Medical Humanities: Some Uses and Problems

Medical humanities: some uses and problems

R Downie Emeritus Professor of Moral Philosophy, University of Glasgow, Glasgow, UK

Correspondence to R Downie ABSTRACT The arts and humanities were allowed into the British medical Department of Philosophy curriculum in 1993 when the General Medical Council re-structured it in a paper 69 Oakfield Ave University of Glasgow entitled ‘Tomorrow’s Doctors’. Since then many medical schools have developed Glasgow G12 8DN humanities modules and the broad term ‘medical humanities’ refers to these. UK They can contribute to medical education in at least three ways: as a supplement to what is already in the curriculum, especially for ethics and communication; as e-mail [email protected] an outside critique of medical practice; and to personal and professional development. Nevertheless, there are practical problems concerning appropriate teachers and methods of assessment. Moreover, the dominant interest is now academic research rather than education.

Keywords communication, critique of medicine, ethics, medical education, medical humanities, professional development

Declaration of Interests No conflict of interest declared

Introduction Early history

The arts and humanities have no clear identifying criteria In any new movement the question of ‘who got there but most commonly they are thought to comprise first’ is always contentious, but a case can be made (I histories, philosophy, literatures, drama and film, visual shall not insist on it) that the use of the humanities in arts and music. Their methods are imaginative, analytical, medical education emerged out of the teaching of critical, or investigative, and they provide insight into medical ethics in Glasgow University in the late 1980s. I human motivation and relationships as well as enjoyment. was fortunate in being allowed to take part in joint They can have a bearing on medicine in at least three teaching on ethics with Sir Kenneth Calman, who was ways. then Postgraduate Dean at Glasgow University. Our discussions with students involved analysis and criticism First, the oldest strand is ‘arts therapy’. Degree courses of medical practice and human motivation. We found in music therapy, art therapy, and so on, have existed for that students were more interested in the details of many years. Practitioners emerging from these courses cases than general principles. Their interest led us to set see themselves as therapists and have their own ways of up an after-hours club for discussion of these matters evaluating their activities. Second, there is the overlapping through literature, film, etc; these meetings were well- movement known as ‘arts in health’. The artists working attended by students and consultants alike. Encouraged in this area are not trained as therapists and wish to by this I organised five annual conferences in the early retain their professional identity as artists, writers, 1990s and anthologised material for discussion.1 More musicians and so on. They use their skills in hospitals and importantly, in 1993 the General Medical Council communities to enhance people’s interest, creativity and changed the undergraduate curriculum making room for enjoyment of life – which of course affect their health. what were then called Special Study Modules: five weeks Third, there is the movement involving the arts and of intensive study of anything a medical school could humanities in medical education. It is unfortunate that offer.2 There was encouragement for involving the the term ‘medical humanities’ has come to be used as an humanities in some Special Study Modules. Funding umbrella term for all three movements. Indeed, as I shall bodies such as Nuffield and Wellcome became interested suggest in the final section of this paper, it is unfortunate and national conferences developed. The present that the term has arisen at all, although I shall continue outcome is that many medical schools in the UK and to use it. It is with the role of the arts and humanities in elsewhere offer options in the medical humanities. medical education that I shall be concerned, although the other areas are also important, inexpensive and If the humanities are to be allowed into the curriculum history successful. it is reasonable to review what they can contribute to medical education or clinical practice. First, they can contribute to topics currently in the curriculum, such as

