humanistic developments (cultural, organizational, political) as by technology. Without a balance of power that better serves the public interest, we risk hubris. This will exacerbate conditions that have already left a workforce overworked and burnt out, and a patient roster dissatisfied and distrustful of healthcare. “Without a new moral ethos," Berwick concludes, “there will be no winners” (p. 1330).
Holism as the basis for caring science
Let’s not forget that scientific inquiry possesses both reductionistic and holistic ways of knowing. A paramount force in the evolution of human health involves a philosophical approach to conceiving the world through a paradigm of holism. Holism allows us to conceptualize totalities, interrelationships, design, and grand theory. J.C. Smuts (1926) who coined the term, understood holism to be the eventuality of any reductionist process, writing, “The Holistic view…does full justice to the structural and mechanistic characters of nature, and indeed it considers Mechanism simply an earlier phase of Holism, and therefor perfectly legitimate up to a point” (pp. 337-338). With a sense of intellectual humility, a complete representation of the wholeness of things is held in abeyance since the grand scope of interrelationships is rightfully imagined to exceed comprehension.
We conceive of interdependence and interrelationships without a complete explanation of the mechanisms therein by extending intuitive knowledge, which, along with other endowments, we inherit as a uniquely human faculty. Consider the irony: as if by a twist of Newton’s third law of motion, as we gain the power to peer into the biological mechanisms of the body, an equal and opposite consequence is that our questioning about the nature of the whole only intensifies. We do, however, assemble expedient models along the way such as the bio-psycho-social-spiritual model of health, which bridges knowledge of unifying principles and the practical objectives of healthcare.
The psycho-spiritual element of the stated model gives it depth, even as we learn how to incorporate its meaning into practice. We are verging on a frontier concerning mind and matter that has yet not been well defined in ancient or modern terms the reality of which will call upon ethical foundations to guide its responsible use. Marshall Vian Summers (1992) has described a particular relationship between mental and physical substance in this way: “The mental environment is the environment in which you think. The physical environment is the environment in which you act. The physical influences the mental, but the mental influences the physical to a greater degree.” The idea of a mental environment – an environment with physical characteristics, but invisible – may not be too difficult to accept as there are some scientific and pop-cultural reference points for such phenomena. To postulate, however, as Summers does, that the physical world is acted on by mental objects “to a greater degree” than the reverse points toward possibilities that occupy the utmost edge of our intellectual and scientific capacities.
Holism has been germane to nursing science for more than a century, embodied by figures such as Florence Nightingale, but the word holistic has entered the healthcare vernacular in recent times partly as a marketing device. When a healthcare agency lists holistic care as a service, it generally means comprehensive care, that is, a breadth of services. Differentiating holistic from comprehensive is significant.
Holistic mindset and how it informs cultural developments
Holistic nurses represent special knowledge and skills that are made explicit in the Core Essentials for the Practice of Basic Holistic Nursing (Erickson et al., Eds., 2017). What may not be apparent is the underlying implication of embodiment: to communicate holistic consciousness, as represented by the Core Essentials, holistic nurses undertake an initiation into unitary thought and experience, each to their capacity. This journey is likely life-long considering the directives of self-care, self-knowledge, and self-reflection – essential modes of the holistic mindset. The proverbial chain-smoking heart surgeon serves as a reminder that in previous times, one’s “walk” was not necessarily accountable to one’s “talk.” When marketing holistic care, healthcare agencies might utilize board-certified holistic nurses to substantiate their products.
Returning now to self-reflection, let’s substitute the qualifying word self with the word system. As Donella H. Meadows (2016), a systems analyst of repute, points out, “paradigms are the sources of systems” (p. 163). Modeling the system, therefore, clarifies the assumptions inherent to the paradigm. To examine the system in this way is, to borrow Berwick’s proposition, a moral analysis, that may shed light on those parts that impede intended outputs. It is a moral light because it intends to know the truth, no matter how inconvenient or disruptive. As a result, priorities may be reordered, and the business of healthcare may be harmonized with the virtues, values, and enthusiasm of its practitioners.
The triple aim, summarized by The Institute for Healthcare Improvement (2023) as “applying integrated approaches to simultaneously improve care, improve population health, and reduce costs per capita” is succinct and resonant. Duty to these aims is distributed over an industry composed of numerous public and private scientific, technological, and organizational fields – a system so complex that the inefficient actors, which eat up monetary inputs and hamper desired outcomes, are obscured.
Systemic barriers and solutions
The tension between proprietary and public interests, each faithful to divergent research priorities, reveals obstinate structural barriers at play. Laying bare a critical mechanism at work within institutional relationships, Barbara K. Redman (2023) refers to large industrial motives by writing, “COI [conflict of interest] is widespread, in part because these industries have purposefully infiltrated multiple networks in order to assure their commercial interests, a documented pattern that has only recently been called out as violating the primary interest of health care/research.” There is a moral incentive to correct behaviors that enter dissonance into a system seeking harmony. Without explicit feedback, as Redman offers it, the system cannot learn to correct.
