Following the latest New Generations workshop in Glasgow University’s Medical Humanities Research Centre (MHRC) on December 11th 2014, New Generations Programme member Emily writes:
A call to arms for the next generation of medical humanities
by Emily T. Troscianko
We began our two days in Glasgow surrounded by hospital beds and medical skeletons, and had the chance to hear from four current medical students about their learning experiences. Their eloquent reflections on how they’ve been taught and how they’ve learned over the past four years raised some interesting questions, particularly about empathy: should a doctor be empathic towards his or her patient, and if so, how much? Can and should empathy be taught and learned, and how should it be expressed in a clinical setting? How much context-specificity does an empathic response require (can you ‘really’ empathise with someone three decades older than you, or with someone of the opposite sex, or with a cancer sufferer if you never have been…)? How do you convey sincerity in emotional response – and what is it anyway? Would simple politeness be a better way of thinking about what matters in all this?
There was quite a bit of scepticism expressed towards the whole existence and value of empathy, especially from our guide for the afternoon, Al Dowie (Senior University Teacher in Medical Ethics at the University of Glasgow), but maybe the controversy can be defused if we remember that there is no Platonic split between ‘reason’ and ‘emotion’, and therefore that the choice a doctor may seem to have to make between a ‘rational’ or ‘emotional’ appraisal of the person sitting in front of them is in fact a non-choice. All appraisal is a mixture of more and less emotional engagement with its object (e.g. Frijda 2007), and responses somewhere on an empathic spectrum from disconnect to identification are inevitable, especially when that object is another person. No one’s saying that empathy = identification; that is, we needn’t feel we actually are the other person, even temporarily. But trying to work out what’s wrong with someone is a profound act of social cognition, involving all the cognitive strategies at our disposal, including inferential ‘Theory of Mind’ practices (attributing a mental state to someone else through strategies of inference and prediction from their external state and behaviour), but also plenty of embodied interaction (accessing and responding to others’ consciousness directly, as it manifests itself through gesture and tone in a given interactive situation) (Gallagher 2011, 2012). There are different ways of empathising – imagining we are the other person – but some form of it is an inextricable part of being able to engage with other people at all.
Letting go of the idealisation of ‘pure reason’ by acknowledging the role of emotion in all of cognition doesn’t mean we need go to the other extreme, as Al Dowie did, and assert that emotion drives everything, and that ‘reason’ or ‘understanding’ simply comes along afterwards to give decisions and actions the veneer of rational respectability. This position gets caught up in dualism from the less common direction (elevating emotion over reason, rather than vice versa), but it gets caught up nonetheless, by trying to separate out and cast as antagonists aspects of the human mind that can’t be and aren’t. Again, if we follow the wealth of recent research on emotion as intrinsic to cognition (e.g. Damasio 2006, Pessoa 2008), or even just attend carefully to our own experiences (can we really classify everyday cognitive responses like confusion, surprise, relief satisfactorily as either ‘rational’ or ‘emotional’?), the problems with the antagonism model become pretty clear. And this point becomes all the more imperative in a medical setting. No one who’s gone through the cognitively exhausting process of tackling an eating disorder, or obsessive-compulsive disorder, or self-harm, or any other condition where the relationships between physiological state, emotion, thought, and behaviour are distorted and health depends on their recalibration, would ever say that understanding is just post-hoc justification. Any such claim would be both medically and ethically mistaken.
It was a surprise, and a fairly depressing one, especially given how much interest philosophical questions of ethics in the medical domain elicited in this session, when various remarks and anecdotes from the students began to make clear just how little respect the clinical world has for the medical humanities. One student who’d taken an intercalated course in medical humanities after her third year told us how, on her first fourth-year placement, only one of all the anaesthetists she’d told about it had responded in the least bit positively, and one had even tried to make her look foolish in front of a surgeon by asking her to tell him what subject she’d chosen (hey, this’ll make you laugh: guess what she chose?!). The consensus seemed to be bafflement (with or without a bit of ridicule thrown in): why on earth would you choose the medical humanities – how is it going to make you a better doctor? And the more profound disappointment was that, after a year of studying it to degree level, all the student herself could say was, well, it had been a useful grounding in the history of medicine, had made her generally better educated and well rounded, but to be honest it hadn’t really been directly useful.
