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Article Excerpt
This essay explores the possibility of a generous medicine through discussion of L. Tolstoy's (1868/2005) War and Peace and Luke Fildes's painting "The Doctor." People confronting illness, like generals as depicted by Tolstoy, are never in control of events, yet they must take responsibility. The physician in Fildes's painting cannot control the course of his patient's disease, but he can, through the closest attention, perhaps deflect that course. The moral dilemma of humans, both healers and ill people, is to be both out of control and ultimately responsible. What we are most responsible for is sustaining generosity. The beginnings of generous medicine are some simple questions, with which the essay concludes.
Keywords: narrative medicine, clinical interaction, communication, care
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Medicine becomes more difficult to delimit, much less to define. No longer restricted to the work of physicians, medicine is an increasingly diffuse collection of scientific, clinical, managerial, corporate, and government practices, bound together through multiple forms of financial transfers and pricing, coding, scheduling, policymaking, documenting observance of guidelines and various regulations, and on occasion, relationships of mutual support between two people, face to face. At the core of this network there remains what I have called (Frank, 2004) fundamental medicine: the intimate encounter between someone ill who brings her or his suffering and someone else who offers hope of relief. (1)
What do we call the one who receives the ill person and responds with both personal presence and skill? Lack of a common designation fragments discussions of care: Professional is too restrictive (what about admissions clerks, technicians, and porters? Do they not offer care?), provider too economic, and worker too mundane in its task focus. Clinician may be the most inclusive term, if the clinic is understood expansively to be any setting in which healing arts are practiced. My preference is for healer because that expresses the hope of the suffering person and the commitment of those who seek to relieve suffering. That said, much of this essay is concerned with physicians specifically, insofar as they retain a singular authority, both clinically and culturally (Brody, 1992). If physicians no longer dominate the medical landscape, they continue to set a tone for how other healers are able to do their work. And, when decisions must be made, physicians are expected to assume an ultimate clinical responsibility.
GENEROSITY AND EFFICIENCY
What, then, is meant by generous medicine? By generosity, I designate a quality less economic than existential. Generosity involves giving, but my concern is with the giving of self in the willingness to recognize the other as fully human--as one with whom vulnerabilities and hopes are shared. Thus, I begin with the shared vulnerability of both healers and patients, and I progress toward a moment of generosity. Now, in the current decade, generosity is both uniquely possible and imperiled. The possibility of generosity is that now, perhaps more than ever in medical history, healers and patients are able to speak to each other as humans who have a sense of their own identity, recognizing the identity of the other. Since the 1970s, people who are ill have spoken about their experiences not as anyone's patients, but as people living with illness (Charlton, 1998; DasGupta & Hurst, 2007; Diedrich, 2007; Frank, 1991, 1995; Harter, Japp, & Beck, 2005; and Morris, 1998, among many possible citations). At the same time, and to some extent in response to this new voice of the ill, a new physician voice can be heard (Charon, 2006; Frank, 2004, chap. 4), expressing itself in relationship with patients rather than regarding patients as clinical objects of treatment. At present, however, both these voices risk being suppressed by changing understandings of medicine.
Medicine--this increasingly diffuse network of multiple interests--is increasingly comprehended within what political scientist Janice Gross Stein (2001) called the cult of efficiency. Stein is not opposed to efficiency, but she has argued that health care can never make efficiency its central value, because efficiency, in itself, is not a value: "Efficiency is about how we should allocate our resources to achieve our goals, not what our goals should be. What our goals are, and how we should value them, is properly outside the language of efficiency" (Stein, 2001, p. 68). To uphold efficiency as a value is to confuse ends, which are inherently valuable, with what can only be the means of achieving those ends. (2) If this confusion persists long enough, the ends themselves become obscure matters of uncertainty; people lose confidence in what they value. This obscuring of ends is evident in studies of nursing (Gordon, 2005; Rankin & Campbell, 2006; Weinberg, 2003) that have shown traditional values of attentiveness to patients' needs being displaced by orientation to institutional imperatives. Increasing reliance on the economic (or economistic) language and logic of personal choice in clinical situations obscures the logic of care, which begins with recognizing all that limits any person's actual capacity to choose (Mol, 2008). My point is not to elaborate on these studies but to respond to the need they underscore: the need to assert positive values that, as valued ends, can restore efficiency and other means to their proper status as means. Generosity is one such value.
COMPLEXITY ENGENDERS VULNERABILITY
To show the fundamental vulnerability to which both healers and ill people are subject--as a first step toward showing the value of generosity as a response to this vulnerability--I offer a nonmedical example from War and Peace (Tolstoy, 1868/ 2005), a book so vast that it can be read as metaphor and allegory for almost any human situation.
Tolstoy has two great themes. One is the power of events over people. Tolstoy argued against historical explanations that present one person--typically the great man--as acting with calculating forethought. In the following passage, Tolstoy describes the Russian retreat that abandons Moscow to the French led by Napoleon. Or, as Tolstoy wants his readers to see the situation, Napoleon has the hubris and illusion to believe that he is leading the French. The...
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