In “Mandatory Evacuation Zone,” Felice Aull has gathered 63 beautifully crafted poems in which she examines the intricacies of language and loss, of grief and healing.  Each of the book’s five sections considers these themes in slightly different ways, always in language that is understated, vivid, and exact.  In Section I, we read poems that focus on the author’s complicated family history and her early loss of homeland.  In “Tracings” (page 15), an unknown relative (thanks to online genealogy searches) reaches the narrator and wants to meet her.  She, however, only wishes to learn “. . . how my parents / and my infant self / made our tortuous way out . . . . ” Brought in infancy from Germany to America, the author suffers the loss of both native homeland and native language (“Notes from an Alpine Vacation” page 16).  She searches photos of her mother and ponders museum note cards illustrated by Holocaust survivors (“Museum Notecards” page 18), imagining what she can’t quite know and yet can’t quite forget.  

Section II finds the narrator as a young woman in American, awakening to sexuality (“Gay Blades,” “Camp Counselors Make Out,”  “On the Staircase” pages 29-31), becoming a wife and mother, and then a grandmother.  A grandchild’s birth is both joyful and yet another “slipping toward / the edge of separation” (“Daughter in her Eighth Month” page 37). 

In Section III, the author turns her gaze to observations of the world around her, around us, aware of how many come to loss and death.  “Be prepare to mourn,” she tells us in “Disaster in October” (page 49), and in the moving poem, “I Saw the Smoke,” re-visions September 11th in words stripped of sentimentality and therefore made more powerful. 

Sections IV and V confront bodily loss through aging and illness, noting how, in so many ways, we try both to capture and to let go: “You snap photo upon photo / hoping to grasp and preserve / what cannot be grasped” (Capturing Alaska” page 66).  We learn of the most personal losses in poems of biopsies, surgeries, and chemotherapy.  When facing the unknown, every event might seem to hold a prediction.  In “Stunning Blows,” a doorman stuns a mouse, claims that it’s dead.  But the narrator, aware of the wages of time, writes, “But I still see it, like death, / moving toward me” (page 81).  At the book’s end, we return to language, how it too can leave us (“Forget That” page 90).  Yet in the collection’s final, gentle poems, the poet is “able, finally / to walk past the park’s redbud tree / without weeping” (“Immunity” page 96).

Although there are many poems that confront loss both recalled and experienced. grief for self and others, illness and the unknown in this collection, there are also poems of great acceptance and ultimate joy: “These gifts and losses, every year, mine” (“The Key to Gramercy Park” page 98).  The poems in “Mandatory Evacuation Zone,” show us how poetry can help us to “declutter” (see “Divesture” page 99) and release, and at the same time, hold on to and embrace.

Kelsay Books, California 2017: 100 pages

Felice’s website: https://www.feliceaull.com/

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A previous version of this review was published in the NYU Literature, Arts, and Medicine Database

Literature mirrors the general culture. There has been a recent explosion of books in which AI is the central plot device moving the narrative forward to endings that range from a utopian fulfillment of human destiny to the catastrophic collapse of civilization and the annihilation of humankind. But AI infiltrated the literary space several decades ago. Philip Dick imagined a world in Do Androids Dream of Electric Sheep? where cyborgs were being hunted down because of fear that they might take over the world. In 2001: A Space Odyssey by Arthur C. Clarke, a robot named Hal murders nearly all the crew of a spaceship on a planetary mission because of a programming error. 

Speak by Louisa Hall is more recent addition to the AI library. But it was published several years before large language models became a routine tool to plan a vacation or write a letter of recommendation. Is it still worth reading in 2025? 

