The relationship betwixt the arts and medicine

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In this paper some of the intriguing links between the arts and medicine are explored. As a starting indicate I consider the notion of whole person understanding as articulated past Downie in an article entitled "Literature and medicine", published in the Periodical of Medical Ideals in 1991.1 I suggest that the arts can contribute to whole person agreement in at least three ways. The arts may stimulate: (a) insight into common patterns of response (shared human being experiences); (b) insight into private difference or uniqueness, and (c) enrichment of the language and thought of the practitioner.

Much literature which explores the relationship between the arts and medicine tends to focus on the value of the arts in increasing our understanding of the particular individual, "whole person agreement" in Downie's sense of the word. This, nevertheless, assumes that "whole person understanding" should focus just on the unique in the individual. This view is, I think, mistaken. If we have the notion of "whole person" seriously then nosotros must recognise that which is unique but besides that which humans may share. I suggest that this broader view is of the greatest importance in whatever consideration of the relationship between the arts and medicine.

  • Arts
  • literature
  • medicine
  • humane practice

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  • Arts
  • literature
  • medicine
  • humane practice

Introduction

My initial interest in the links between the arts and medicine derived from an examination of various approaches to instruction ethics to undergraduate nursing and medical students. While examining the literature on the teaching of health intendance ideals, I began to discover a deviation in the pattern of arroyo betwixt the United Kingdom (UK) and the Usa of America(USA). Within the Great britain when ethics was taught in nursing or medical programmes a professional philosopher and/or a infirmary chaplain was engaged to teach a specified number of sessions, usually on topics such equally abortion, assisted reproduction, euthanasia and the ethics of transplants. Such programmes were becoming increasingly sophisticated and might likewise include some sessions on Kantian duty-based moral theory and Utilitarianism. In the late 1980s when Kenneth Boyd was completing The Pond Report,2 all ethics education in medical curricula in the Britain was on an elective basis. The United Kingdom Fundamental Council for Nursing, Midwifery and Health Visiting (UKCC) had gone much further by insisting that in the development of new nursing and midwifery programmes a certain number of contact hours must be spent on professional person, ethical and legal issues in nursing.3

However, in the USA increasingly the pedagogy of ethics, particularly to medical students, tended to be embedded in more wide-based medical humanities programmes which included history, constabulary, and the arts (with a detail focus on literature) as well as philosophical ideals.

Why turn to the arts in medical or nursing education? Surely there is already plenty in these respective curricula without demanding even more content be added and captivated? Peradventure and so. Indeed, when I began to use literature and film in my teaching of health care ideals, initially I did it for the elementary reason that this seemed to be a more than constructive mode to assistance students identify and consider ethical issues.

In essence I used this material as part of a consciousness raising activity. Use of literature or film brought certain issues into sharp focus, making them more alive for students. Students were presented with characters, some of whom they immediately identified with, such equally the student nurse portrayed well-nigh the beginning of Whose Life is it Anyway? iv Alternatively they gained insight into the perspective, hurting and frustration of a character like Ken Harrison, who in the normal course of events could easily be labelled a troublesome, uncooperative patient whom staff might endeavor to avoid. The arts—drama, brusk story, or a verse form—might be used, in Alan Bennett's poignant phrase, to highlight the "casual cruelties routine inflicts".5

In her book Heroism as a Nursing Value half-dozen Vassiliki Lanara draws attending to the influence which classical Greek Literature had on the development of nursing and particularly on the development of nursing's focus on holistic patient care. From my first contact with nursing I was brought up on a diet which emphasised (a) the vocational influence of the religious orders with its pinnacle of service and obedience, and (b) the ground forces influence, again focusing on service, obedience and adding discipline. In 20th century versions of nursing history the most prominent character in the evolution of nursing in Ireland and the UK is Florence Nightingale. Thus Lanara'due south emphasis on the impact of early Greek literature provided an entirely new insight into nursing's historical evolution.