This sounds to me like a call to arms – softly spoken, perhaps, but one we need to recognise and act on. If a highly motivated and intelligent medic chooses to spend a year devoting herself to the medical humanities, don’t we need to make sure she comes out of it not saying something polite about being a more rounded individual now, but inspired and energised by all the ways it’s going to contribute directly and indirectly to her future professional practice?
Maybe with this in view we need, for a start, to dare to say that critiquing stuff isn’t all we do. Jane Macnaughton (Professor of Medical Humanities at Durham University) invoked a common distinction between the ‘clinical’ and the ‘critical’ disciplines, but this does the humanities no favours at all. If we’re doing our jobs right, we create as much as we demolish, just as much as the sciences do. Sure, we can do an impressive, historically inflected dissection job on a medical account of depression (or whatever), but think how much else we’re capable of that doesn’t amount to mere deconstruction. Glasgow’s medical-humanities blurb for the intercalated course makes some good though somewhat vague suggestions: it ‘will allow medical students to further develop the non-biomedical dimensions of their professional attributes and competences, such as the doctor-patient relationship, cultural competence, and respect for patient autonomy’. But we can be ambitious here, in the specifics as well as the general principles, and we need to be.
We can use our detailed understanding of how poetry and prose work to set up a programme that has direct and demonstrable benefits for women prisoners (Robinson and Billington 2013), or work with a national charity to enhance our understanding of how eating disorders may be affected by reading fiction. We can use our expertise in phonetics and linguistics to design a mobile app for screening and monitoring disorders affecting speech. We can collaborate with the Royal Society of Medicine to bring theological and philosophical insights on compassion to bear on healthcare practice . And these are just four projects I happen to know about or be involved in, mostly happening right on my doorstep in Oxford.
Let’s not limit ourselves to writing the medics’ histories for them, or showing them how we’re so much subtler than they are. Let’s work together with clinicians – and with experimental psychologists, and with statisticians, and IT consultants, and whoever else we can interest and learn from, and actually talk and listen in a genuine conversation. Let’s make sure we have at least a nodding acquaintance with some of what current research in the cognitive and medical sciences can teach us about how human minds actually work. Let’s critically appraise that work too, by all means, but not let our various insecurities prevent us from ever doing more than that. Let’s try to make it so that, in a decade’s time, the medic who does a year of medical humanities doesn’t even need to pause for thought to find ten knock-down answers to the surgeon who asks her ‘and how will that make you a better doctor?’ And so that she doesn’t get confronted with this kind of hostile dismissiveness in the first place.
Both disciplines lose something when they fail to engage constructively with one another: we should certainly try not to earn the medics’ contempt, but they need also to make the effort to learn and broaden their horizons to encompass what the humanities do best. Hostility and at least perceived contempt from the sciences may well be a factor in encouraging the humanities to be inward-looking and defensive. We need open and engaged scientists in order to get the best out of the humanities, and vice versa. Let’s seize this mutual responsibility and make it count.
References
Damasio, Antonio R. 2006. Descartes’ Error: Emotion, Reason and the Human Brain. 2nd ed. London: Vintage.
Frijda, Nico H. 2007. The Laws of Emotion. Mahwah, NJ: Lawrence Erlbaum.
Gallagher, Shaun. 2011. “Aesthetics and Kinaesthetics.” In Sehen und Handeln, edited by Horst Bredekamp and John Michael Krois, 99–113. Berlin: Akademie.
Gallagher, Shaun. 2012. “Empathy, Simulation, and Narrative.” Science in Context 25: 355–81.
Pessoa, Luiz. 2008. “On the Relationship between Emotion and Cognition.” Nature Reviews Neuroscience 9:148-58.