288 J R Coll Physicians Edinb 2016; 46: 288–94 © 2016 RCPE history 289 by Miroslav Miroslav by This is where the This is where 8 ……… (limited pity). (boundless pity). (boundless Animal Rights Animal Pity for dogs that crydogs Pity for for ever and ever amen. ever and ever for Pity for mice that squirm. mice that Pity for Medical humanities: some uses and problems and uses some humanities: Medical This abbreviated version gives the flavour the flavour gives version This abbreviated 7 Hieronymous Bosch be with them Bosch Hieronymous But the limitations of compassion or empathy empathy or compassion limitations of the But 6 Pity for earthworms that wither helplessly that earthworms Pity for can just fuck off. They shouldn’t have been born. have shouldn’t They just fuck off. can Patients with progressive amyotrophic lateral sclerosis amyotrophic progressive with Patients are satirised in a poem entitled Animal satirised in a poem Rights are who was one of the doctor a distinguished Czech Holub, the of half second the in Europe writing in poets best 20th century. of it: of The discussion! animated produce can poem This who will is that doctors, reached usually conclusion we should try worse, tears and sweat, with be faced blood, to calm response and measured a controlled, to have will emotion get in the much - too ailments of all kinds and is quiet waiting is needed What the job. of way the patient. attention to giving concentrated listening, know ‘We say: will educators medical some point this At and is taught in courses on communication it and this, on is indeed a vast literature There listening skills.’ are The assumption is that there skills. communication teachable and learnable and generalisable skills that are theirbut are there Perhaps applicable. widely therefore beyond to extend much is unlikely applicability universal speakingnot terms, technical avoiding matters as such These things are the message. and repeating too quickly, but the attempt to have of course of the first importance, ofset a to communication of reduction complete a problems, their and Patients fail. to bound is skills discrete any for too varied are doctors and their personalities, entirely be to communication to approach reductionist is not a manipulative Good communication successful. creative. technique but is inherently arts and humanities, especially creative writing or drama creative especially arts and humanities, The arts can bring out the myriad can be of help. or film, unsuccessfully and successfully can people which in ways each other. with communicate us with the question: What would you have done? done? have you would What question: us with the judgement. sharpen can Stories principles and morality than to more is there case any In adverbial its term might we what morality has concepts; and but how do not just what we It matters aspect. said that what is In this context it is sometimes when. many are there and empathy, or compassion is needed in medical matters such of teaching the for advocates training. They They 3 288–94 This is where novels, short novels, This is where 5 Perhaps they do, but there is no but there do, they Perhaps 4 2016; 46: 2016; © 2016 RCPE J R Coll Physicians Edinb Coll Physicians J R reason to impoverish our discussions by restricting restricting by discussions our impoverish to reason a sometimes example, For moral concepts to just four. or an angry up to a manager, need to stand may doctor tact, equanimity, courage, as Qualities such relative. humility even – be needed may patience or honesty hospitals that is point general The wrong. go when things a as society of microcosms general practices are or whole – with heightened tensions – and it is therefore to concepts moral of range the entire necessaryhave to their problems. understand In this section I shall be concerned with ethics, with ethics, be concerned I shall section In this The them. between connections the and communication been of course Hippocratic tradition in ethics has such as the Declaration of in updated versions re-stated Medical World as the Code of the adopted Geneva, been have times codes In recent (1968). Association the quasi-law and medical law specific by more made and UK Council in the General Medical the from issuing central of is Ethical regulation elsewhere. similar bodies covers means no importanceclinician but it by a for is medical what it offers because of relevance everything ‘ethics’ But view. of point medical a ethics from or ethics, ordinary name for wrong, right and is just a professional beyond well extend bad, and good wrong, and right and of medicine. the boundaries ethical problems An influential attempt to connect the of morality was sphere of medicine with the broader Principlesentitled The book a in made of Biomedical Ethics Childress. F. James and Beauchamp L. Tom by e th function of The supplementary humanities ethics and communication. I shall call this the the shall call this I communication. ethics and the Second, supplementary of the humanities. function third-party detached, able to offer are humanities wider a into practice medical of putting way a scrutiny, the Third, shall call this the critical function. I perspective. and the personal contribution to a make humanities can medical some least at of development professional I shall contributions positive Despite these practitioners. humanities face some serious that the medical suggest problems. argued that ethical problems in medicine can be resolved resolved be medicine can in problems ethical that argued ordinary morality: principles from the use of four by some (do beneficence harm), non-maleficence (don’t and decisions) the patient’s (respect autonomy good), a exerted has Their book patients fairly). justice (treat medical to ethics of teaching the on influence dominant about problems are But there generations. for students supporterinfluential An principles. four the use to how four the that argues Gillon, Raanon approach, the of a vocabulary discussing moral principles offer for in medicine. problems stories, plays and films are helpful. They can provide provide can They helpful. films are and plays stories, and confront of life of the problems versions condensed R Downie