The novel is a composite narrative centered around five interwoven stories spanning the time period from 1663 to 2040. In the first narrative, a young Puritan girl who finds herself in an unwanted marriage, records her thoughts in a diary that she is writing on a treacherous ocean voyage to America. Fast forward to the 20^th century and we meet Alan Turing who is writing letters to the mother of young man to whom he was emotionally attached and who died prematurely. He is troubled by his inability at times to communicate with people. A decade later we meet Karl and Ruth Dettman, a couple whose families escaped Nazi Germany but under vastly different circumstances. The husband, Karl, is a computer scientist who has developed a program named MARY to enable computers to interact with humans. Ruth, his wife, is a historian who has built a career centered on the publication of old diaries like the one written by the young woman traveling to America. She is trying to convince Karl to expand the memory of his computer program and enrich it with more human material, but Karl stubbornly refuses because he is concerned about the power of his program to overwhelm its users if its database is expanded. Finally, we jump ahead to 2040, and we read the transcripts of the trial of Stephen Chinn, a man who is being prosecuted for the production of robots that are too life-like. Chinn is being accused of causing physical and psychological harm to the people who have used his robots and of weakening normal relationships between people. A young adolescent named Gaby, who was given a doll powered by a version of MARY, is one of his alleged victims. His own personal recollections are folded into the trial proceedings, as he tries to describe his intentions, justify his actions, and make amends for where they may have gone awry. 

Taking stock of our world today, there is clear evidence that AI can improve the day-to-day lot of people, make life more convenient and efficient, and promote better health outcomes. However, much of the current angst that permeates discussions of AI is focused on the potential economic and sociopolitical consequences. There is fear that systematic adoption of AI will lead to widespread loss of jobs and financial distress for people left behind. The generation of false data and uncontrolled dissemination of unfiltered information may, it is feared, foster social unrest and destabilize democratic institutions.  

All of these predictions, for good or for bad, center on the word “intelligence.” If it is defined as the creative use of information towards a specific goal– my definition, to be sure — then it exists along a gradient and there is not an opposing term. In that case, the mixed picture about the future of AI seems accurate. Humans can process information to both noble and destructive ends. If machines are provided information by humans, then it is likely that there will be worthy and flawed outcomes. It is not a reflection of the logical structures or neural networks that are built into us as humans or artificially placed into machines. It simply is the nature of intelligence. Information is agnostic and it can be processed in a limitless number of ways; there is no guarantee of what will happen when it is processed. 

On the other hand, if we center our predictions on the word “artificial,” there is an opposing term, namely “genuine.” Speak looks beyond AI as intelligence and forces us to think about its impact on interpersonal communication and interactions. The design of the robots that are being created in fiction and in our world of 2025 is steadily improving. The voices become more lifelike, the reactions more emotionally appropriate, the reactions more convincing. They display keen intelligence and manifest seeming empathy with their handlers. Like the artificial friend in Klara and the Sun by Kazuo Ishigura, the robots may even appear to have more feelings and awareness of the ever-changing psychological state of their owners than family members and friends. But it will always remain artificial. Speak forces us to ponder whether interactions between human beings have an element that cannot be programmed, that is not simply manipulation of information. It is that piece that accounts for the genuine nature of relationships between people and it is that component that is vital for human growth and maturation. The interconnected stories in Speak raise the concern that reliance on AI, in whatever embodied form it takes, to provide support and companionship may inevitably fail and leave damaged humans in its mechanical wake. The intelligence of AI may not be sufficient for humans to thrive. It remains difficult to put into words exactly what to call this additional component of human interaction. Thankfully, there is literature, and creative novels like Speak, to help us grapple with what it might be and to help us steer a course where AI is developed thoughtfully with full awareness of its limitations and potential for good and harm. 