Lanara's argument supports the claim of Eric Cassell (in his archetype work, The Place of the Humanities in Medicine 7) that the humanities take always been part of medicine. Cassell goes on to country:

"They (the humanities) will play an increasingly of import, necessary and specific role every bit medicine evolves beyond its present romance with technology towards a more balanced view of the origin and handling of disease."8

Maybe Cassell is correct at least to the extent that the humanities will be increasingly important for medical and wellness care pedagogy. In that location is a growing interest in this area effectually the U.k.. This is evidenced for case in the development of the Middle for the Arts and Humanities in Health and Medicine at the University of Durham. New medical curricula appear to leave open the possibility of a strong humanities influence in undergraduate medical education.9 There are also a number of nursing programmes that include elements of the humanities as part of the cadre curriculum.x

Why the humanities?

However, it does demand to be asked why we should applaud a swing to increased humanities input in health professionals' education. Perhaps we may accept every bit a starting point for this discussion a paper past Downie entitled "Literature and medicine".1 In this article Professor Downie suggests that there are iv types of connection betwixt literature and medicine. 1 type of connection benefits literature; another provides entertainment value; a third type potentially provides insight to the diverse professions regarding how they stand in the public perception; and finally a fourth blazon tin can be helpful to the practice of medicine (and, I suggest, nursing) by providing glimpses of what Downie terms "whole person understanding".

Downie points out that many authors and poets, indeed some who have made significant contributions, were also medical doctors, for example Dante and Chekhov. A number of these have brought to their literary works the insights which the practice of medicine provides. Disease, disease and the medical context also provide the mixture of emotion, drama, irony, humour, claret and gore which is grist to the mill of the novel, play, motion-picture show and indeed TV serial. They are also meat and drink for the artist.

Public stereotype

It is within a similar context that insight may be gained in terms of the public stereotype and continuing of diverse professional groups. Indeed there are a number of glimpses of different approaches to the practitioner-patient relationship in films such as Passionfish 11 and Whose Life is it Anyhow? 4 I accept found that the presentation of clips from these 2 films generates considerably more discussion, and seems to get out a much stronger impression, than but suggesting that students read and discuss the models of professional-patient relationships described in Szasz and Hollander12 Veatchthirteen or Morse.xiv Such insights into particular approaches to that human relationship are probably of general involvement to professional bodies; beyond this they are of direct interest to the neophyte practitioner attempting to find useful part models for practice.

It is the fourth blazon of connection between the arts and medicine, discussed past Downie,1 which interests me in particular. Downie argues that it is this connection which illuminates what he refers to equally the "whole person approach" to medical practice. He contrasts the whole person approach with the scientific approach to medicine. The latter, he suggests, sees medicine'southward concerns as focused on general patterns, club and uniformity.

Downie goes on to suggest that one of the recognised strengths of medicine is its scientific discipline orientation: the attempt to move between observation of patterns, hypothesis testing and theory (or model) development regarding the causes and potential treatments for disease. The primary focus is on the body, body systems and full general patterns of disease and response. This focus is useful, necessary, and has brought of import advances in diagnosis and in chemotherapeutic and surgical intervention. Yet, Downie claims that this arroyo, while valid and conspicuously useful, is insufficient. While the focus is on the full general blueprint, the specific demand and particularity of the individual patient is in constant danger of being missed. Greenhaugh and Hurwitzxv provide a number of useful examples of this supposedly reductionist type of exercise. (At that place is an interesting debate to exist undertaken regarding the accuracy of describing medical science as reductionist. Information technology might be argued to the opposite that medical research is in fact largely systems-based and therefore holist in the classic social scientific discipline sense of this term.16 Still, this contend is for another mean solar day.)

For the purposes of our nowadays word allow us grant that Downie is right in his claim, that because of the focus on general patterns of disease and response in medical scientific discipline and practice, the specific demand and particularity of the individual patient is in abiding danger of being missed. Downie argues that "whole person understanding" requires ii things: (i) knowledge of the person'southward biography (or extended case history), and (two) some imaginative sympathy with that biography.

