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How we conceive of autonomy, goodness, and justice (or their absence) serves as a fulcrum to reimagine the care clinicians offer for patients like Amy. The philosopher Andreas Esheté argues that in the revolutionary triad of liberty, equality, and fraternity, it is fraternity that serves as the scaffold for both liberty and equality. And yet, ironically, fraternity is the feature most likely to be omitted from modern descriptions of justice. In other words, in the context of a contemporary emphasis on personal fulfillment and social fairness, we eclipse the role of fraternity – mere friendship – in our pursuit of justice. With Amy and other insufferable patients, an emphasis on liberty and equality (autonomy and justice) proves inadequate. As Sheldon Vanauken writes in Under the Mercy, “We can all agree that we ought to love our neighbors, except of course the awful ones we happen to have.”

An ethic of fraternalism cannot be based on Amy’s utility – what she might offer us, an interesting case history or clinical pearl perhaps. Amy’s case may have been interesting at first, but we admitted her so many times that there seemed to be nothing left for us to learn from her. A fraternalism of pleasure was impossible; her care was far from enjoyable.

If an ethic of fraternalism is to contribute to the moral imagination of medicine, it must be this third category, friendship of virtue – sometimes called a moral friendship – in which we commit to seek the good of the other regardless of the experience of caring for them, what they might offer us in return, and perhaps especially what they “deserve.”

A family member recently asked if it makes me angry “when people don’t take care of themselves.” I pointed out that patients who “don’t take care of themselves” are often burdened by other cares (such as taking care of others who can’t take care of themselves). “Self-care,” a near-perfectly ironic term, is often available to the optimized elite who can afford yoga and counseling. Those who don’t have a vision for bodily well-working – who are apathetic toward their creatureliness – are often the ones most in need of medicine. My family member wasn’t convinced.

Read more in Plough.

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