SPEAK  
Louisa Hall 
EccoPress, New York 2016, 356 pp 
Web image by Medhum.org

Alive: Our Bodies and the Richness and Brevity of Existence by Gabriel Weston 

Boston: David R. Godine, 2025, 304 pages 
ISBN 9781567928235 

The physician experience, medical history, motherhood, anatomy, and worries about her diseased mitral valve are tenderly sutured together by ENT surgeon Weston in her exploration of “the poetry of the body.” In thirteen chapters, she eloquently contemplates “the strange, unbridgeable gap that exists between the body science describes and the one each of us is living inside right this moment” (p194). In describing the anatomy of bones, brain, breasts, genitals, gut, heart, kidneys, liver, lungs, skin, and womb, Weston writes with a wit and intense curiosity reminiscent of popular science writer Mary Roach. But the book’s splendor arises from its attention to the art of doctoring. Weston notes how good physicians require a kind of “bifocal vision” that allows them to see the generalities of the human body but also the unique details of an individual patient. She extols empathy and elevates vulnerability: “We are not separable from those we care for, just as our strength is not separable from our vulnerability” (p263). Melding science and sentiment, mixing professional life with personal life, Weston enlivens anatomy and pays homage to the physician-patient relationship.  

The Land in Winter by Andrew Miller 

London: Sceptre, 2024, 384 pages 
ISBN 9781529354270 

Andrew Miller’s remarkable 1997 debut novel Ingenious Pain chronicles the complex life of an 18^th century highly skilled English doctor incapable of feeling pain. Twenty-seven years and many novels (Oxygen, Pure, The Optimists) later, Miller’s latest book spotlights a main character who also happens to be an English physician – but this flawed human being hurts (especially emotionally). Eric Parry is a 36-year-old country doctor having an extramarital affair with a married woman while his wife Irene is pregnant. Next door to their cottage is a farm owned by Bill Simmons and his pregnant wife Rita who suffers from mental illness and enjoys reading science fiction. It is winter (December, 1962 – January, 1963) and for a time the rural community is paralyzed by a brutal blizzard. Happy endings are in short supply here. One of the pregnant women has a miscarriage while sitting on the toilet. Characters get injured. Some patients die. Eric’s infidelity is exposed. Still, compassion and empathy occasionally sprout amidst the bleakness and the cold. Irene is cognizant that her husband’s work is hard as he “had to deal with people’s suffering all day” (p55). Eric excels at examining patients with a manner that “calmed” them. Secrets, loneliness, belonging, complicated personal relationships, and poor decision-making are essential elements of the plot. The story asks readers to contemplate whether virtuousness is a necessary requirement to be a “good doctor.” 

Doc or Quack: Science and Anti-Science in Modern Medicine by Sander L. Gilman 

London: Reaktion Books, 2025, 320 pages 
ISBN 9781836390152 

Bloodletting and purging (“heroic medicine”) employed for a wide array of diseases. Laetrile (a chemical present in apricot seeds) used for treating cancer. Hydroxychloroquine and Ivermectin prescribed for COVID-19. Spanning centuries, the list of wacky, ineffective, and sometimes dangerous remedies for illness is quite lengthy. In this standout history of scientific medicine from the mid-19^th century to the present, Gilman navigates “the ever-shifting boundary between good medicine and quackery” (p15). He reviews the rise of allopathic medicine that resulted from “following the science” as discovery and knowledge migrated from the laboratory to the bedside. He writes about the model of the physician-healer, the placebo effect (along with the morality of deception), superstitions (of both doctors and patients), and the faddish nature of medical practice. Gilman is rightly concerned about physicians experiencing burnout and patients feeling disconnected from their doctors in truncated office visits. He wonders if empathy and efficacy can coexist in contemporary healthcare. Three “case studies” are presented: peptic ulcer disease, the development of ophthalmic surgery, and acupuncture for back pain. A thoughtful study of historically “good” and “bad” medicine and the occasional blurring between the two. 

Additional recommended books published in 2025: 

The Mind Electric: A Neurologist on the Strangeness and Wonder of Our Brains
by Pria Anand 

The Age of Diagnosis: How Our Obsession with Medical Labels Is Making Us Sicker
by Suzanne O’Sullivan 

Web photo by Bermix Studio 

Herein I argue not only that video games are an epistemically valid artform but also that the health humanities should actively incorporate them into critical discussions. As any diligent qualitative researcher would say, such arguments must position the writer, so I’ll begin by briefly describing how I came to this topic.  

