Br. J. med. Psycho/. (1977). SO. 305-31 I
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Altruism and the practice of medicine Issy Pilowsky
Biological and psychological research into the antecedents of altruism has considerable significance for those involved in the teaching or practice of medicine. The evidence available indicates that altruistic behaviour is a universal phenomenon influenced by intra-individual, interpersonal, situational and sociocultural factors. A central theme which emerges is the strikingly ambivalent nature of the altruistic drive. The factors which may facilitate or inhibit altruism in medical students and doctors are discussed. Some ways of ensuring that medical training does not seriously distort altruism are suggested.
Research into the origin and nature of altruism is a relatively recent phenomenon. It has however, produced a body of knowledge which carries significant implications for medical practice and training, particularly if one believes that a close relationship exists between the practice of medicine and the altruistic impulse. While the nature of this association is obviously not a straightforward one, many assert that altruism plays an important role in influencing individuals to enter upon the study of medicine, which then, somewhat paradoxically, dehumanizes them so that the ability to perceive patients as human beings is progressively diminished (Eron, 1955; Becker, Geer, Hughes & Strauss, 1%1; Coombs & Boyle, 1971). If this is indeed the case, there would appear to be a distinct need for medical educators to consider the findings of altruism research and their possible relevance to current training programmes. It is the purpose of this paper to make some initial efforts in this direction. The problem of definition .Utruism is a term not easily defined; nor is it among the aims of this paper to arrive at a generally acceptable definition. Whether biologically or psychologically based, most definitions of altruism have been criticized for being either too vague or too stringent, and attempts to demonstrate or refute the existence of this behaviour generally founder on the reefs of disagreement over criteria to be met. In particular, it is the element of conscious self-sacrifice which has caused most problems when included as a central ingredient of any formulation. Philosophers have, of course, debated these issues at length, both before and since Auguste Comte coined the term in the mid-19th century (Milo, 1973). While the relevance of these deliberations to medicine is freely acknowledged, their discussion is beyond the scope of this paper, focusing as it does on the origins and determinants of altruism (defined operationally) as elucidated by biological and psychological researchers. Leeds (1963) considers an altruistic act to be one which is an end in itself (and not directed at gain); which is committed voluntarily and which has a beneficial effect. Aronfreed (1968) however, states that ‘an act displays altruism’ when ‘the choice of one act, in preference to an alternative act, is at least partly determined by the actor’s expectation of consequences which will benefit another person rather than himself ’. Midlarsky (1968) on the other hand offers criteria which are somewhat less absolute. This author considers ‘altruism’ to be a subcategory of ‘aiding’. Thus while ‘aiding’ refers to ‘all behaviours - involving either a sharing of one’s “wealth” or a sharing of discomfort or danger - where one individual comes to the assistance of another in distress,’ altruism refers to ‘helpful actions which incur some cost to the individual but bring either very little or nothing by way of gain, relative to the magnitude of the investment ’. Going further, Midlarsky suggests four criteria for altruism: The gain (if any) to one individual must be small in relation to the investment; the act must not be prescribed by an II
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individual’s role or the demand characteristics of an experiment; the act must be ‘costly’ to the particular individual (benefactor) and alternative acts must be available (including doing nothing) which involve the benefactor in no greater cost than being helpful. Midlarsky acknowledges that her criteria are stringent and difficult to meet, and suggests therefore that it might be simplest and best to direct research efforts towards the elucidation of those variables which induce helpfulness as well as those which impede or prevent it in situations where one might expect it to occur. Are there innate dispositions towards the acquisition of altruistic behaviour? This knotty issue invariably arises in any consideration of this topic, and its resolution is clearly of some importance. It is perhaps natural therefore that biologists have become increasingly interested in this area. Some have indeed proposed that an innate disposition toward altruism may confer adaptational advantages to a species, and Hebb (1971), has asserted, perhaps somewhat provocatively, that ‘the only decisive evidence of the existence of altruism as such, comes from large brained infra-human mammals ’. As previously observed, much depends on definition. Power (1975) for example, while drawing attention to the fact that social policy makers are bound to be influenced by any research which purports to establish whether ‘humans, like other animals, are either basically aitruistic or selfish ’, defines ‘true altruism ’ as ‘the promotion of others ’ reproductive success while reducing one’s own inclusive fitness’. This model, expressed in terms of natural selection, is typical of those which Trivers (1971) believes are ‘designed to take the altruism out of altruism’. Darlington (1972) however, states that ‘biological altruism, broadly defined, includes all those behaviours by which some individuals benefit others of the same species without benefitting themselves ’. A survey of the relevant literature, with particular attention to care-giving behaviour by animals towards others who are sick, injured or distressed, indicates that although this type of response does occur in many species, both in laboratory and naturalistic situations, it is not invariably evoked. Thus altruistic behaviour has been reported in laboratory rats (Rice & Gainer, 1962), whales, dolphins and porpoises (Caldwell & Caldwell, 19661, birds (Chauvin, 1971), rhesus monkeys (Masserman, Wechkin & Terris, 1965), howler monkeys (Zuckerman, 1932) and chimpanzees, both in field (Goodall, 1971) and laboratory settings (Miles, 1%3). In relating this type of evidence from other species to man, Campbell (1972) concludes that ‘in man genetic competition precludes the evolution of. . .genetic altruism. The behavioural dispositions which produce complex social interdependence and self-sacrificial altruism must instead be products of culturally evolved indoctrination, which has had to counter self-serving genetic tendencies. Thus. . .man is profoundly ambivalent in his social role ’. It is fairly self-evident that no society could long survive a situation in which altruism was systematically accepted and not reciprocated. In this regard writers such as Campbell (1972) and Trivers (1971) have emphasized the importance to group survival of the balance between ‘altruistic’ and what they refer to as ‘cheating’ tendencies. While these authors differ in the degree to which they are prepared to ascribe the origins of this balance to evolution in either the genetic or the cultural sense, they do agree that it is the balance as such, which is crucial to species survival. In Trivers’ (1971) words ‘each individual is seen as possessing altruistic and cheating tendencies, the expression of which is sensitive to developmental variables that were selected to set the tendencies at a balance appropriate to the local, social and ecological environment’. Further, he asserts that ‘given the universal and nearly daily practice of reciprocal altruism among humans today, it is reasonable to assume that it has been an important factor in recent human evolution and that the underlying, emotional dispositions affecting altruistic behaviour have important genetic components ’.