They can also illustrate how a human response to a criteria for science in that they are observational, patient is compatible with a technical concern. Paintings reductionist to the factors being researched, and can be good examples of this. There is a painting called experimental. Their results are quantifiable, generalisable, ‘The Doctor’ by Sir Luke Fildes which hangs in the Tate and frequently offer causal explanations. They are Gallery.9 It presents an eloquent portrayal of what (as it therefore objective in the sense of being independent of seems to me) medicine is all about; the doctor, the personal bias. The second category is more doubtfully patient (a sick child), the parents anxious in the scientific. Observational studies may record quantitative background, and the quality of the relationship between changes but such studies belong more to the category them all. The emotional impact of the painting is of natural history than to science. This of course is in no enhanced by noting some of the technical details, e.g. the way to denigrate their importance: facts must be known angle of the doctor’s back, the space between his eyes before causal explanations are attempted. Regarding the and the sick child, the highlighting of the child in bed. An third category, qualitative studies are even more appreciation of technical detail in art or music can enrich doubtfully scientific, being based very much on the emotional impact. The psychiatrist Jonathan Green interpretation and value judgments of the observing argues that works of art ‘carry their cultural power by researcher. They are certainly observational but attempts being ways of embodying states of mind’ and that to generalise them by making the qualitative quantitative ‘inferring mental states is not only a core psychiatric skill will actually reduce their value. If something is quantitative, but also one we exercise in looking at art’. In a telling or measurable, there must obviously be factors to be image he says: ‘The painting sucks in attention to itself’.10 measured. But in measuring, say, ‘patient-centredness’ the He is speaking of psychiatry but what he says is surely factors selected for measuring, such as the making of true of medicine more generally. Technical awareness eye-contact or the angle of the chair, are quite arbitrary. and human response can enhance each other and can Some patients do not want to be looked at. The produce a unique mode of attention.11 Fine art and reductionism necessary for quantification makes such music can bring this out. studies misleading. The fourth sort of research, randomised trials, is regarded as the ‘gold-standard’ of medical research and is the kind of research most often The critical function reported in the press. But is this the ‘gold-standard’ of science? Are randomised trials observational, The origins of modern scientific medicine are to be reductionist, experimental, quantifiable, generalisable and found in the school of Hippocrates (around 460 BC). objective or independent of personal bias? The central doctrine of the Hippocratic School is that every disease has a cause which can be discovered and They are certainly observational and quantifiable, and is curable, and that this knowledge is generalisable. His they are reductionist in that they set out to test discrete scientific approach ignores the individuality of patients factors, such as the efficacy of a given drug. But they and concentrates on what diseases have in common. For cannot fully satisfy the generalisability criterion in that example, Hippocrates writes: ‘Every phenomenon will be they are concerned only with statistical probabilities. found to have some cause’ or ‘Each disease has a natural Moreover, there may sometimes be questions about cause and nothing happens without a natural cause’.12 how the volunteers for the trials are chosen, how the Medicine has been profoundly influenced by this tradition, trials are financed and how their results are evaluated to the extent that it is sometimes seen as an applied and promoted. In other words, there may be doubts science. As an example of the critical function of the raised about the objectivity criterion. More importantly humanities I shall examine this position. they have two other limitations: one affecting their credentials as science and the other their position in It can be claimed that science is relevant to medicine in clinical practice. four different ways. First, from the Greeks to the present day there have been investigations into the normal and It could be argued that, even if we ignore their possible pathological workings of the body, carried out by failings in objectivity and generalisability, randomised sciences such as anatomy, physiology and biochemistry. trials do not contribute to the primary purpose of Second, there are observational studies which report science, which is to offer an understanding of nature. such matters as changes in birthweight over a period. Scientific understanding is usually provided by causal Third, there are qualitative studies which might be explanations or theoretical models or by providing the concerned, for example, with the interaction between connecting principles of nature. If science is seen in this doctors and patients. Finally, there are randomised way, randomised trials are really natural history rather clinical trials. Are these different sorts of research than science in the full sense. Of course, there are other equally scientific? views of science. For example, the 17th century history philosopher Francis Bacon expresses an alternative view The subjects in the first group – anatomy, physiology, when he says that: ‘Truth and utility are here the very biochemistry – are clearly sciences. They satisfy the usual same thing’.13 Without going as far as that the aim of