At the time of writing, I am a resident in psychiatry in New York City. I grew up and completed my formal education in the Middle Atlantic region, and video games have been a part of my life the entire way. As a child, I was fortunate enough to play both handheld (e.g., Nintendo Game Boy) and console (e.g., PlayStation) systems. I gravitated toward role-playing games (RPGs), those in which the player acts as a particular character to live through ​​that character’s narrative (often a hero’s journey). I especially loved fantasy and science fiction RPGs, which mirrored my passions in literature. Aesthetically, they transported me to rich worlds with stunning visuals. Practically, they taught me skills I didn’t realize I was learning (e.g., map reading, orientation in a digital space, manual dexterity). Emotionally, they carried me through incredibly challenging moments, providing a mentally stimulating escape when my child and adolescent brain needed time to process.  

The messaging had always been clear: if you want to do nothing with your life, then go ahead and play video games in your parents’ basement. Whenever I heard this, I became smaller. Despite my life aspirations and dreams of being a physician, I couldn’t help remembering that I was indeed the child living in his parents’ basement playing video games. I felt I was one step away from failure at any moment. I still enjoyed my games immensely, but I constantly created timelines for when I would “give them up.” Video games became a vice, a tumor that I needed to excise lest it devour me. 

But I couldn’t.  

Every time I attempted to leave video games in my past, something brought them back: the newest installation in my favorite series, a need for variation in my leisure activities, an offer to play a collaborative game remotely with new friends, a need for active escape. Still, I kept it secret. I talked about it with my closest friends, but only if they too struggled with the same addiction.  

Until one day I stopped. I made the active choice to talk about it with my peers, co-residents, and supervisors if it naturally presented itself. And, miraculously, the shame started to ease. I realized that video games nourish my life in ways that other activities do not. In some respects, they offer the narrative of literature, the visuals of movies, and the interactivity of board games all wrapped in one beautiful image. I started to question why I could spend countless hours reading or watching shows without concern but immediately felt guilty when I played a game. This piece, and subsequent series, seeks to challenge this socialized notion that video games are a waste of life force.  

Just like other forms of media, video games both comment on and transform the human experience. Video games have expanded into innumerable genres and formats. Gone are the days when you needed a desktop computer or a gaming system to play; the size and pervasiveness of the mobile game market is near incomprehensible. Video games have become a part of mainstream culture. It’s time we change our viewpoint on them and treat them like the critical pieces of media they are. Through MedHum, we will join in rewriting this narrative, highlighting the value of video games within the health humanities. First on our docket is an open-world game called Forspoken, a game with a bit of controversy in its reception. Stay plugged in to read it soon! 

Web image by Aditya Sethia

At bottom, these two categories of judgment largely overlap. My concern here is the role of the physician’s own emotions (or, as we like to say in medicine, in order to sanitize them, affects) in judgments of either category. Do the physician’s own emotional responses contaminate her judgment when making clinical or moral decisions in patient care? Or, rather, do her emotional states constitute essential components of medical judgment? 

Clinical Judgment 

Medicine has a long tradition that attributes a special quality to the diagnostic and therapeutic thought processes of good clinicians, an attribute independent of intelligence or medical knowledge. Traditional views of clinical judgment included personal experience, received knowledge in the profession, and evidence from empirical studies. Emphasis was put on developing the “clinical eye” or clinical intuition as a result of personal experience, perhaps guided by role model physicians. In 1967 the Yale clinician and epidemiologist Alvan Feinstein published his book, Clinical Judgment, which was the first (as far as I am aware) systematic and scholarly analysis of judgment in medicine.¹ What Feinstein added to the mix was a firm grounding in epidemiological methodology; notions like prevalence, sensitivity, specificity, predictive value. What constituted evidence became more scientific and less subject to bias. However, Feinstein acknowledged the important influence of a personal relationship with the patient in good clinical judgment. 