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Altruism in the clinical context The evidence available therefore, suggests the presence of a universal potential for altruistic behaviour, commonly evoked by others in distress. It would be surprising therefore if these tendencies were not mobilized in the clinical context and since such impulses may, in the short and long term have either beneficial or deleterious effects on patients it seems important to consider the factors which influence their expression. We may now turn to the findings of human altruism research and consider their implications for the teaching and practice of medicine. In doing so, I have drawn on the excellent papers of Trivers (1971), Krebs (1970) and Midlarsky (1968), who, between them have extensively reviewed the research into the antecedents of human altruism, at the societal, institutional and individual levels. Sociocultural influences on altruistic behaviour These operate mainly through the development and transmission of norms and values. The universal condemnation of certain non-altruistic behaviours by all cultures and codes has been commented on by Campbell (1972) who states ‘the commandments, the proverbs, the religious “law represent social evolutionary products directed at inculcating tendencies that are in direct opposition to the “temptations ” representing for the most part the dispositional tendencies produced by biological evolution. For every commandment we may reasonably hypothesize a tendency to do otherwise which runs counter to the social-systemic optimum’. Trivers (1971) believes that the predisposition for moralistic aggression and indignation plays an important role as a protective mechanism, against the possibility of altruists being taken advantage of by non-reciprocaters or ‘cheaters ’, and is consequently selected for in the evolutionary-genetic sense. Society’s attitude to the care of the sick vividly displays the ambivalence hypothesized by Campbell (1972). The medical student or doctor who seeks for evidence of society’s total commitment to the care of the sick, injured and disabled, as espoused by all explicit codes and mores, is bound to be struck by as much neglect as care, as much indifference as concern. Public disputes over the proportion of funds to be allocated for medical as opposed to other services, are rarely absent from newspaper columns. The state of many hospitals compares unfavourably with that of structures dedicated to the pursuit of pleasure or recreation. But these relatively general cues are not the only means by which society’s ambivalence is communicated to the medical profession. In these days of state supported medical services, the importance of cost-effectiveness is repeatedly emphasized. The fact that finances are not unlimited is well known, the doctors are therefore required not only to consider which treatment regime is best suited to the patient’s needs, but also the cost to the community, and the contribution which the treated individual will be capable of making to the common weal. Thus the care of the elderly and the disabled has clearly been placed lower on the list of priorities than that of other sections of the community and, where costly facilities have been provided for the retarded or the chronically disabled, the wisdom of such expenditures is frequently questioned. Nonetheless, society clearly expected doctors to display unalloyed altruism and indicates surprise and indignation when, instead, they manifest precisely the same ambivalent attitudes as their fellow citizens. Campbell’s (1972) prediction that there should exist ‘Certain uniformities in the popular moralizings of all complex societies ’ might well apply to institutions and professions. Significantly, it is the medical profession which has felt the need to evolve a system of moral guidelines such as.are embodied in the Hippocratic Oath. Could this flow from the realization that when a particular group of individuals is expected to behave consistently in an altruistic manner, the need for stringent controls becomes particularly strong? The existence of medical boards charged with the surveillance of professional behaviour points to a deep fear that medical ”
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men may take advantage of their patient and exploit them in their own interests rather than seeking to provide for their needs. We may conclude, therefore, that not only does society display quite unequivocally its own ambivalence towards the ill and disabled, but that it anticipates, and guards against, such tendencies in its doctors. Such societal pressure must inevitably generate role conflicts in the medical profession, and may help to explain the regularity with which doctors and policy makers clash over health care delivery issues. It may be well for both groups to acknowledge the central dilemma which faces those who would wish to provide services which have altruistic connotations. While these sociocultural problems are far from being solved, the altruistic behaviour of individuals may be more amenable to influence. Much work has been directed at the elucidation of variables influencing altruistic behaviour at the individual and small group level. These studies have focused on both donor and recipient characteristics and have examined the effects of variables such as transient individual states, personality structure, social settings, interpersonal perception and demographic factors (Midlarsky, 1968; Krebs, 1970). Attributes of the benefactor It has been observed that certain characteristics of the benefactor may influence the likelihood of his manifesting altruistic behaviour. In particular, there is considerable agreement as to the role of competence. Thus individuals are found more likely to render aid to another in a specific situation, if they regard themselves as possessing the competence to provide appropriate help. In many situations they will not be moved to acton if the appearance of the potential recipient suggests the presence of a problem to which they do not feel equal. It seems highly probable that this variable constitutes an important factor influencing the altruistic behaviour of both medical students and doctors. Since a substantial objective of any training programme is to sensitize individuals to their areas of deficient competence, so that they might take appropriate steps to deal with them, a medical student must inevitably experience a heightened awareness of his lack of competence throughout his training. One can predict that this aspect of his self-perception will act to inhibit his altruistic impulse but one might also comment that, in the patient’s best interests, it is probably as well that it should. However, it seems desirable to avoid an excessive reaction of this sort as far as is compatible with patient safety. This may be achieved by allocating responsibilities for aspects of patient evaluation and care to the student, which are indeed within his competence. Tasks of this sort can include history taking and problem clarification, as well as certain circumscribed technical procedures demanding limited psychomotor skill. Of particular importance is the ready availability of supervision so that the student may be assured of prompt guidance should he be concerned as to the appropriateness or adequacy of his efforts. Success, failure and guilt The findings of certain workers suggest that individuals are more likely to show altruistic behaviour after the experience of achieving success, than after failure. While this relationship is by no means clear cut it does suggest that medical students who feel they are not reaching their goals, will show less altruistic behaviour. This possibility provides further support for the educational practice of praising what is done well, more often than criticizing inadequacies. However, it is interesting to note that when subjects feel that their failure has involved harm to another, they are more likely to show altruistic behaviour thereafter. This suggests that student errors should be discussed in terms of their implications for patient care and (whenever possible) a specific patient; although clearly, too great an arousal of guilt may produce a lowered sense of competence and inhibit altruistic behaviour.