21 291 22 But there is also a long is also But there 18 In opera doctors hardly hardly doctors In opera 19 Most shaming of all, the demigod demigod the of all, shaming Most 20 In other words, he is stressing that he is stressing In other words, essional Prof or Dr Lydgate in George Eliot’s in George Eliot’s or Dr Lydgate 24 17 Medical humanities: some uses and problems and uses some humanities: Medical . Canterbury Tales Indeed, it can be argued that personal development development personal that argued be can it Indeed, 23 we have duties to ourselves, to develop our own human own our develop to ourselves, to duties have we ever come out well. ever tradition which depicts doctors in a satirical way, as way, satirical in a doctors which depicts tradition in of Physique example the Doctour for of fun, figures Chaucer’s The myth does not make it clear whether Zeus was not make does The myth or private medicine, of the introduction at annoyed hubris – the attempt by whether it was a punishment for length. its ordained beyond life Asclepius to continue about discussion good can produce the myth Either way The to what medicine should attempt. if any, the limits, more a gentler and perhaps humanities can offer the than life critique of the medicalisation of effective Illich. Ivan say, of, arguments ‘in-your-face’ of medicine, Asclepius, came to a bad end. There are are There end. bad to a came Asclepius, medicine, of the mark but he over-stepped of him, various accounts was die, should decreed whom Zeus had when a patient, the to According Asclepius. by death from back brought in his hand’ (same old glittered ‘Gold Pindar poet Greek thunderbolt. with a both story)Zeus destroyed and Personal and Development is a development that professional It could be argued medical knowledge to update courses matter of attending for matter a is development personal whereas skills, and and is of no concern to of a doctor the private life accountancy as such spheres, In some medical educators. continuity is no there that be correct it may plumbing, or But this or public and private life. professional between tell easily can Patients in clinical medicine. is not the case concerned dealing with a genuinely are whether they who has been on a and educated doctor or someone training course and has learned what the compassionate Stuart the Mill puts John say. or do meant to is doctor ‘It is important what not only when he writes: point well that do are what manner of men they but also men do, it.’ . Eliot is ‘…the first English novelist to ‘…the first English novelist is Eliot Middlemarch. a of the emergence precision delineate with historical to both is devoted one who kind of doctor’, new to his patients. and research pompous and self-important. But literature can provide provide can But literature self-important. and pompous is It self-reflection. for mirror a up hold can antidote, an such well, out come in literature doctors some that true what limits to sees who Macbeth in doctor the as medicine can do, is a moral duty. Morality is often considered as a matter a as considered often is Morality duty. moral a is others. to duties our ensuring balances, and checks of many speaking, Historically view. But this is a recent to role large a morality give of the nature of accounts for The Greeks becoming a particular type of person. for respect maxim of Kant’s Even this. stress instance in which he says in full, quoted is rarely ends as persons or person own whether in your nature, ’Respect human in that of another’. 15 288–94 The humanities, or some of them, them, of some or humanities, The 16 2016; 46: 2016; Many readers may wish to disagree wish to disagree may readers Many 14 © 2016 RCPE J R Coll Physicians Edinb Coll Physicians J R with some or all of it, but in disagreeing they will they but in disagreeing with some or all of it, enterprise. in the philosophical be engaged themselves within arise outlined can kind the of criticisms Second, A philosophical critique of some aspects medicine itself. to professional of medical practice is not exclusive philosophers. historyMedical what is critique of a offer can also in the sense of research standard’ ‘gold the considered on a wider historical perspective that it can offer as working Mackenzie, Sir James example, For research. regarded a GP in the first half of the 20th century, clinical research. for place the proper general practice as in cardiology in Burnley, pioneering work out He carried Clinical Institute for Andrews in the St and London failures and – its successes of his work A study Research. of looking at medical research. ways new – can suggest can bring out sharply how medical issues, such as public as such medical issues, how sharply out bring can things’. other ‘a lot of tied in with are health, highly in society and are a high status have Doctors not therefore is It do. they work the for respected seen as are doctors some surprising that occasionally of medicine in a focus Drama can also place the narrow of the People, An Enemy play In Ibsen’s wider perspective. and popular immensely as is first depicted Dr Stockman of proposed his report on the water contamination many But accurate. scientifically as acclaimed is baths and jobs tourism, involving emerge, considerations other The people’. the of ‘enemy up an he finishes and on, so editor: newspaper the play’s by main point is well-made this you to and science, of man a and doctor a ‘You’re I in isolation. is to be considered the water of business tied up with far it’s how realise perhaps don’t think you things.’ other of lot a funding bodies generally is to promote what they regard regard what they is to promote generally funding bodies matter it does not then, Perhaps, as useful knowledge. scientific provided truly are trials whether randomised are there secondly, But, useful knowledge. produce they in clinical practice: useful knowledge that limitations to It nature. their statistical from limitations which stem been the fact that a drug has from not follow does that it will cases efficacious in 65% of be efficacious with or the it might be harmful, Indeed, patient. a given refuse might side-effects, the told being upon patient, the not are trials randomised words, other In consent. medicine Clinical clinical medicine. be-all-and-end-all of of but the evidence ‘evidence-based’, claims to be of with that unfavourably trials compares randomised laboratorycourta of that science or law. of the the critical function of of this aspect In concluding the material is First, points. two stress humanities I must of a very brief illustration of what a way by only offered discussion. for can provide philosophy as humanity such in the argument developed I have and Jane Macnaughton detail elsewhere. R Downie