In this sense he was following a tradition that has been prominent among physician writers for over 250 years and was often expressed metaphorically by reference to the heart. For example, John Gregory, Professor of Medicine at the University of Edinburgh wrote in 1772: “Of the physician’s character, the chief quality is humanity, the sensibility of heart that makes us feel for the distress of our fellow-creatures, and which, in consequence, incites us… to relieve them.” Physicians “by being daily conversant with scenes of distress, acquire that firmness of mind so necessary in the practice of physic.”² Yet he warned his readers to maintain “a gentle and humane temper” because “rough and blustering manners generally accompany a weak understanding and a mean soul.”² In 1803 Gregory’s student, Thomas Percival, instructed physicians to, “Unite tenderness with steadiness in your care of patients and cultivate the tender charity that the moral practice of medicine requires.” He warned his readers that medical practice makes the practitioner vulnerable to “coldness of heart,” and he concluded: “This coldness of heart, this moral insensibility, should be sedulously counteracted before it has gained an invisible ascendancy.”³ 

Physicians reiterated this dynamic throughout the nineteenth century. Morril wrote that “the study of medicine has a peculiar tendency to harden the disposition,” which makes it incumbent on students to cultivate “an affectionate sympathizing spirit,” while Jones reflected on medicine’s “manifest tendency to harden and corrupt the heart.”⁴ And famously, in his 1889 graduation address at the University of Pennsylvania, William Osler encouraged the graduates to cultivate the virtue of “aequanimitas,” which would assist them in meeting, “the exigencies of practice with firmness and courage without, at the same time, hardening the human heart by which we live.”⁵

In the early twentieth century, Francis W. Peabody, chief of the Harvard medical service at Boston City Hospital, published an influential description of this tension between the “intensely personal” values needed in caring for patients and the “entirely impersonal” aspects of treating disease. Peabody recognized that the hospital setting creates a hostile environment for humanism, but urged students to commit “time, sympathy, and understanding” to creating a “personal bond” with their patients, which will make them more effective healers, as well as give them personal satisfaction.⁶ This tradition was most recently and eloquently summarized in A Flag in the Wind, Thomas Inui’s now famous report to the American Association of Medical Colleges (2003).⁷ Each of these writers emphasized the importance of tenderness or sensibility of heart, while warning students and practitioners against the tendency of medical practice to chill, harden, or corrupt the heart. 

A second tradition, almost diametrically opposed to the first, experienced a growth spurt in the mid-twentieth century and has become the most prominent model for medical education and practice in recent decades. In terms of diagnosis and therapy, the ascendency of randomized clinical trials, statistical techniques for the metanalysis of multiple studies, evidence-based medicine, algorithms, and clinical decision rules has progressively reduced the role of judgment in medicine because decisions are presumably to be based on complete, rather than incomplete, knowledge. Judgment is to be replaced by decision rules that can be applied without the adverse influence of spooky elements like intuition, biases, experience, emotion, or idiosyncratic beliefs. 

In tandem with this, the doctor’s proper stance toward her patient became detachment, rather than personal engagement, and the doctor’s emotions became stumbling blocks, rather than beneficial to care. This tradition holds that emotional experience decreases objectivity, which harms the patient because it compromises clear thinking and harms the physician because it makes her vulnerable to emotional stress, depression, and burnout. In summary, what was once a pernicious tendency to harden the heart is no longer considered pernicious, but rather a positive development that should be fostered by medical education.^8-11 Clinical judgment, according to this tradition, should ignore the heart and focus exclusively on the mind. 

Moral Judgment 

Medical morality originated in ancient writings from Greece, India, and China that specify the personal traits and moral duties of medical practitioners. These documents include such duties as honoring their teachers, acting in their patient’s best interests, and keeping “whatever I shall see or hear in the course of my profession” confidential. These admonitions were later incorporated into a Judeo-Christian-Islamic framework that added a theological dimension (e.g. respect for human life, compassion, fidelity, and vocation) to medical morality—for example, in the Oath of Maimonides: “May I never see in the patient anything but a fellow creature in pain.” Or, in the Islamic oath, “I swear by God to be . . . an instrument of God’s mercy.” This work was secularized in the eighteenth and nineteenth centuries by writers who adapted Aristotelian virtue theory to the profession. The basic idea, then, was that learning to be a physician involved a process of character formation in which certain defining virtues were incorporated as personal traits or qualities, thus enabling physicians to make correct moral judgments in their professional lives. 