Altruism and the practice of medicine 309 Attributes of the recipient
Interpersonal attractiveness, similarity to the benefactor and dependency have all been found to be positively related to the likelihood of altruistic behaviour. In most societies, and particularly in pluralistic ones, the chances that a doctor or student will not share a patient’s socioeconomic and ethnic background are high indeed. Even in the absence of language barriers, they are more likely to experience altruistic impulses towards a patient who is of their own social and cultural background than one who is not. This effect may, however, be offset by the perception of the patient as dependent, perhaps as a function of his socioeconomic and ethnic status. In some instances, the doctor may actually prefer to think of the patient who differs from him as not only dissimilar, but also inferior, since such status may be seen as rendering the patient less likely to detect or comment on any shortcomings in his benefactor. There is clearly no simple answer to the problem of student- or doctor-patient dissimilarity, but a step in the right direction might be for teachers to discourage stereotyping and to emphasize a proper appreciation of sociocultural factors and their significance, while at the same time, drawing attention to the unique attributes possessed by individual patients and the importance of their understanding to the effectiveness of therapy. Dependence in the potential recipient represents a crucial variable. As Krebs (1970) points out ‘the essential attribute of a recipient is his perceived need for aid. In almost all of the reported studies on altruism, altruistic behaviour was elicited by dependency’. We may expect this factor to result both in a tendency for the patient to emphasize his own dependence, and a desire on the part of doctors and students to perceive and foster this attribute in the patient. However, it is in relation to dependence, that the ambivalence to which Campbell (1972) and Trivers (1971) have drawn attention, may be most graphically manifested. Confronted by dependent behaviour the medical profession shows most clearly the effects upon it of societal fears of being ‘cheated’ by recipients of altruism and the possible contravention of the norm of reciprocal altruism. Thus dependency as such is not sufficient to evoke altruism. The perceived origins and causes of the patient’s dependency invariably influence the benefactor’s response. As a number of studies have shown, altruism is more likely to occur if the dependence appears to have a cause external to the potential recipient, and is less likely if he is considered responsible for his problems. These findings tally well with the tendency for patients who have attempted suicide or suffer alcohol-related disorders, to be given short shrift by some doctors and students. Patients who are seen as responsible for their dependency almost to the point of malingering or simulating, do not elicit altruistic responses, but often quite overt hostility or indifference. This attitude may be extended, not only to patients who are believed to be consciously malingering but, also, to those showing forms of abnormal illness behaviour (Pilowsky, 1%9) such as hysterical conversion reactions and hypochondriasis (Mead, 1965), as well as those suffering from psychological disturbances which, it may be felt, should be under conscious control. Thus, in referring to hypochondriacal patients, King (1916) writes of ‘the terror of the doctor ’ and Alvarez (1944) advises that the physician ‘ should try to get them out of the office as quickly as possible because the time they take up is spent to no good purpose’. The ambivalence shown to those seeking financial compensation following industrial injuries is particularly well known. The effects of such recipient characteristics can only be offset by teaching aimed at increasing the students’ diagnostic and therapeutic competence in relation to clinical problems of this type, as well as open and informed discussion of the variables (societal, biological and personal) which influence their resolution. It may well be that such discussions need to be undertaken regularly, not only in the context of clinical teaching, but by the profession as a whole. Finally, we may consider the role of models in the genesis of altruism. It has been shown (Bandura & Walters, 1963) that exposure to altruistic models may encourage altruistic behaviour.
3 10 Zssy Pilowsky
Although these findings do not explain precisely how the process works, they are nonetheless of interest to medical educators. Clearly, students will be influenced in their approach to patients by observation of attitudes manifested by their instructors; and since the instructor’s attitude to the patient may easily be misinterpreted it is most important that they be explicitly considered in any clinical teaching exercise. A number of studies have shown that behaviour models provided by groups may be a potent factor in inhibiting altruism under certain circumstances. For example, individuals have been found less likely to take action in an emergency, or give aid, if others are present or believed to be present. In particular, as Latane & Darley (1970) have shown, the presence of others who seem unconcerned, often inhibits altruism. These findings suggest that members of a medical team may be inhibited by each other’s presence, students may be inhibited by each other and indeed a clinical teacher may be less altruistic in the presence of students. Consequently a clinician may be most likely to show altruism when alone with a patient; and is thus, paradoxically, not available as a model for students at what is perhaps the most opportune moment. On the positive side, it has also been found that group behaviour may encourage altruism. As Midlarsky (1968) points out, group size does not act in isolation; factors such as group morale and cohesiveness are also important and can inhibit or facilitate altruism depending on the degree to which the affected individual feels identified with the group. The relevance of such findings to the formation of student groups is fairly self evident.
