The humanities in medicine
During the first half of the last century and earlier, the medical profession did precious little about disease. Was it Oliver Wendell Holmes who said, ‘Take out the poppy, take out the foxglove and the willow, it is my belief that, if the rest of the material medica were thrown into the sea, it would be so much the better for mankind, and so much the worse for the fish,’ or words to that effect? Those were the days in which the role of the medical man was to cure sometimes, to relieve often, to comfort always. The idea of the nobility of medicine was born in those days and the doctor was often a scholarly man of culture.
We have changed. An incident in the coffee lounge of a hospital I worked at several years ago remains etched in my memory. Two surgeons were speaking of a compatriot working in their own speciality. ‘If I had such and such a disease, I would go to so and so,"he said. ‘He is a bastard, but he is a damned good surgeon.’ What we need is that damned good surgeon or physician. It should not matter whether he is a bastard or an angel.
So where do the humanities come in? My dictionary defines the humanities (in plural) as ‘learning or literature concerned with human culture,’ and includes philosophy, history, law, literature, linguistics, etc. Does this have anything to do with medical practice?
We enter the profession when we are fresh out of school, and are too young and inexperienced to make a rational career choice. We are not prepared for the extent of human suffering we have to see, get involved in and sometimes be partly responsible for. How do we respond to this? We need to develop a philosophical attitude, what William Osler labelled Aequanimitas, to be able to take a detached view without getting emotionally involved. Some are unable to do this. They may drop out of the profession, after wasting a few years of their lives and depriving someone else of a precious medical seat, or they may move to branches of medicine like public health where contact with individual patients does not exist. Most of us get inured to it. Some of us get totally hard hearted and cease to think of the patient as a person. He or she becomes just a case.
Modern medicine is complicated, especially in our country, and perhaps particularly in nephrology. We are no longer as helpless as we were, but there are enormous costs associated with effective therapy, and we are often in a situation where there is a way to cure a patient or to give him several years of useful, comfortable life, but the price is beyond his reach. It is perhaps better to feel that one has a disease for which no solution exists, than to know there is a solution but one lacks the wherewithal to pay for it. It is not just the patient who is thus disheartened. I am distressed that only a small minority of patients who need dialysis and transplantation succeed in going through with the procedure. There seems to be no justice in the world. How can one condemn to death a patient one could save, just because he has no money? Even when transplantation is possible, it poses a great moral dilemma. The removal of a kidney from a donor, however deep the love that drives the donation, is legally classed as grievous hurt, and carries a risk of death. Are we justified in inflicting harm on any person, however much that person desires it?
Once we find ourselves in the profession, there are three ways in which we may proceed. We may regard it as a business, a trade, a mere commercial transaction, a way to make money. We might take it as a profession requiring advanced knowledge or training, and view the sick as a scientific problem to be solved. This has given rise to the word ‘clinical’, defined in the dictionary as coldly detached and impersonal, objective, dispassionate. Or we can take it as a vocation, a mode of life requiring dedication. I suggest we would get the most satisfaction out of this last. There is no use being devoted to our patients if we are not also good, so it is necessary to be professional too. We should not think of it as a business, but I know of no doctor in this country who has to starve. All of us do reasonably well and live in comfort, if not necessarily in luxury.
The only branch of medicine where the need to consult a doctor (and the outcome) is, as a rule, joyous is obstetrics. We practitioners of all other disciplines of medicine thrive on human suffering. If we are to succeed, people must fall ill and come to us. A society in a state of positive health will have no need for the medical profession. Fortunately for us, though sadly for mankind, positive health exists only in the textbooks of social and preventive medicine and in the deliberations of the World Health Organization. I am often troubled by the fact that I thrive on the misfortunes of others. One needs some guidance to think through these things.