He argues that the disciplines which develop and extend whole person understanding are "history and literature in all its aspects… .The humanities rather than the social sciences, are concerned with the particularity of situations and with their meaning and that concern is the way to whole person agreement."17

Whole person understanding

Information technology seems apposite at this point to consider why one would want "whole person agreement" in medicine or nursing. I suggest that nurses have never institute dealing only with general patterns of response as piece of cake as Downie seems to propose—as it were in some sense divorcing the listen from the body and dealing only with the concrete. Despite our current literature's many references to the ills of the task-allocation method of organising nursing piece of work,18 the notion of providing condolement and intendance has permeated the nursing approach—at least in terms of rhetoric and education. The notion of comfort and care has traditionally been articulated in terms that made the psychosocial and spiritual dimension of patient care explicit. For instance, in the development of nursing enquiry over the past 20 years, one sees a clear shift in the USA, Australia, and the UK. This shift is away from the traditional scientific research methodology, found in medicine and social scientific discipline, to more narrative-based methodologies such as grounded theory,19 phenomenology20 and hermeneutics.21 The move indicates clear attempts by nurse researchers and scholars to recognise and learn from individual patients, regarding their item experience and perceptions of illness, disease and treatment.

Even so, why is this particularisation of the illness experience thought necessary in the pedagogy of health intendance practitioners? The answer is, in many ways, quite straightforward. Practitioners are daily confronted with complex individuals who may be experiencing significant anxiety, vulnerability and fright, because of some real or imagined disease or illness. These individuals normally present to the md or the nurse in the belief that the professional can practice something to help to brand the individuals' feel or indeed their lives better. Gordon Allport argued22 that each person is like every other person, like some other people, like no other person. Each of united states of america contains within u.s. both general patterns and the item, that which is peculiar to me and my context.

Contribution of the arts

The arts, particularly literature, may contribute here in at least three divide, merely inter-linked, ways. The arts may stimulate: (a) insight into common patterns of response (mutual or shared man feel); (b) insight into individual deviation or uniqueness, and/or (c) enrichment of language and thought.

(A) INSIGHT INTO Common PATTERNS OF RESPONSE

A piece of work of art potentially provides ane with sufficient imaginative insight to recognise general patterns of emotion and human response, which are non reducible to purely physical, biological mechanisms. Therefore while literature provides us with rich characterisation which can provide role models, it too appeals to something akin to the Jungian collective unconscious, to the archetypal stories of man existence. As Gardner argues: "Art rediscovers, generation by generation, what is necessary to humanness".23

Therefore information technology is not merely the case that scientific discipline, medical science included, forces i to focus on general patterns of disease, behaviours and response, while the arts force us to focus on the particular. Literature too includes some image of the general, some frequently strong paradigm of that which we share as human beings; some insight into the homo status equally such—otherwise one would take difficulty relating to much literature and works of art. I believe I disagree with Downie on this final indicate. Downie's focus is exclusively on the particular, which he argues gives "whole person understanding". He suggests that to argue that literature tin do more, within this context, is but to fall into the danger of being accused of suggesting that the arts do desperately what scientific discipline does well. Notwithstanding he does in passing land the following: "Whereas scientific discipline, including social science, proceeds by induction from specific instances to generalised (often idealised) patterns, literature explores unique situations which may include conflict of values. It thereby enables u.s. to larn insights into universal man predicaments."17

I am challenged at this signal to consider the difference between Downie'south specific instances of inductive thought and the unique situations which he suggests leads to insight into aspects of "universal homo predicaments". Are exploration and insight solely confined to the arts, and is consecration the preserve of science? Scientists such as Ian Fleming or the astronomer Jocelyn Bell may well recognise more of the creative in scientific discovery than Downie's assay would advise. I recall possibly a more than authentic suggestion is that the arts do differently that which science sometimes does well. If one considers medical science or man sciences in full general—psychology, sociology and so forth—all of these sciences are concerned with human being behaviour and/or experience. Is this a subject field matter different from that which concerns the creative person? The contrasting notion that the arts do badly that which scientific discipline does well would seem to be based on a mistaken supposition that what is of interest regarding human perception, emotion, awareness and response is entirely individualistic, utterly unique and particular. All the same, it may exist useful to apply a piece of literature to challenge this opinion. Reflect for a moment on i'south response to the post-obit passage from John Bayley's account of trying to cope with his wife, the late Iris Murdoch, while she suffered Alzheimer's affliction.

