Austin Lam is a medical student at the University of Toronto.
In a session on narrative medicine in medical school, a clip from the film Wit (2001) was shown in which Vivian Bearing (portrayed by Emma Thompson), an English literature professor, was told that she has Stage IV cancer by Dr. Harvey Kelekian (portrayed by Christopher Lloyd). In this scene, he was, to put it mildly, less than considerate of the gravity that the discussion had for Vivian. He was Efficient. Domineering. Self-interested.
As Dr. Kelekian lectured her on the experimental treatment regime, he emphasized how she would be contributing to “our knowledge." In response, she repeated the word knowledge in a state of disorientation, seemingly to both him and herself.
What struck me the most was a question that came to mind: even if he had communicated in a gentler and more compassionate manner, even if he had mastered the art of breaking bad news, why would I still be left with a visceral feeling of discomfort?
At first glance, a fulsome sense of niceness would seem to be the answer — the answer to the power imbalance between patient and physician, amongst other problems, demonstrated in this movie scene. In fact, niceness has been emphasized as an integral factor in treating patients.
The problem is that even if Dr. Kelekian, or his non-fictional ilk, were nice — maybe even counting amongst the nicest people in one’s life — there remains an ostensibly irreconcilable gulf between his stance of epistemic objectivity (“our knowledge”), embedded in the praxis of medicine, and that of so-called subjectivity in Vivian’s phenomenological reality, grounded in her experiences. The divide is not a Manichean duality. It is not that there is an inherent ‘rightness’ or ‘wrongness’ in one or the other.
The trouble lies in how the manner of approaching the patient’s concern(s) is framed: to explore that which is objective, and to this, adding considerations of the subjective (or the reverse in some cases). The conceptual divide between objective and subjective is not and cannot be solved by niceness. A change in attitude hardly substitutes for what is needed, namely, conceptual/philosophical sensibility, and corresponding epistemic humility.
One can imagine a hypothetically transformed nice Dr. Kelekian who nevertheless works under the guiding principle that his set of meanings, those belonging to “our knowledge,” are the ones that are objectively correct — and that when his patient’s meanings align, then all is well; but when they do not, then something has to give. An area not only of mis-understanding, but of non-understanding emerges between the ostensibly nice physician and the patient.
The patient may have a differing position that is judged to be ultimately misguided. It may be seen as a tolerable position or maybe even one with which the physician sympathizes but nonetheless sees as wrong — possibly accompanied by perceptibly nice phrases such as “I hear you, this is what I think…”. The physician may ultimately be ‘right,’ but in what sense? And so, here lies my discomfort: the imperialism of medicine’s epistemic stance of objectivity. Equally, however, this discomfort does not necessarily translate into an espousal of untethered subjectivity.
What follows is not the demand that medicine requires expertise in academic philosophy. Rather, there ought to be a recognition that meanings can have truth, and that this does not require the meanings to be processed, subsumed, or translated into one objective account, the one taken-up and assumed by medicine. This kind of singular account has been characterized by philosophers Hubert Dreyfus and Charles Taylor as the following position: “the condition of my understanding you as you think and act in your terms is that I construe you as making sense in my terms most of the time.”
The underlying stance is that of ‘observer to object’ — the medical gaze — a notion introduced by philosopher Michel Foucault in The Birth of the Clinic: An Archaeology of Medical Perception. The medical gaze has been described as “how doctors modify the patient’s story, fitting it into a biomedical paradigm, filtering out non-biomedical material.” Despite many criticisms of Foucault’s ideas, his notion of medical gaze galvanizes further refinement in conceptualizing the constitutive forces in the patient-physician relationship.
The objectifying medical gaze necessitates a correction. However, this cannot be one of plastering ‘subjective’ elements onto ‘objective’ elements nor one of unbridled relativism for fear of losing grasp with reality and ending up with an impoverished category of ‘inner appearances.’ An account of understanding that transcends objective and subjective is needed. Philosopher Hans-Georg Gadamer provided this in his book Truth and Method.
Summarized by Dreyfus and Taylor, Gadamer’s argument is “ontologically based: human beings are in contact with the real … Gadamer makes central the paradigm of a ‘conversation,’ in his understanding of human science, rather than that of an inquiring subject studying an object. Success comes, not with an adequate theory of the object, but with the ‘fusion of horizons.’” In essence, he challenged the subject-object dichotomy with his ‘conversation’ paradigm.
Again, Dreyfus and Taylor elegantly wrote:
“If understanding the other is to be construed as fusion of horizons and not as possessing a science of the object, then the slogan might be: no understanding the other without a changed understanding of self … Real understanding always has an identity cost.”
The necessary identity cost cannot be paid for by niceness per se, it demands something more: an authentic conversation, where authenticity involves heeding the call of Conscience in a Heideggerian sense.