and Medical Ethics
VMKV Medical College, Salem - 636 308
Literature and Medical Ethics
Poet William Carlos Williams was also a doctor, and he was often asked how he sustained equal interests in poetry and medicine. His explanation: I found my practice, by trial and error, that to treat a man as something to which surgery, drugs and voodoo applied was an indifferent matter. To treat him as material for a work of art made him somehow come alive to me".
- The autobiography of William Carlos Williams
'Its store of snow is the Hill's burden, its outpouring of streams is borne by all the world'
- Rabindranath Tagore
Growing techniques of modern medical treatment modalities, super-subspecialties and plans to prepare physicians for the 21st century have become the burden of Medicine. The outpouring of qualified physicians whose services will be borne by the entire humanity thus becomes the responsibility of Medicine and different medical associations of the different countries. With medical technology and research altering boundaries of care, a necessity is created suitably to alter and outline medical curricula to meet such demands of the future. With such demands pressurizing the field of Medicine and the newer system of advertisements of medical proficiency in the news media place a greater need for introducing and allocating a place for ethics in the learning of Medicine.
Ethics is considered to be the study dealing with the philosophical aspect of human action trying to assess the question of right and wrong, and judge the moral consequences of such human action and inaction. Medicine is a profession where knowledge is directed to alleviate human suffering, elevate human well-being and prolong human life. Medical ethics which deals with such ethical issues pertaining to health care forms as integral part of the education of the physician.
It is felt that the study of medical ethics is dry, indoctrinated and far removed from day to day practice. The phenomenal growth of knowledge in every branch of medicine takes the major share of time of a medical student or a physician in acquiring skills to complete in the field. Even in such a busy schedule of learning if time is allocated for such a study there appears to be a lack of genuine interest in learning the subject coupled with lack of trained staff to teach the subject effectively. Apart from that, finding a proper time and place to introduce the subject in medical education still remains elusive.
Experimenting with various methods of teaching by introducing the subject at preclinical, premedical clinical and post-graduate levels, different institutions have faced the task of delivering the subject to kindle the interests of medical students in medical ethics. In one such endeavour literary classics have been selected carefully to simulate certain moral situations a physician may face in his tenure of medical practice. Such simulation of events taken from literary classics seemed to have caught the imagination of physicians and rekindled their interests in such a study of ethics.
Literature is life, Literary classics present and confront us with the problems of daily human experience including medical ones. The creative imagination of the poet or a dramatist or a novelist presents us with 'unreal" or 'fictitious' characters and events. But these are 'real' in a very deep sense, real in proportion to their verisimilitude, so 'real' sometimes that we come to realize and know the working of the human heart and mind, the motives behind human actions, the powers of evil, the strength of goodness, the nature of human passions, the weakness or firmness of the will against adverse situations, the superiority of mind over matter through our acquaintance with characters in fiction better then with those of real life. Rather, sometimes, we come to know of the existence of certain facts and feelings for the first time in our lifetime through such literary presentations. Thus, literature prepares us as well as teaches us the basic value of life.
`Man has places in his heart which do not yet exist, and into them enters suffering, in order that they may have existence'.
- Leon Bloy
Basic values like compassion, love, truth, righteousness are nurtured in us through such literary-classics. Quotations taken from different sources when off repeated infuse such basic values of life into us. During our early school education selected literary works are taught to us to create such an awareness of basic values of human life and dignity. But modern technological developments lay more importance on life value neglecting basic values. Learning of language has become a method of gaining knowledge in a profession for a student. This is very true of medical education and is aptly described by the write up in the Wall Street Journal that called 'the drive for a top grade especially intense among premedical students who find they need sky high grades in basic courses just to be considered for graduate study. One result of this is a narrowing of educational pursuits and interests at the under-graduate level. Concentration on sciences is so pervasive in premedical education; the humanities must be included in the medical school curriculum. It has been shown that of the various types of students admitted to the medical schools in USA, a relatively small proportion of students who have majored In the humanities do somewhat better than average in medical school, representing highly motivated students. Thus, the need to include humanities in medical curricula and the teaching of medical ethics in particular requires a proper shaping of the curriculum which may bring about a smooth merging of humanities with medical science subjects.
Being at an experimental stage, predicting the suitable time for the incorporation of medical ethics in medical curricula may be premature. The results of certain universities which have tried to teach medical ethics at graduate and postgraduate levels have given encouraging results when taught in the light of literary classics. It also indirectly suggests that evolving a suitable syllabus or mode of teaching is entirely the responsibility of the respective medical school keeping in view the importance given to such a study. It is clear that teaching medical ethics is essential to present day physicians who have greater chances of being placed in ethical dilemmas.