natures. The personal development of the doctor firework displays may improve the health in a deprived matters both for him/herself and for patients and also, as area more than funding another GP. It has been said that I shall suggest, for life outside medicine and in retirement. if your only tool is a hammer all your problems become nails.27 A doctor who can look beyond his prescription Personal development can be furthered by the arts but pad might be able to suggest other remedies. For it should be noted that it can also be furthered by an example, singing has been shown to lead to improvements interest in pure science. Science as taught in medical in chronic obstructive pulmonary disease and to the training necessarily has goals internal to medicine, but enhancing of mental health and wellbeing.28 pure science has goals internal to itself – as a way of understanding the universe and its creatures. In that way Moving to the more general aspect of an arts contribution it is educative. As simple illustrations of science depicted to medicine we can note that the most noticeable as a broadening or educative pursuit I point to the feature of medical training and practice is that it is highly television programmes of Sir David Attenborough, focused and clearly useful to society. Every code of Professor Brian Cox or Professor Jim Al-Khalili. If asked, ethics stresses that the doctor must above all provide a ‘What use is your science?’ they would be puzzled service to others, and every aspect of medical training is (although no doubt they would think quickly if a grant practical and goal-directed. One consequence is that application were involved!). What shines through their medicine tends to colonise the whole personality of presentations is their belief that the sciences they doctors. There is said to be a tombstone which bears enthusiastically explain and expound are among the the inscription: ‘Here lies John Smith who was born a glories of the human mind. It is also worth issuing the man and died a grocer’. Whatever can be said about warning that the humanities themselves are not grocers there is a moral here which doctors should necessarily humanistic or educative. For example, a consider. The demanding and prolonged nature of historian of the French Revolution if asked what it taught medical training coupled with the tiring and often about social equality or democracy might well reply, ‘I am emotionally draining nature of patient care may leave not interested in that kind of question. I am just time for little else, resulting in the diminishing of a interested in the documents and facts’.25 A historian with doctor’s personality. This is where the arts and humanities that approach is trained rather than educated. The sad can offer a remedy. truth is that many arts subjects have become infested with jargon and are inward-looking, and consequently fail The nature of the remedy emerges when I admit that in their basic humanising function. many practitioners of the arts and humanities would be uncomfortable with my attempt in this paper to suggest Nevertheless, the arts can make a contribution to how they may be useful in medical education. For them personal development and via that to professional the arts and humanities are simply worthwhile for their development. Their contribution can be stated own sake. One of Aristotle’s criteria for the highest good controversially: they provide an antidote to medical is that it must be completely useless.29 This sounds comic training and the whole ethos of medicine. There are two to modern ears. But Aristotle is surely right. Whatever is aspects to this, one specific and one more general. useful is useful for a given end, which itself may become a means to a further end. Hence, there will be a never- The more specific contribution which the arts can make ending chain of means and ends unless we find activities to personal and professional development is best which are worth pursuing just for their own sake. The expressed by the term introduced by Edward de Bono arts and humanities can be included with pure science – a former lecturer in medicine at Oxford University - among these worthwhile activities. Simply by being ‘lateral thinking’.26 His main point is that we tend to see worthwhile for their own sake, the arts and humanities the world in terms of certain patterns or groupings. The can broaden the outlook and enrich the personality of a person with a disposition to lateral thinking is the doctor. This is important throughout a career but also in person who can break away from familiar patterns and retirement. Having retired from an absorbing career, discover new ways of looking at things. Intellectually, many doctors think: what now? Seeds sown in medical lateral thinking may emerge as a sceptical disposition education may finally mature and new interests can towards received opinion and routine. There is a fair develop. amount of both in medical training and practice, but the arts can sometimes suggest alternative ways of approaching problems. More generally, many doctors see Some Problems medical solutions to all the problems of life, and have encouraged the public and governments to do likewise. The medical humanities are currently faced with at least Thus, mental illness, disability and drug addiction are three types of problem: of administration, of content and history usually understood by doctors and the public as medical of dominant aim. Administratively it is not easy to find problems when in fact there may be other approaches appropriate teachers. Ideally, medical students who have to them. Perhaps organising festivals, pageants and chosen an area of the humanities of interest to them