Summary The purpose of this paper has been to draw attention to an area of human behaviour which has been the focus of much research in the past few decades, and which is of considerable relevance to the teaching and practise of medicine. It appears that altruistic behaviour, whatever its origins, is a form of activity universally observed and delicately modulated by a constellation of sociocultural, situational and personality factors. Society’s ambivalence towards those in need would seem to have its origins in survival-oriented behaviours which may be understood in biological and cultural evolutionary terms. The doctor, inevitably influenced by this ambivalence, occupies a singularly exposed and demanding social role. The community need to perceive doctors as altruistic alternates with the need to condemn them as self-seeking, just as often as doctors vary in their perception of patients from being worthy recipients of aid to being undeserving ‘cheaters ’. This conflict between man and his appointed helpers is as old as man himself, and must, it would seem, be regarded as an inevitable consequence of his very nature (Trivers, 1971; Campbell, 1972). In the last analysis, however, man cannot easily exist, without the knowledge that, in the last resort, competent medical help will be made available to him. In the absence of such certainty the morale of individuals in any community must inevitably be severly impaired. It is for this reason perhaps, that society scrutinizes the altruistic behaviour of the medical profession so closely. Given the central role of altruism in medical practice, there seems every reason for the profession to turn its attention to the understanding of this aspect of human behaviour. References ARONFREED, J. (1968). Conduct and Conscience. New York: Academic Press. ALVAREZ, W. C. (1944). A gastro-intestinal hypochondriac and some lessons he taught. Gastroenterology 2, 265-269. BANDURA, A. & WALTERS, R . H. (1%3). Social learning and Personality Development. New York: Holt, Rinehart & Winston.
BECKER,H. S., GEER,B . , HUGHES,E. C. & STRAUSS,A. L. (l%l). Boys in White. Chicago: University of Chicago Press. CALDWELL, M. C. & CALDWELL, D. K. (1966). Epimeletic (care-giving) behaviour. In K . S. Norris (ed.), Cetacea, Whales, Dolphins and Porpoises. Berkeley: University of California Press. CAMPBELL, D. T. (1972). On the genetics of altruism
Altruism and the practice of medicine 3 11 and the counter-hedonic components in human culture. J. social Issues 28, 21-37. CHAUVIN, R. (1971). Animal Societies. London: Sphere. COOMBS,R. H. & BOYLE,B. P. (1971). The transition to medical school: Expectations versus realities. In R. H. Coombs & B. P. Boyle (eds), Psychological Aspects of Medical training. Springfield, Ill.: Thomas. DARLINGTON, P. J. (1972). Nonmathematical models for evolution of altruism, and for group selection. Proc. natn. Acad. Sci. U.S.A. 69, 293-297. ERON,L. D. (1955). Effect of medical school education on medical students’ attitudes. J. med. Educ. 30,559-566. GOODALL, J. van L. (1971). In the Shadow of Man. Boston: Houghton MiWin. HELIB,D.0. (1971). Comment on altruism; the comparative evidence. Psychol. Bull. 76, 409410. KING,J. (1916). Hypochondria. Med. Rec. 90, 195- 1%. KREBS,D. L. (1970). Altruism -an examination of the concept and a review of the literature. Psycho/. Bull. 73, 258-302. LATANE,B. & DARLEY, J. M. (1970). Social determinants of bystander intervention in emergencies. In J. Macaulay & L. Berkowitz
(eds), Altruism and Helping Behaviour. London: Academic Press. LEEDS,R. (1%3). Altruism and the norm of giving. Menill-Palmer Q. 9, 229-240. J. H., WECHKIN,S. & TERRIS,W. MASSERMAN, (1%5). Altruistic behaviour in rhesus monkeys. A m . I . Psychiat. 121, 584-585. MEAD,B. I. (1%5). Management of hypochondriacal patients. J. Am. med. Ass. 192, 33-35. E. (1%8). Aiding responses: Analysis MIDLARSKY, and review. Merrill-Palmer Q. 14, 229-260. MILES,W.R. (1%3). Chimpanzee behaviour: Removal of foreign body from companion’s eye. R o c . natn. Acad. Sci. U.S.A.49, 840-843. MILO, R. D. (ed.) (1973). Egoism and Altruism. Belmont Calif.: Wadsworth. I. (1%9). Abnormal illness behaviour. PILOWSKY, Br. J. med. Psychol. 42, 347. POWER,H. W.(1975). Mountain bluebirds: Experimental evidence against altruism. Science, N.Y.189, 142-143. RICE, G. E. & GAINER,P. (1962). Altruism in the albino rat. J. romp. physiol. Psychol. 55, 123-125. TRIVERS,R. L. (1971). The evolution of reciprocal altruism. Q. Rev. Biol. 46, 35-37. ZUCKERMAN, S. (1932). The Social Life of Monkeys and Apes. London: Kegan, Paul, Trench, Tribner.
Received 9 December 1975; revised version received 25 February 1976 Requests for reprints should be addressed to Professor I. Pilowsky, Department of Psychiatry, University of Adelaide, Adelaide, South Australia, 5001.