George L. Engel (1977), a key figure in medical thought, asked for a “general systems theory” outlook that is best represented today by the concept of a learning health system, defined in the National Academy of Medicine report, Priorities on the Health Horizon (2020) as, “[a system] in which the alignment of evidence, informatics, incentives, and culture naturally accelerates advances in health system effectiveness, efficiency, equity, and continuous learning.” Feedback, in all its forms, is essential for self-correction. Transparency, and in Berwick’s words, “absolute transparency” (p. 1330) and a free flow of information, is, therefore, a central ethos of the 3rd Era.
Cultural norms do change. Consider evidence-based practice (EBP) in clinical care. Evidence-informed is the recent term, and the upgrade is not simply semantic. Evidence-informed practice is an approach drawing on multiple forms of data (not just quantitative) and permits clinicians to use their experience, clinical observations, and knowledge of their patients to inform decisions (Woodbury & Kuhnke, 2014). EBP was adopted as a standard to reduce disparate practices and erroneous methods. Adherence, however, has risked an overreliance on the strictest forms of evidence as the only means to arrive at meaningful hypotheses, reasonable conclusions, and a sound set of working theories.
Frankly, “big pharma” and “big food” (monikers that highlight the proximity of large industrial interests to the political process) exert heavy influence on the pool of evidence and the popular mindset resulting in policies and protocols constraining clinical agency and common sense. There is more than a quest for best practice underway; there is a battle for control and propagation of information. Engel grasped the situation decades ago by stating, “In science, a model is revised or abandoned when it fails to account adequately for all the data. A dogma, on the other hand, requires that discrepant data be forced to fit the model or be excluded.” In the U.S., peer review, to extend the analogy, seems to be a task of forcing square pegs into round holes, most notably as it pertains to marketing proprietary pharmaceuticals, precluding earnest attempts by clinicians to form unbiased judgments and evaluate the utility of ambiguous data.
As an example of informational discontinuity, take the American Heart Association’s (2019) recent advisory summarizing the research basis for removing dietary cholesterol targets from their guidelines. Their meta-analysis showed mixed evidence for an association between cholesterol intake and cardiovascular disease. While the Association's diet guidance holds to the Mediterranean pattern, including “liquid vegetable oils,” considering that many patients treated for heart attack have normal blood lipid panels ought to provide a strong basis for re-evaluating current understanding. Referring to reputable sources online (e.g., Mayo Clinic, Cleveland Clinic, CDC) offers familiar guidance and textbook explanations of pathology. Recommendations to lower saturated fat and increase vegetable oil intake, based on a combination of epidemiological metrics and extant nutritional guidelines, have attempted to reduce morbidity with questionable success.
It takes some information two decades before coming into use. For instance, it is not commonly known that recommendations to consume seed oils have a convincing contraindication (Nelson, 2022). If animal fats were treated with the same appreciation given to the vegetable kingdom, there might be greater consensus on their nutritional value to human life. If seed oils are problematic for people’s health, that would be a disruptive revelation.
The nutritional zeitgeist concerning dietary fat, however, vilified a nutrient that nourished the species for millennia and replaced that resource with types and quantities of oils foreign to human consumption until relatively recent times. The regenerative narrative recognizes animal husbandry as a valuable tradition consonant with, rather than dissonant with, environmental stewardship. Key to building soils and sequestering carbon, the intimate relationship between managed animals and land makes dietary fat a product of nature’s design, rendering fat from ecological systems for the good of humankind. Our relationship with animals as food could be considered one of our most ethical expressions of interrelationship since the interdependence of species is meant to sustain all into the future.
The call for information freedom by bringing evidence into the light of day, essential to improving healthcare, is clarion. As though information flow was a sacred law, Meadows declares an eleventh commandment: “Thou shalt not distort, delay, or withhold information” (p. 173). She continues: “You can drive a system crazy by muddying its information streams. You can make a system work better with surprising ease if you can give it more timely, more accurate, more complete information.” Now there is an ethos equally conscientious as it is disruptive.
The new model of care will support holistic values
The belief that the body can heal is axiomatic to the new era and better experienced than taken on faith. A groundswell of anecdotal and clinical evidence emanating from small health businesses, many web-based, affirms this evolving belief. In response to this evidence, rather than say, "That's not possible," we might ask, "How is that possible?" and then proceed to generate and test new hypotheses and research agendas.
Healing is best served by an integrative care model defined by Jonas and Rosenbaum (2021) as involving “the optimal combination of all evidence based approaches to help heal the person as a whole.” Importantly, an integrative model is interdisciplinary and incorporates the expertise of multiple health and healing professionals.