This work was brought up-to-date in recent decades by philosophically-minded physicians, like Edmund Pellegrino¹² and Eric Cassell^{13, 14}, who argue that judgment in medicine should be an instantiation of the Aristotelian intellectual virtue called phronesis, or practical wisdom.⁹ They remind their readers of the moral goals intrinsic to the profession, and that certain physician character traits or virtues further those goals, e.g. compassion, fidelity, integrity, courage, humility, self-improvement. They argue that, in fact, that all clinical judgment is informed by moral judgment. 

Although moral judgment was thought essential in deciding what to do for patients, it was proscribed in making decisions about the intrinsic value of patients. The ethos of medicine strongly warns against judging the patient’s personal worthiness or value, even if the physician considers the patient’s beliefs or actions hateful. Thus, professional ethics dictates that you remain detached from any behavior that would compromise treatment of enemy soldiers, criminals, terrorists, or patients that you find personally hateful or disgusting. 

Beginning in the 1960s and 1970s, the professional virtue tradition was supplemented by (or challenged by, depending on your perspective) a new moral framework that generally goes by the name biomedical ethics. This development became necessary for a variety of reasons, most notably (a) technological advances in medicine that enhanced the ability to prolong life and especially to harm, as well as to help, patients; (b) new societal emphasis on individual and civil rights; (c) increasing opportunities for conflicts of interest in medical practice; (d) revelations about medical research conducted without the subjects’ knowledge or adequate consent; and (e) concerns about the lack of equity in the provision of health care services. 

The biomedical ethics movement involved a concerted response to these issues by a great number of moral philosophers, theologians, legal theorists, and physicians. In the United States the movement acquired its canonical form as a result of the publications of two bodies, the National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research (1974-78) and the President’s Commission for the Study of Ethical Problems in Medicine and Biomedical and Behavioral Research (1978-1983). The former developed the ethical framework (i.e., Common Rule) that has since guided all research involving human subjects. The latter delineated and elaborated four basic ethical principles: respect for autonomy, beneficence, nonmalificence, and justice. 

In biomedical ethics the focus is entirely on explicit justification of individual decisions (i.e. who should make them, what principles should be invoked), rather than on the qualities or character of the decision maker. Importantly, the model is one of shared decision making between patient and clinician, with adult patients having the determining voice, unless they lack decision making capacity. 

The notable aspect, for my purposes here, is that principles, like respect for autonomy, are intellectual constructs rather than personal traits, like virtues. There is no explicit role for such traits in biomedical ethics. I take it that virtues like compassion, empathy, humility, or courage cannot be actualized without an emotional component. You cannot act compassionately without experiencing some feeling. Thus, while traditional medical morality highlights sensibility of heart, biomedical ethics (at least in theory) exclusively involves intellectual considerations. Principle-based biomedical ethics is often labeled “thin” because, theoretically at least, it leaves out particularistic features of the patient’s community, culture, beliefs, and personal story. Advocates of care, feminist, and/or narrative ethics maintain that such features have great moral relevance to health care decisions. They argue for a “thick” form of health care ethics that takes particularities into account.

“Thickness” in decision making applies to physicians in decisions about the best (or most virtuous) way to allocate their time and effort. Part of this thickness relates to the physician’s feelings, emotions, or “tenderness,” to use Thomas Percival’s term. Consider the following case example. 

Case Example 

The case is an excerpt taken from “Narrative Medicine and Negative Capability,” an essay by the cardiologist Terrence Holt.¹⁰  Holt illustrates his discussion of the complexities of moral judgment in medicine by describing a situation he once experienced when he was a resident in the cardiac ICU: 

“It is about eleven in the morning, and I have been up since six in the morning the day before. The patient has been under my care eleven days… About fifteen minutes earlier, in response to her request and after several days of discussion, I had asked the nurse to turn off the pump that had been keeping her alive. The family members are around the bedside. The patient is awake… She will probably be dead within the hour. 