305
Printed in Great Britain
Altruism and the practice of medicine Issy Pilowsky
Biological and psychological research into the antecedents of altruism has considerable significance for those involved in the teaching or practice of medicine. The evidence available indicates that altruistic behaviour is a universal phenomenon influenced by intra-individual, interpersonal, situational and sociocultural factors. A central theme which emerges is the strikingly ambivalent nature of the altruistic drive. The factors which may facilitate or inhibit altruism in medical students and doctors are discussed. Some ways of ensuring that medical training does not seriously distort altruism are suggested.
Research into the origin and nature of altruism is a relatively recent phenomenon. It has however, produced a body of knowledge which carries significant implications for medical practice and training, particularly if one believes that a close relationship exists between the practice of medicine and the altruistic impulse. While the nature of this association is obviously not a straightforward one, many assert that altruism plays an important role in influencing individuals to enter upon the study of medicine, which then, somewhat paradoxically, dehumanizes them so that the ability to perceive patients as human beings is progressively diminished (Eron, 1955; Becker, Geer, Hughes & Strauss, 1%1; Coombs & Boyle, 1971). If this is indeed the case, there would appear to be a distinct need for medical educators to consider the findings of altruism research and their possible relevance to current training programmes. It is the purpose of this paper to make some initial efforts in this direction. The problem of definition .Utruism is a term not easily defined; nor is it among the aims of this paper to arrive at a generally acceptable definition. Whether biologically or psychologically based, most definitions of altruism have been criticized for being either too vague or too stringent, and attempts to demonstrate or refute the existence of this behaviour generally founder on the reefs of disagreement over criteria to be met. In particular, it is the element of conscious self-sacrifice which has caused most problems when included as a central ingredient of any formulation. Philosophers have, of course, debated these issues at length, both before and since Auguste Comte coined the term in the mid-19th century (Milo, 1973). While the relevance of these deliberations to medicine is freely acknowledged, their discussion is beyond the scope of this paper, focusing as it does on the origins and determinants of altruism (defined operationally) as elucidated by biological and psychological researchers. Leeds (1963) considers an altruistic act to be one which is an end in itself (and not directed at gain); which is committed voluntarily and which has a beneficial effect. Aronfreed (1968) however, states that ‘an act displays altruism’ when ‘the choice of one act, in preference to an alternative act, is at least partly determined by the actor’s expectation of consequences which will benefit another person rather than himself ’. Midlarsky (1968) on the other hand offers criteria which are somewhat less absolute. This author considers ‘altruism’ to be a subcategory of ‘aiding’. Thus while ‘aiding’ refers to ‘all behaviours - involving either a sharing of one’s “wealth” or a sharing of discomfort or danger - where one individual comes to the assistance of another in distress,’ altruism refers to ‘helpful actions which incur some cost to the individual but bring either very little or nothing by way of gain, relative to the magnitude of the investment ’. Going further, Midlarsky suggests four criteria for altruism: The gain (if any) to one individual must be small in relation to the investment; the act must not be prescribed by an II
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individual’s role or the demand characteristics of an experiment; the act must be ‘costly’ to the particular individual (benefactor) and alternative acts must be available (including doing nothing) which involve the benefactor in no greater cost than being helpful. Midlarsky acknowledges that her criteria are stringent and difficult to meet, and suggests therefore that it might be simplest and best to direct research efforts towards the elucidation of those variables which induce helpfulness as well as those which impede or prevent it in situations where one might expect it to occur. Are there innate dispositions towards the acquisition of altruistic behaviour? This knotty issue invariably arises in any consideration of this topic, and its resolution is clearly of some importance. It is perhaps natural therefore that biologists have become increasingly interested in this area. Some have indeed proposed that an innate disposition toward altruism may confer adaptational advantages to a species, and Hebb (1971), has asserted, perhaps somewhat provocatively, that ‘the only decisive evidence of the existence of altruism as such, comes from large brained infra-human mammals ’. As previously observed, much depends on definition. Power (1975) for example, while drawing attention to the fact that social policy makers are bound to be influenced by any research which purports to establish whether ‘humans, like other animals, are either basically aitruistic or selfish ’, defines ‘true altruism ’ as ‘the promotion of others ’ reproductive success while reducing one’s own inclusive fitness’. This model, expressed in terms of natural selection, is typical of those which Trivers (1971) believes are ‘designed to take the altruism out of altruism’. Darlington (1972) however, states that ‘biological altruism, broadly defined, includes all those behaviours by which some individuals benefit others of the same species without benefitting themselves ’. A survey of the relevant literature, with particular attention to care-giving behaviour by animals towards others who are sick, injured or distressed, indicates that although this type of response does occur in many species, both in laboratory and naturalistic situations, it is not invariably evoked. Thus altruistic behaviour has been reported in laboratory rats (Rice & Gainer, 1962), whales, dolphins and porpoises (Caldwell & Caldwell, 19661, birds (Chauvin, 1971), rhesus monkeys (Masserman, Wechkin & Terris, 1965), howler monkeys (Zuckerman, 1932) and chimpanzees, both in field (Goodall, 1971) and laboratory settings (Miles, 1%3). In relating this type of evidence from other species to man, Campbell (1972) concludes that ‘in man genetic competition precludes the evolution of. . .genetic altruism. The behavioural dispositions which produce complex social interdependence and self-sacrificial altruism must instead be products of culturally evolved indoctrination, which has had to counter self-serving genetic tendencies. Thus. . .man is profoundly ambivalent in his social role ’. It is fairly self-evident that no society could long survive a situation in which altruism was systematically accepted and not reciprocated. In this regard writers such as Campbell (1972) and Trivers (1971) have emphasized the importance to group survival of the balance between ‘altruistic’ and what they refer to as ‘cheating’ tendencies. While these authors differ in the degree to which they are prepared to ascribe the origins of this balance to evolution in either the genetic or the cultural sense, they do agree that it is the balance as such, which is crucial to species survival. In Trivers’ (1971) words ‘each individual is seen as possessing altruistic and cheating tendencies, the expression of which is sensitive to developmental variables that were selected to set the tendencies at a balance appropriate to the local, social and ecological environment’. Further, he asserts that ‘given the universal and nearly daily practice of reciprocal altruism among humans today, it is reasonable to assume that it has been an important factor in recent human evolution and that the underlying, emotional dispositions affecting altruistic behaviour have important genetic components ’.
