The annals of literature are packed with writers who also practiced medicine: Anton Chekhov, Arthur Conan Doyle, William Carlos Williams, John Keats, William Somerset Maugham, and on and on. As doctors, they saw patients at their most vulnerable, and their medical training gave them a keen eye for observing people and what makes them tick.
But if studying medicine is good training for literature, could studying literature also be good training for medicine? A new paper in Literature and Medicine, “Showing That Medical Ethics Cases Can Miss the Point,” argues yes. In particular, it proposes that certain literary exercises, like rewriting short stories that involve ethical dilemmas, can expand doctors’ worldviews and make them more attuned to the dilemmas real patients face.
The paper dissects ethical case studies, which students in nursing and medical school often encounter in classes. Typically, these studies—most based on actual medical cases—summarize a conflict about a course of treatment or another aspect of someone’s care. The students have to decide what the doctor or nurse should do next, or determine what the doctor or nurse did wrong. The idea is to get students thinking about problems they might face in the future, before they actually confront these issues in a pressure-filled clinical situation.
The paper’s author, Woods Nash, a medical-humanities scholar at the University of Houston, points out that ethical case studies have a distinct literary style—or lack thereof. They emphasize action over characterization, and provide a bare minimum of atmosphere. They’re also short—usually a few hundred words—which cuts out most of the nuance and motivation for characters’ behavior. The brevity and lack of nuance aren’t just literary faults, but actually limit the usefulness of case studies, Nash argues.
To demonstrate these shortcomings, he turns to fiction. In his new paper, he distills a typical ethics case study from a short story called “Fetishes” by the physician-writer Richard Selzer. In the story, a middle-aged woman named Audrey faces a hysterectomy. On the eve of the surgery, her anesthesiologist informs her, rather bluntly, that she’ll have to remove her dentures beforehand. Audrey doesn’t want to, because her husband—an anthropologist who regularly travels for months at a time—was out of the country when she got them and still doesn’t know she has them, even decades later.
Audrey argues that letting her husband see her without them will shatter her “dignity.” The anesthesiologist pooh-poohs her concerns and orders her to remove them for her own safety. Audrey eventually confesses her dilemma to a younger resident with a physical handicap (a limp), who establishes a much better rapport with her. He agrees to slip them back in during her recovery, before her husband can see.
In his paper, Nash reduces this 10-page story to a stark 215-word summary, then analyzes it using a typical ethical framework in medicine known as principalist ethics. He notes that many bioethicists would criticize the anesthesiologist for not respecting Audrey’s autonomy and dismissing her concerns about the dentures. But the analysis would also be blind to the subtler dynamics that make the story resonate, he argues. It’s not a story about lack of autonomy as much as about a woman whose male doctors (including the dentist who pressured her into getting dentures in the first place) condescend to her. The short summary also overlooks how the younger resident connected with Audrey—by establishing a human bond first, instead of simply walking in and dictating treatment.
Audrey “perceives [the doctors] as behaving smugly, belittling her because she is a woman, and relishing the power they wield over her,” Nash writes. “Until these underlying issues are resolved, recommendations to communicate more openly, respect patient autonomy, and reduce risks would remain insufficient.” Such recommendations, he adds, “do not penetrate to the problem’s roots.”
So how can students penetrate to the roots? Nash proposes a simple exercise, one he’s employed in his classes for three years. He has each student read a story like “Fetishes” and reduce it to a case study. Then the students read their classmates’ summaries of the same story, and examine how they differ—in the underlying assumptions, or the details emphasized or omitted. Among other lessons, Nash says the exercise teaches students that “the style of a case is not ethically neutral” and that “there can be no definitive statement of a case.”
Short stories aren’t perfect, either. Like doctors, fiction writers have their own biases and limitations, and the traditional Western canon represents a rather narrow (and mostly white and male) perspective. But unlike the pseudo-objective tone of case studies, stories like “Fetishes” at least attempt to promote overlooked points of view. And instructors certainly could seek out stories by authors of diverse backgrounds.
Overall, Nash says he’d prefer to “jettison” medical-ethics case studies entirely. He writes in an email, “The real world is messy, of course, and ethics cases often teach us (implicitly) to clean up that mess by oversimplifying it.” Furthermore, case studies “are themselves a byproduct and reflection of clinical practice’s overemphasis on efficiency. Not just in primary care, but in many areas of medicine, doctors spend far too little time really listening to patients and trying to appreciate the depths of their patients’ problems.”
Other scholars agree that medical-ethics case studies have limitations. Leslie McNolty and Matthew Pjecha, program associates at the Center for Practical Bioethics in Kansas City, praised Nash’s paper overall, especially the idea of rewriting short stories to help teach inexperienced medical and nursing students.
But they caution against too sweeping a condemnation of case studies. “In nearly every discussion of real ethical issues, you’ll hear someone say [things like], ‘I wish I knew more about her husband,’ or ‘why’s she so afraid of dementia,’” McNolty says. When presented with case summaries, in other words, people often do ask questions and seek out more information.
Along those same lines, Pjecha notes that “people actually using [case studies] in ethics committees in hospitals”—as opposed to students in classes—“are aware of how austere and truncated they are.” Often, someone who treated the patient on which the case is based will be present to answer more questions. Overall, Pjecha says, ethics committees see case studies “as an important first step, but then you unpack it further, and it spins into a story.”
Still, Nash stands behind the idea of eliminating case studies. “Good short stories are far more effective means of teaching students and health-care professionals to wrestle with the mess, to pay attention to narrative perspective and detail, and to become more comfortable with ambiguity,” he says.
They’re also, Nash points out, much better reads. “Why continue to use ethics cases if short stories are better at inviting realistic reflection and more enjoyable to read and discuss?” It’s a sentiment that Chekov, Maugham, and others who wrestled with such issues in both their life and work would appreciate.