Tears are coursing down my face. I am being very quiet about it, but in a very quiet way I am sobbing as freely as I know how. I’m determined to stay with the patient during this ordeal. But meanwhile I am thinking: This is crazy. I’ve got several unstable patients who need attention. And there’s that arterial line in twenty-four that needs changing… At the same time I am utterly sad, haunted by memories of my father’s… death ten years ago. 

But somewhere a voice is also thinking: I’ll never get to lunch at this rate. I’m so backed up I’ll never get out of here on time.”¹⁵

Reflections 

I want to reflect on several aspects of Dr. Holt’s judgment in light of the clinical and moral traditions that I have outlined. First, the writer appears to combine deep emotional experience with a sense of detachment. He experiences (a) feelings of sadness and compassion, (b) awareness that at least in part those feelings arise from grief over his father’s death, and (c) detached reflection about his own needs and the work he has to do that afternoon. This combination appears consistent with older admonitions that physicians should maintain “sensibility of heart,” but to be at variance with the contemporary belief that emotional connection with patients is incompatible with good judgment—assuming, of course, that his current choices constitute good judgment. Do they? 

Second, from the perspective of contemporary biomedical ethics, Dr. Holt had already fulfilled his ethical duty when he respected the patient’s right to refuse treatment, and consequently withdrew mechanical ventilation. In addition, he may have consciously employed the principle of nonmalificence if he believed that the respirator was only prolonging the patient’s suffering. He has no moral duty to maintain a compassionate vigil. In contemporary terms, his actions would be considered supererogatory—commendable, but not a moral duty. 

Third, but how commendable is his behavior? It is clear that Dr. Holt’s course of action could have arisen, at least in part, from unresolved emotions related to his father’s death ten years earlier. He admits to strong feelings of sadness, loss, and grief, even to the extent of crying. Is this a case of countertransference, a psychological defense mechanism, rather than a true expression of moral virtue? We need to consider the extent to which the emotions about his father’s death are nurturing appropriate compassionate behavior, or, alternatively, contributing to a form of hyper-compassion that is preventing him from attending to other duties. 

Fourth, this brings us to the question of harm. Given the level of criticality among his ICU patients, Dr. Holt’s compassionate vigil has a reasonably high risk of negatively impacting the others’ care. He does, after all, have an established duty to provide the best medical care he can to each of his other patients in the ICU. They all have identified and pressing needs. To what extent, if any, does his behavior represent an abrogation of his duty to others? In bioethical terms, he may well be discounting the ethical principles of beneficence and justice in his desire to demonstrate compassion. 

To demonstrate this, we can take the narrative a step further. Suppose the man whose arterial line needed to be changed (e.g. nurses have noticed local redness and swelling) develops septic shock shortly after the first patient dies. Dr. Holt has spent more than an hour in the room with the dying patient and his family. Did his delay in removing the infected arterial line precipitate the septic shock? Perhaps it could have been averted had he changed the line earlier that morning? Has his compassion for one patient and his family caused a life-threatening complication in another? 

This leads to a fifth consideration. Let’s return to the concept of clinical judgment as being informed by phronesis, a type of wisdom relevant to practical things, requiring an ability to discern the right or virtuous action in a given situation. Thomas Aquinas considered phronesis to be equivalent to prudence, and medical writers like Pellegrino tend to use the terms interchangeably. Pellegrino and Thomasma, in The Virtues of Medical Practice, describe prudence as the virtue that fosters the ability to choose the right way of acting.11 From this perspective, was Dr. Holt’s decision a prudent decision? Would it have been more prudent to excuse himself and go tend to his other duties? 