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Altruism in the clinical context The evidence available therefore, suggests the presence of a universal potential for altruistic behaviour, commonly evoked by others in distress. It would be surprising therefore if these tendencies were not mobilized in the clinical context and since such impulses may, in the short and long term have either beneficial or deleterious effects on patients it seems important to consider the factors which influence their expression. We may now turn to the findings of human altruism research and consider their implications for the teaching and practice of medicine. In doing so, I have drawn on the excellent papers of Trivers (1971), Krebs (1970) and Midlarsky (1968), who, between them have extensively reviewed the research into the antecedents of human altruism, at the societal, institutional and individual levels. Sociocultural influences on altruistic behaviour These operate mainly through the development and transmission of norms and values. The universal condemnation of certain non-altruistic behaviours by all cultures and codes has been commented on by Campbell (1972) who states ‘the commandments, the proverbs, the religious “law represent social evolutionary products directed at inculcating tendencies that are in direct opposition to the “temptations ” representing for the most part the dispositional tendencies produced by biological evolution. For every commandment we may reasonably hypothesize a tendency to do otherwise which runs counter to the social-systemic optimum’. Trivers (1971) believes that the predisposition for moralistic aggression and indignation plays an important role as a protective mechanism, against the possibility of altruists being taken advantage of by non-reciprocaters or ‘cheaters ’, and is consequently selected for in the evolutionary-genetic sense. Society’s attitude to the care of the sick vividly displays the ambivalence hypothesized by Campbell (1972). The medical student or doctor who seeks for evidence of society’s total commitment to the care of the sick, injured and disabled, as espoused by all explicit codes and mores, is bound to be struck by as much neglect as care, as much indifference as concern. Public disputes over the proportion of funds to be allocated for medical as opposed to other services, are rarely absent from newspaper columns. The state of many hospitals compares unfavourably with that of structures dedicated to the pursuit of pleasure or recreation. But these relatively general cues are not the only means by which society’s ambivalence is communicated to the medical profession. In these days of state supported medical services, the importance of cost-effectiveness is repeatedly emphasized. The fact that finances are not unlimited is well known, the doctors are therefore required not only to consider which treatment regime is best suited to the patient’s needs, but also the cost to the community, and the contribution which the treated individual will be capable of making to the common weal. Thus the care of the elderly and the disabled has clearly been placed lower on the list of priorities than that of other sections of the community and, where costly facilities have been provided for the retarded or the chronically disabled, the wisdom of such expenditures is frequently questioned. Nonetheless, society clearly expected doctors to display unalloyed altruism and indicates surprise and indignation when, instead, they manifest precisely the same ambivalent attitudes as their fellow citizens. Campbell’s (1972) prediction that there should exist ‘Certain uniformities in the popular moralizings of all complex societies ’ might well apply to institutions and professions. Significantly, it is the medical profession which has felt the need to evolve a system of moral guidelines such as.are embodied in the Hippocratic Oath. Could this flow from the realization that when a particular group of individuals is expected to behave consistently in an altruistic manner, the need for stringent controls becomes particularly strong? The existence of medical boards charged with the surveillance of professional behaviour points to a deep fear that medical ”
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men may take advantage of their patient and exploit them in their own interests rather than seeking to provide for their needs. We may conclude, therefore, that not only does society display quite unequivocally its own ambivalence towards the ill and disabled, but that it anticipates, and guards against, such tendencies in its doctors. Such societal pressure must inevitably generate role conflicts in the medical profession, and may help to explain the regularity with which doctors and policy makers clash over health care delivery issues. It may be well for both groups to acknowledge the central dilemma which faces those who would wish to provide services which have altruistic connotations. While these sociocultural problems are far from being solved, the altruistic behaviour of individuals may be more amenable to influence. Much work has been directed at the elucidation of variables influencing altruistic behaviour at the individual and small group level. These studies have focused on both donor and recipient characteristics and have examined the effects of variables such as transient individual states, personality structure, social settings, interpersonal perception and demographic factors (Midlarsky, 1968; Krebs, 1970). Attributes of the benefactor It has been observed that certain characteristics of the benefactor may influence the likelihood of his manifesting altruistic behaviour. In particular, there is considerable agreement as to the role of competence. Thus individuals are found more likely to render aid to another in a specific situation, if they regard themselves as possessing the competence to provide appropriate help. In many situations they will not be moved to acton if the appearance of the potential recipient suggests the presence of a problem to which they do not feel equal. It seems highly probable that this variable constitutes an important factor influencing the altruistic behaviour of both medical students and doctors. Since a substantial objective of any training programme is to sensitize individuals to their areas of deficient competence, so that they might take appropriate steps to deal with them, a medical student must inevitably experience a heightened awareness of his lack of competence throughout his training. One can predict that this aspect of his self-perception will act to inhibit his altruistic impulse but one might also comment that, in the patient’s best interests, it is probably as well that it should. However, it seems desirable to avoid an excessive reaction of this sort as far as is compatible with patient safety. This may be achieved by allocating responsibilities for aspects of patient evaluation and care to the student, which are indeed within his competence. Tasks of this sort can include history taking and problem clarification, as well as certain circumscribed technical procedures demanding limited psychomotor skill. Of particular importance is the ready availability of supervision so that the student may be assured of prompt guidance should he be concerned as to the appropriateness or adequacy of his efforts. Success, failure and guilt The findings of certain workers suggest that individuals are more likely to show altruistic behaviour after the experience of achieving success, than after failure. While this relationship is by no means clear cut it does suggest that medical students who feel they are not reaching their goals, will show less altruistic behaviour. This possibility provides further support for the educational practice of praising what is done well, more often than criticizing inadequacies. However, it is interesting to note that when subjects feel that their failure has involved harm to another, they are more likely to show altruistic behaviour thereafter. This suggests that student errors should be discussed in terms of their implications for patient care and (whenever possible) a specific patient; although clearly, too great an arousal of guilt may produce a lowered sense of competence and inhibit altruistic behaviour.