Health coaching is a powerful complementary discipline that will play a meaningful role going forward. Coaching is blossoming as a viable, highly skilled, and evidence-informed service based on relational art and science. Coaching supports the client's need to take an active role in their health. The coaching process strengthens the individual’s innate meaning and motivation for growth and change. Furthermore, coaches do not predetermine a goal or assume they know how the client will reach it; the person makes these determinations, which can bring important issues to the surface that may at first seem peripheral. Holistic coaching is particularly effective because it taps into multiple ways of knowing about one’s inner and outer world.
Holistic nurse coaching may address a specific health concern but also extends to goals that surround health such as work/career, decision-making, relationships, wellness, and spiritual practice. More importantly, holistic coaches apply expertise in mind-body approaches. These approaches often go beyond thinking or problem-solving about the goal. For example, techniques that involve movement/embodiment (essentially getting "out of the head" and into the body), visualization, insight, intuition (both the client's and the coach's), breathing, prayer, "parts work" (historically called subpersonality work) in addition to basic skills such as deep listening and powerful questions.
All together these can be neatly summarized as mind-body approaches. The Holistic coach facilitates a process of self-inquiry leveraging the client's mental, physical, and spiritual intelligence. The holistic coach also employs core competencies set forth by the International Coaching Federation. What people need to know is that coaching not only is an emerging vocation; it is a highly skilled trade supported by standards of practice and will play an important role in integrative care models aimed at increasing the quality of life for consumers. There is a current effort underway to include coaching as a billable service under CPT codes.
The industrious activities of healthcare account for gargantuan sums of knowledge, expertise, and public consumption. The new era will require that normative processes be subject to a moral light, distilling practical wisdom and welcoming diversity in clinical expertise.
Berwick, D. M. (2016). Era 3 for Medicine and Health Care. JAMA, 315(13), 1329–1330. https://doi.org/10.1001/jama.2016.1509
Engel, G. L. (1977). The Need for a New Medical Model: A Challenge for Biomedicine.
Erickson, M., & Sandor, K. (Eds.) (2017). Core Essentials for the Practice of Basic Holistic Nursing: Overview. American Holistic Nurses Credentialing Center.
Gunja, M. Z., Gumas, E. D., & Willilams II, R. D. (2023, January 31). U.S. Health Care from a Global Perspective, 2022: Accelerating Spending, Worsening Outcomes.
The Commonwealth Fund, Issue Briefs: Improving Healthcare Quality. https://doi.org/10.26099/8ejy-yc74
Jonas, W. B., & Rosenbaum, E. (2021). The Case for Whole-Person Integrative Care. Medicina, 57(7), 677. https://doi.org/10.3390/medicina57070677
Meadows, D. H., & Wright, D. (2008). Thinking in systems: A primer. Chelsea Green Pub.
Nelson, C. (2022, May 18). Are Seed Oils Toxic? The Latest Research Suggests Yes. Zero Acre. https://www.zeroacre.com//blog/are-seed-oils-toxic
Redman, B. K. (2023). Rebalancing commercial and public interests in prioritizing biomedical, social and environmental aspects of health through defining and managing conflicts of interest. Frontiers in Medicine, 10, 1247258. https://doi.org/10.3389/fmed.2023.1247258
Smuts Hon J.C. (1927). Holism And Evolution. Macmillan And Company Limited. http://archive.org/details/holismandevoluti032439mbp
Summers, M.V. (1992). Self-Expression & the Mental Environment. Wisdom from the Greater Community Book 2. Retrieved December 4, 2023, from https://www.newmessage.org/the-message/volume-6/wisdom-greater-community-book-2/self-expression-the-mental-environment/
The IHI Triple Aim | IHI - Institute for Healthcare Improvement. (2023). Retrieved April 18, 2023, from https://www.ihi.org:443/Engage/Initiatives/TripleAim/Pages/default.aspx
Whicher, D., Rosengren, K., Siddiqi, S., & Simpson, L. (Eds.). (2018). The future of health services research: Advancing health systems research and practice in the United States. National Academy of Medicine.
Woodbury, M. G., Bscpt, Msc, J., & Kuhnke, J. (2014). Evidence-based Practice vs. Evidence-informed Practice: What’s the Difference? Wound Care Canada, 12, 18–21.
Thomas P. Forlano, BSN, RN, is a freelance writer and travel nurse specializing in correctional health. He earned a B.S. in Health Psychology & Spirituality from Bastyr University and a B.S.N from Regis University. As an alumnus of the Wisdom of the Whole Coaching Academy, Thomas is currently pursuing board certification in holistic nurse coaching. Beginning formal meditation studies in 2008 as guided by Steps to Knowledge: The Book of Inner Knowing, Thomas draws on extensive firsthand knowledge of spiritual practice. His present creative project engages with chronic illness narratives portrayed through pastel artwork.