Literature offers us wonderful route maps. As a medical student I have myself been greatly influenced by A J Cronin,s The citadel. He covered much of the same subject in his autobiography, Adventures in two worlds; but The citadel is much more interesting. He describes the temptations that beset the budding practitioner and guides the reader through the pitfalls and the solutions. I will not go through a lengthy bibliography here, but each of you will find some books that make you think. I derive inspiration from Albert Schweitzer’s Out of my life and thought: an autobiography. He wrote in German, but an English translation is available. Incidentally he did not just have a great career as a surgeon, but was a musician and music scholar of more than ordinary attainments, an ordained curate and a theologist, a philosopher, and a philanthropist.
We are faced with questions throughout our careers, some we have never considered. I was struck by an incident that was discussed for several weeks in the correspondence columns of the BMJ. A smuggler used to bring drugs from the continent into the UK by putting the powder into condoms and swallowing them. Once safely through Customs, he waited for the consignment to make its way out, retrieved it, washed the package and repacked it, and then delivered it to the dealers. One day his luck ran out and the condom burst in the intestine, and he was poisoned with a severe overdose that put him in hospital and nearly killed him. The treating physician did not report the matter to the police, maintaining that his duty of professional secrecy to the patient precluded his doing so. I would probably have done the same thing. However, the students took the matter into their own hands and reported the patient. Their argument, which on reflection I am convinced is correct, was that this man led so many of the youth of the country to become drug addicts and waste their lives. If he were left free, he would resume his activities and ruin yet more youngsters. His career needed to be cut short, in the larger interests of the country.
Too often we do not think beyond the surface. A patient needs a transplant and comes to you. What is simpler than to make arrangements to provide him one? There are so many poor people ready to sell a kidney for a pittance. The donor did not come to you as a supplicant, so his rights automatically take second place. A patient wants a false certificate, or wants you to support him in getting an insurance claim, though the policy was taken after suppressing some vital information of preexisting disease. The organisation that is being defrauded is faceless, a large impersonal insurance company that has plenty of money to pay for it. As one aggrieved patient complained to me, ‘Your signature could give me five lakhs of rupees. All you need is to change that five years to five months and sign it. It is not your money. What justification do you have to deny me?’ I know many doctors who would agree with that viewpoint and would sign without hesitation. How does one get to think beyond the superficial?
The history of medicine makes the study of medicine more interesting. It is fascinating to trace the development of our knowledge of disease processes. It is inspiring to learn of the giants who have paved the way for us. ‘Lives of great men all remind us, we can make our lives sublime, and, departing, leave behind us, footprints on the sands of time.’ (Henry Wadsworth Longfellow)
I hope I have convinced you that we need some acquaintance with the humanities, to prepare us to face the psychological trauma that medicine often gives us, the loss of a patient, the need to deny someone lifesaving treatment because he cannot pay for it. We need to have the basic knowledge to consider the ethical dilemmas that beset us. We need to be inspired to do better and to be better. The answers come from literature, philosophy, religion, history, biography. I often turn to the Bhagavad Gita, not as a religious text, but as a guide to solve all the problems we face as doctors. That is clearly not an evidence-based assertion and might be dismissed by the more scientifically minded. There are more arguments. One needs to be able to put facts across to a patient with clarity, and to be able to understand how the patient might think.
How does one introduce a doctor to the joys and the utility of reading? In some of us the reading habit is inculcated early in life; for others, the university should provide the opportunity. Some education in the humanities would equip us better to deal with the problems posed by the sick, and would certainly make life more enjoyable. Even to the most dedicated doctor, a life spent in attending to the sick with no break at all, no diversion of any sort, would be a dull one indeed. Osler recommended spending the last hour of the day reading something outside one,s profession. He made a list of books that he suggested be kept at the bedside, and read in bed, when it would not matter if the reader fell asleep, book in hand. I was taught as a child that it was wrong to read in bed, and I have never felt comfortable doing so, and not all of Osler,s selection appeals to me, but I try to read something outside my profession whenever I travel, so that I am not completely ignorant of what happens in the world, or of branches of learning outside my own.
What is right in medicine is often a matter of perspective. We need to widen our knowledge base to enable us to see the issues from all sides, to become ‘full men’, and we need to be taught at an early stage to be offered an entry to the humanities to make us better men and women, and thereby better doctors.