Altruism and the practice of medicine 309 Attributes of the recipient
Interpersonal attractiveness, similarity to the benefactor and dependency have all been found to be positively related to the likelihood of altruistic behaviour. In most societies, and particularly in pluralistic ones, the chances that a doctor or student will not share a patient’s socioeconomic and ethnic background are high indeed. Even in the absence of language barriers, they are more likely to experience altruistic impulses towards a patient who is of their own social and cultural background than one who is not. This effect may, however, be offset by the perception of the patient as dependent, perhaps as a function of his socioeconomic and ethnic status. In some instances, the doctor may actually prefer to think of the patient who differs from him as not only dissimilar, but also inferior, since such status may be seen as rendering the patient less likely to detect or comment on any shortcomings in his benefactor. There is clearly no simple answer to the problem of student- or doctor-patient dissimilarity, but a step in the right direction might be for teachers to discourage stereotyping and to emphasize a proper appreciation of sociocultural factors and their significance, while at the same time, drawing attention to the unique attributes possessed by individual patients and the importance of their understanding to the effectiveness of therapy. Dependence in the potential recipient represents a crucial variable. As Krebs (1970) points out ‘the essential attribute of a recipient is his perceived need for aid. In almost all of the reported studies on altruism, altruistic behaviour was elicited by dependency’. We may expect this factor to result both in a tendency for the patient to emphasize his own dependence, and a desire on the part of doctors and students to perceive and foster this attribute in the patient. However, it is in relation to dependence, that the ambivalence to which Campbell (1972) and Trivers (1971) have drawn attention, may be most graphically manifested. Confronted by dependent behaviour the medical profession shows most clearly the effects upon it of societal fears of being ‘cheated’ by recipients of altruism and the possible contravention of the norm of reciprocal altruism. Thus dependency as such is not sufficient to evoke altruism. The perceived origins and causes of the patient’s dependency invariably influence the benefactor’s response. As a number of studies have shown, altruism is more likely to occur if the dependence appears to have a cause external to the potential recipient, and is less likely if he is considered responsible for his problems. These findings tally well with the tendency for patients who have attempted suicide or suffer alcohol-related disorders, to be given short shrift by some doctors and students. Patients who are seen as responsible for their dependency almost to the point of malingering or simulating, do not elicit altruistic responses, but often quite overt hostility or indifference. This attitude may be extended, not only to patients who are believed to be consciously malingering but, also, to those showing forms of abnormal illness behaviour (Pilowsky, 1%9) such as hysterical conversion reactions and hypochondriasis (Mead, 1965), as well as those suffering from psychological disturbances which, it may be felt, should be under conscious control. Thus, in referring to hypochondriacal patients, King (1916) writes of ‘the terror of the doctor ’ and Alvarez (1944) advises that the physician ‘ should try to get them out of the office as quickly as possible because the time they take up is spent to no good purpose’. The ambivalence shown to those seeking financial compensation following industrial injuries is particularly well known. The effects of such recipient characteristics can only be offset by teaching aimed at increasing the students’ diagnostic and therapeutic competence in relation to clinical problems of this type, as well as open and informed discussion of the variables (societal, biological and personal) which influence their resolution. It may well be that such discussions need to be undertaken regularly, not only in the context of clinical teaching, but by the profession as a whole. Finally, we may consider the role of models in the genesis of altruism. It has been shown (Bandura & Walters, 1963) that exposure to altruistic models may encourage altruistic behaviour.
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Although these findings do not explain precisely how the process works, they are nonetheless of interest to medical educators. Clearly, students will be influenced in their approach to patients by observation of attitudes manifested by their instructors; and since the instructor’s attitude to the patient may easily be misinterpreted it is most important that they be explicitly considered in any clinical teaching exercise. A number of studies have shown that behaviour models provided by groups may be a potent factor in inhibiting altruism under certain circumstances. For example, individuals have been found less likely to take action in an emergency, or give aid, if others are present or believed to be present. In particular, as Latane & Darley (1970) have shown, the presence of others who seem unconcerned, often inhibits altruism. These findings suggest that members of a medical team may be inhibited by each other’s presence, students may be inhibited by each other and indeed a clinical teacher may be less altruistic in the presence of students. Consequently a clinician may be most likely to show altruism when alone with a patient; and is thus, paradoxically, not available as a model for students at what is perhaps the most opportune moment. On the positive side, it has also been found that group behaviour may encourage altruism. As Midlarsky (1968) points out, group size does not act in isolation; factors such as group morale and cohesiveness are also important and can inhibit or facilitate altruism depending on the degree to which the affected individual feels identified with the group. The relevance of such findings to the formation of student groups is fairly self evident.