For a beginning the subject could be introduced during seminars for the preclinical students. Such seminars could be planned before the beginning of every academic year. The topics of seminars could be broad based and may reflect various medical situations starting from simple ethics to the most complex e.g., procedures involving heart transplantation, IVF or other modern day medical practice. Medical ethics as a subject intended to sharpen moral and ethical sensitivity of a physician may include topics such as (i) a smile is a charity, (ii) the Daedalus effect, (iii) reverence for life, (iv) Love's Labour's Lost and (v) Speak your truth quietly and clearly.
A title like 'A smile is a charity' is suggestive of general qualities that go to make a physician who understands that
Little acts of kindness
Nothing do they cost
Yet when they are wanting
Life's charm is lost
It teaches the simple truth that a pat or a smile or personal concern shown by the duty doctor brings back the confidence into the patients' admitted in the ward. This personal reassurance express in the form of small acts of kindness play a very important role in revitalizing the patient and his hope to fight the disease or mentally prepare him to face the awaiting surgery or sometimes reconcile himself to a poor prognosis. Suitable material could be exacted from a book like Cancer Ward and could be discussed in the light of the title.
The Daedalus effect so beautifully adapted to illustrate how to deal with ethical questions relating to Hepatitis virus by Blumerg could be taken as a good metaphor to be discussed at length in relation to problems resulting out of modern medical practice including the ethical problems created by identification of people who are AIDS positive. This will provide a forum to discuss at length the merits and the possible side effects of such screening programs for AIDS. Though screening for AIDS may help prevent the spread of the disease, it may end up in isolating them as social outcasts even by the medical community. In such a situation how the physician needs to react to help prevent such isolation and at the same time ensure that the spread of infection is controlled may be discussed. Such a seminar will also become relevant for the present day physician as it will help teach ethical principles effectively.
The life and career of Albert Schweitzer stand an a good example of an illustrious and morally conscious life, of a physicians. The phrase "Reverence for Life" coined by him sums up medical ethics in the most apt form. The excess embryos stored by freeze thaw technique during in vitro fertilization procedure; how they have to be handled, or, when do they need to be discarded, or, how long they could be stored-such ethical discussions could find solutions for such problems without undermining the sanctity of human life. Schweitzer's life could be also taken for discussion in order to illustrate the problems faced by the doctors while serving in rural areas.
Love's Labour's Lost is the title of a play by Shakespeare which sums up the mental makeup of a physician when all his efforts to be a morally conscious and honest doctor fail him economically. How he has to change to put himself back on the track of economic progress through various means could be discussed at length. The exploitation of pharmaceutical industry and of the pharmaceutical industry by the doctor, the tendency to overprescribe could be focused. The book Strong Medicine written by Arthur Hailey could act as a good reference book for such a seminar.
"Speak your truth quietly and silently' is a line taken from Desiderata found in Old Saint Paul's Church, Baltimore, dated 1692. It reads as follows:
'Go placidly amid the noise and haste,
and remember what peace there may be in silence.
As far as possible without surrender
be on good terms with all persons.
Speak your truth quietly and clearly,
and listen to others, even the dull and ignorant; they too have their story..."
Many a time a physician is faced with the problem of delivering the message of diagnosis of a disease like cancer or poor prognosis. During such moments he needs to speak quietly and clearly to the patient, preparing him to receive the message with hope and loss emotional strain. The lines illustrate that by being a listener a physician may learn many things from the patient. His sufferings, his reactions and side effects could help the physician learn wore about the disease and therapy. Machines and mechanization of diagnostic procedures seem to take the personal touch of physician from the patient. Being a good listener, will help to establish a strong physician patient relationship between the doctor and the patient.
These are some of the illustrative
examples of a package of delivering medical ethics in a literary
but humane atmosphere. English literature is voluminous and inexhaustible,
medical situations are innumerable. An imaginative blending of
the two heightens interest and sharpens the moral and ethical
sensitivity of the physician as he goes about acquiring and practicing
his clinical skills.
1. Radwany, S.M., Adelson, B.H. The use of literary classics in teaching medical ethics to physicians. JAMA 1987:257:1629:31.
2. Warren, K.S. The humanities in medical education. Ann. Intern. Med. 1984:101:687-701.
3. Medical education in the United States 1979-80; Section 2. Undergraduate medical education. JAMA 1980:244:2810-27.
4. Trautman J. Pollard C. Literature and medicine; on annotated bibliography, 2nd edn. Pittburgh: University of Pittsburgh Press, 1982.
5. Blumberg, B.S., Fox, R.C., The Daedalus effect: Changes in ethical questions relating to hepatitis B Virus. Ann. Intern. Med. 1985:102:390-4.
6. Brabazon J. Albert Schweitzer: a biography. New York: Patnam & Sons, 1975.
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