292 J R Coll Physicians Edinb 2016; 46: 288–94 © 2016 RCPE history 293 32 Medical humanities: some uses and problems and uses some humanities: Medical In any case, in contemporary in healthcare case, In any 31 An excellent description of the educational role we we An excellent educational role description of the the centre of in the name is captured envisaged originally called was It Calman. Sir Kenneth by up set in Durham, Arts and Humanities in Health and the for the Centre brings out that there This acronym Medicine (CAHHM). contribute may they and artshumanities, and many are medicine. of areas different to practical ways in different perspectives historical or philosophical can offer They existing to approaches alternative or new suggest and thinking can encourage creative all they Above courses. will It patients. to approach balanced and humane a and aim is turned into be unfortunate if this outward-looking activity. academic purely inward-looking an Conclusion there is not enough time to listen to anything so grand so anything listen to time to enough is not there as ‘narrative’. a the medical humanities seems now The dominant aim of the at I commented teaching. than rather be research to ‘medical term the of startintroduction the that it that is reason The unfortunate. been humanities’ has comprise an ‘medical humanities’ that the has suggested if something is to be an academic Now academic subject. such bodies funding and research, be must there subject research for millions of pounds given have Wellcome as the ‘academic’ more the But subject. alleged this into the become the medical humanities of practitioners educational their original from will drift away they more in the medical is that researchers The danger purpose. to similar only humanities will finish up speaking and students medical the to than rather researchers to interest. hoped originally clinicians we interest. While this is admirable it hardly warrants the warrants it hardly this is admirable While interest. term the of analysis the to devoted literature extensive ‘narrative’. 288–94 30 2016; 46: 2016; © 2016 RCPE J R Coll Physicians Edinb Coll Physicians J R In terms of their content, the medical humanities are the medical humanities are In terms of their content, other many But literature. with identified often as I and, to students of interest equally humanities are to medical education. of relevance tried to show, have medical the of narrowing this of One consequence with an obsession has been humanities to literature has The word ‘narrative’. especially certain words, ‘evidence- what become to the humanities movement term which encapsulates a clinicians; medicine’ is to based importantof factors other obscuring now is but truths ‘narrative’ importanceThe word the of clinical relevance. of what on listening to patients’ accounts lies in its stress The term has arisen as part wrong. think has gone they an from away clinical attention move an attempt to of on laboratory concentration exclusive other and tests Clinicians to the patient. it to redirect and measurements It story. the patient’s listened to always course have of history’case ‘taking a the relevant of one and called was which elicit questions the ask able to being skills is surely In a sense then an emphasis on helpful information. to alter the clinical an attempt is simply ‘narrative’ part the patient feel of to make balance in that direction, scientific just an object of rather than the treatment should take part in the relevant humanities classes. But classes. humanities part in the relevant take should is solution good Another to timetable. this is difficult and humanities the from someone by joint teaching are there Again, medical school. the from someone willing finding colleagues of to co-operate. problems the from someone be may volunteer a Commonly, subject his/her in making interest humanities with an the from someone or students, medical to interesting Some in a humanity. an interest medical school with medical training specialists in the are universities to be funding to likely is not but there humanities, have may they and them in medical schools, employ however Moreover, with students. problems credibility the humanities in medical education taught, are they of attainment and concerning levels problems have assessment. of methods R Downie

references

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