Summary The purpose of this paper has been to draw attention to an area of human behaviour which has been the focus of much research in the past few decades, and which is of considerable relevance to the teaching and practise of medicine. It appears that altruistic behaviour, whatever its origins, is a form of activity universally observed and delicately modulated by a constellation of sociocultural, situational and personality factors. Society’s ambivalence towards those in need would seem to have its origins in survival-oriented behaviours which may be understood in biological and cultural evolutionary terms. The doctor, inevitably influenced by this ambivalence, occupies a singularly exposed and demanding social role. The community need to perceive doctors as altruistic alternates with the need to condemn them as self-seeking, just as often as doctors vary in their perception of patients from being worthy recipients of aid to being undeserving ‘cheaters ’. This conflict between man and his appointed helpers is as old as man himself, and must, it would seem, be regarded as an inevitable consequence of his very nature (Trivers, 1971; Campbell, 1972). In the last analysis, however, man cannot easily exist, without the knowledge that, in the last resort, competent medical help will be made available to him. In the absence of such certainty the morale of individuals in any community must inevitably be severly impaired. It is for this reason perhaps, that society scrutinizes the altruistic behaviour of the medical profession so closely. Given the central role of altruism in medical practice, there seems every reason for the profession to turn its attention to the understanding of this aspect of human behaviour. References ARONFREED, J. (1968). Conduct and Conscience. New York: Academic Press. ALVAREZ, W. C. (1944). A gastro-intestinal hypochondriac and some lessons he taught. Gastroenterology 2, 265-269. BANDURA, A. & WALTERS, R . H. (1%3). Social learning and Personality Development. New York: Holt, Rinehart & Winston.
BECKER,H. S., GEER,B . , HUGHES,E. C. & STRAUSS,A. L. (l%l). Boys in White. Chicago: University of Chicago Press. CALDWELL, M. C. & CALDWELL, D. K. (1966). Epimeletic (care-giving) behaviour. In K . S. Norris (ed.), Cetacea, Whales, Dolphins and Porpoises. Berkeley: University of California Press. CAMPBELL, D. T. (1972). On the genetics of altruism
Altruism and the practice of medicine 3 11 and the counter-hedonic components in human culture. J. social Issues 28, 21-37. CHAUVIN, R. (1971). Animal Societies. London: Sphere. COOMBS,R. H. & BOYLE,B. P. (1971). The transition to medical school: Expectations versus realities. In R. H. Coombs & B. P. Boyle (eds), Psychological Aspects of Medical training. Springfield, Ill.: Thomas. DARLINGTON, P. J. (1972). Nonmathematical models for evolution of altruism, and for group selection. Proc. natn. Acad. Sci. U.S.A. 69, 293-297. ERON,L. D. (1955). Effect of medical school education on medical students’ attitudes. J. med. Educ. 30,559-566. GOODALL, J. van L. (1971). In the Shadow of Man. Boston: Houghton MiWin. HELIB,D.0. (1971). Comment on altruism; the comparative evidence. Psychol. Bull. 76, 409410. KING,J. (1916). Hypochondria. Med. Rec. 90, 195- 1%. KREBS,D. L. (1970). Altruism -an examination of the concept and a review of the literature. Psycho/. Bull. 73, 258-302. LATANE,B. & DARLEY, J. M. (1970). Social determinants of bystander intervention in emergencies. In J. Macaulay & L. Berkowitz
(eds), Altruism and Helping Behaviour. London: Academic Press. LEEDS,R. (1%3). Altruism and the norm of giving. Menill-Palmer Q. 9, 229-240. J. H., WECHKIN,S. & TERRIS,W. MASSERMAN, (1%5). Altruistic behaviour in rhesus monkeys. A m . I . Psychiat. 121, 584-585. MEAD,B. I. (1%5). Management of hypochondriacal patients. J. Am. med. Ass. 192, 33-35. E. (1%8). Aiding responses: Analysis MIDLARSKY, and review. Merrill-Palmer Q. 14, 229-260. MILES,W.R. (1%3). Chimpanzee behaviour: Removal of foreign body from companion’s eye. R o c . natn. Acad. Sci. U.S.A.49, 840-843. MILO, R. D. (ed.) (1973). Egoism and Altruism. Belmont Calif.: Wadsworth. I. (1%9). Abnormal illness behaviour. PILOWSKY, Br. J. med. Psychol. 42, 347. POWER,H. W.(1975). Mountain bluebirds: Experimental evidence against altruism. Science, N.Y.189, 142-143. RICE, G. E. & GAINER,P. (1962). Altruism in the albino rat. J. romp. physiol. Psychol. 55, 123-125. TRIVERS,R. L. (1971). The evolution of reciprocal altruism. Q. Rev. Biol. 46, 35-37. ZUCKERMAN, S. (1932). The Social Life of Monkeys and Apes. London: Kegan, Paul, Trench, Tribner.
Received 9 December 1975; revised version received 25 February 1976 Requests for reprints should be addressed to Professor I. Pilowsky, Department of Psychiatry, University of Adelaide, Adelaide, South Australia, 5001.