"The agony of travel nowadays. … I am fumbling in my wallet, checking the tickets. They are hard to separate, and after shuffling them wildly again and once again I can still discover just i return ticket. The whole system is cool; why must they give us four separate tickets when ii would exercise? It'south definitely not there. I rush to the ticket office, where a queue is fabricated to unwind in serpentine way betwixt rope barriers. My ticket man has drawn his little mantle and gone off. The client at the other guichet seemed to desire a round the world ticket, and to be in no hurry about getting it. He and the ticket clerk canvass the possibilities in leisurely mode. Iris clutches me anxiously, urging us to run to a train which has just come in, the wrong railroad train I hope. At last the ticket man is gratuitous. I produce the receipt and the delinquent tickets. No, he can do nix—information technology wasn't his sale. I turn abroad in despair. Why can't we just go habitation?

"Iris has non understood the problem and keeps urging me towards the wrong train. …

"On the train I continue counting the tickets. The elderly couple reverse await sympathetically at Iris. I am conspicuously the 1 who's become a problem.

"Utterly wearied and drenched in sweat. Vague center sensations too. And the whole thing so trivial."24

Personally this passage stimulates a vivid enteric sympathy based on memories of similar personal struggles to retain control in public—amidst toddler, infant, buggy, and numberless in busy train and underground stations, with bad-mannered narrow turnstiles, jostling crowds, bewildered children and personal isolation. Neither feel, Bayley's nor mine, is entirely unique; each is at least partially an image of a mutual human being sense of personal isolation and powerlessness.

(B) INSIGHT INTO INDIVIDUAL Departure/UNIQUENESS

The second way in which the arts may contribute is past providing detailed insight into the lives and concerns of others. Thus exposure to the arts may help produce a tolerance for ambiguity and individual deviation.

Downie suggests that:

"We acquire from literature by imaginative identification with the situations or characters in literature, and by having our imaginations stretched through being made to enter into unfamiliar situations or to see points of view other than our ain. Learning of this kind is generative of a deep understanding which is essential to humane doctoring."25

Why and so is this deeper understanding essential to humane practice? I take argued elsewhere26 that the respond to this question is continued to issues of function enactment and moral strategy. Imaginative identification or, every bit I term it, activity of the moral imagination is essential to good health care practice. It is activity of the moral imagination that enables the practitioner to connect with a patient at the level of human agreement and compassion. This understanding and compassion is a necessary chemical element in humane nursing or medical do.

An important relationship between art and nursing or medicine is therefore one that enables the moral imagination of the practitioner to be stimulated and developed in such a manner that sensitive, empathetic, constructive care is the probable result. Alzheimer'south disease or canker encephalitis are clear examples of the humanly devastating conditions the diagnosis and treatment of which highlight the importance of rigorous scientific investigation. Such investigation seems fundamental to any attempt to observe a handling for (or means of preventing) the man misery and loss wrought past these atmospheric condition which assault a man life and produce physical evidence of devastation and cloudburst in the cerebral cortex. How this brain destruction is connected with the changes of homo personality and intellect is petty understood, except nosotros know that human memory is crucially involved. How these conditions are experienced by sufferers is also trivial understood, though in that location is mounting evidence of the distress, fear and anxiety which may exist in both sufferers and their loved ones.

"There are so many doubts and illusions and concealments in any shut relationship. Fifty-fifty in our present situation they tin come equally an unexpected daze. Her tears sometimes seem to signify a whole inner earth which Iris is determined to go along from me and shield me from. At that place is something ghastly in the feeling of relief that this can't be so: nevertheless the illusion of such an inner world all the same at that place—if it is an illusion—can't aid haunting me."27

Bayley goes on aptly to describe the problem for medicine as science and art:

"Showing me a tracing from the about elaborate of the brain scans Iris underwent a twelvemonth or so ago, the md indicated the area of cloudburst at the top. The doctors were pleased past the clearness of the indication. I thought and then—the former foolish thought of the amazon—that her brainworld had lost its unknown mysteries, all the subconscious life that had gone on in it. Information technology had been there, physically and geographically in that location. And now it had proved to be empty. The grey substance that sustained its mysteries had ceased to function, whatever a 'role', in at that place, can possibly mean.

"Twice Iris had said to Peter Conradi that she feels at present that she is 'sailing into darkness'… Information technology seems to convey a terrible lucidity about what was going on. But can one exist conscious in such a way without possessing the consciousness that tin can produce such language? If consciousness tin can go on producing such words, why not more, equally lucid?

"Were I an expert on the brain I should detect it hard to believe in such flashes of lucidity revealing, as it were, a whole silent merely conscious and watching globe. It would be as if—to use a clumsy illustration from my subconscious city in the jungle—a wink of lightning were to reveal its existence, and then the explorers found that it didn't be afterward all.

"The words which Iris used with such naturalness and brilliance cannot be stacked there silently, sending out an occasional signal. Or can they?"28

Medicine as scientific practice needs to seek agreement of the degenerative, destructive physiological processes at work, in order to attempt to prevent, ameliorate or relieve the symptoms. Medicine as art needs to recognise the human being who is experiencing the symptoms, which particular symptoms the individual is experiencing and what that experience is like for this detail individual, in order to ensure that prescription is accurate, adequate and likely to be complied with.

(C) Idea AND Linguistic communication

A farther attribute of the contribution that the arts, particularly literature, makes to health care exercise is that literature enriches the language and thus the thought processes of practitioners; in a manner which provides a wealth of concepts and ideas with which to think about and conceptualise patient care. This is in fact illustrated in the brusque passage quoted in a higher place from Bayley'south memoir to Iris Murdoch—for example the image of "sailing into darkness". This notion of the importance of language and the connections between the language we use and the manner in which we think has long occupied scholars in a number of disciplines from cerebral developmental psychology to moral philosophy.

In the area of moral philosophy, the late Iris Murdoch herself29 and the philosopher Cora Diamond30 take, among others, argued that nosotros are suffering from a vocabulary and so reduced in the relevant concepts that it cannot back up appropriate discussion of the moral problems and crises which confront human beings.

Having a sufficiently rich vocabulary to support a language of patient intendance is, I believe, greatly important. This is because of the as yet poorly understood connectedness between thought and language. That thought and language are connected is undeniable. How that connection works is some other question. As the Russian psychologist Vygotsky states: "Thought undergoes many changes as it turns into speech. It does not simply find expression in spoken language; it finds reality and form."31

In a like vein the philosopher of education P H Hirst reminds united states of america: "In so far then as we can meaningfully be said to think in anything—we think in words".32 Nosotros need many words to think beyond demyelination or dysfunctional neurotransmitters to begin to appreciate the human being, experience and triumphs of our patients.

In terms of patient care I suggest that ane of the most useful assignments to fix students who accept merely covered the pathophysiology of a chronic debilitating illness is to read Kafka'due south Metamorphosis,33 or, for the student of depressive illness, Janice Galloway's The Play tricks is to Keep Breathing.34

Decision

In that location are numerous works of literature which provide rich characterisation and role models as food for the spirit, and stimulus to the moral imagination. At that place are likewise numerous works which provide, sometimes ironically, insight into the practitioner-patient relationship and indeed into the human being condition. Good literature will also enrich our language with words, concepts and visions of human being beingness. This I believe summarises the relationship betwixt the arts and medicine.

"Truthful art is moral: it seeks to amend life and non debase it. It seeks to concur off, at least for a while, the twilight of the gods and united states!"35

Is this non as well the goal of nursing and medicine?

M Therese Southgate—physician and sometime deputy editor of the Periodical of the American Medical Association may usefully take the final give-and-take:

"Medicine and art have a common goal: to consummate what nature cannot bring to a cease … to accomplish the ideal … to heal creation. This is washed by paying attention. The physician attends the patient; the artist attends nature … . If we are attentive in looking, in listening and in waiting, so sooner or later something in the depths of ourselves will respond. Art, like medicine, is non an arrival; it's a search. This is why, perchance, we call medicine itself an art."36

References

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