Sixth, let’s look briefly at Dr. Holt’s situation through the lens of narrative ethics, which is a relatively new perspective that highlights medicine’s traditional focus on particular cases or stories as providing the context for individual judgments.12 In this framework, Dr. Holt’s actions make for an engaging story. There is little doubt that his response to what is going on with the patient and his family suggests a more affirmative and inspirational narrative than had he chosen to continue with his ordinary duties. This version is more comforting for the patient and his family, it is more personally fulfilling for the doctor himself, and more compelling for the reader than the more prudent alternative. For better or worse, heroic or passionate behavior is generally far more interesting than prudent behavior. Does that make it right? 

Conclusion 

Judgment in medical practice is complex and omnipresent, involving decisions that range from diagnosis and treatment of illness to the assessment of relevant patient characteristics and choice of appropriate words. A great deal of this judgment has an important moral dimension. In this paper, I have argued that medical judgment also frequently integrates emotional content into the decision-making process; and the role of emotion can be important and beneficial, rather than damaging. In fact, traditional medical virtues – e.g., compassion, fidelity, courage, humility – are habits of the heart that are intrinsically associated with emotion, as well as rational cognition. 

The case I have presented illustrates this complexity. It also illustrates the role of incomplete knowledge in medical judgment. For example, if we knew more about the benefits and risks of Dr. Holt’s actions, we might come to a more definitive judgment about whether, under the given circumstances, his clinical/moral judgment was right or wrong, correct or incorrect. Surely, respecting the patient’s decision to discontinue the ventilator was morally right, but what about his subsequent decision to spend considerable time with the patient and his family, while postponing other duties? Well, that is a question of judgment.

References

1. Feinstein A. Clinical Judgment. Baltimore, Williams & Wilkins, 1967.
2. Gregory J. Lectures on the duties and qualifications of a physician. London, W. Strahan and T. Cadell, 1772. [Reprinted in McCullough LB (Ed.) John Gregory’s Writings on Medical Ethics and Philosophy of Medicine. Dordrecht, Kluwer Academic, 1998.]
3. Percival, Thomas. Percival’s Medical Ethics. Ed. C. D. Leake. Huntington, NY: Robert E. Krieger, 1975.
4. Warner JH, Rizzolo LJ. Anatomical instruction and training for professionalism from the 19^th to the 21^st centuries. Clinical Anatomy. 2006; 19: 403-414.
5. Osler W. “Aequanimitas,” in Hinohara S, Niki H (Eds). Osler’s ‘A Way of Life” & Other Addresses With Commentary & Annotations. Durham, Duke University Press, 2001., pp. 21-29.
6. Peabody FW.  The care of the patient. JAMA. 1927; 88: 877-882.
7. Inui TS. A Flag in the Wind: Educating for Professionalism in Medicine. Washington, DC: Association of American Medical Colleges, 2003.
8. Hafferty FW, Franks R. The hidden curriculum, ethics teaching, and the structure of medical education. Acad Med. 1994; 69: 861-871.
9. Coulehan J, Williams PC. Vanquishing virtue: The impact of medical education. Acad Med. 2001; 76: 598-605
10. Coulehan J. Williams PC. Conflicting professional values in medical education. Cambridge Quarterly of Healthcare Ethics, 2003; 12: 7-20.
11. Coulehan J. Today’s Professionalism: Engaging the Mind, but Not the Heart. Acad Med. 2005; 80: 892-898.
12. Pellegrino ED, Thomasma DC. The Virtues in Medical Practice, Oxford University Press, 1993.
13. Cassell EJ. The Nature of Suffering and the Goals of Medicine, 2^nd edition, Oxford University Press, 2004.
14. Cassell EJ. Doctoring. The Nature of Primary Care Medicine. Oxford University Press, 1997.
15. Holt TW. Narrative medicine and negative capability. Lit. Med. 2004; 23(2): 318-333.
16. Jones AH. Narrative in medical ethics. Brit Med J. 1999; 318: 253-256/
17. Lothe J, Hawthorne J. Narrative Ethics, Value Inquiry Book Series, Rodopi, 2013

EDITOR’S NOTE:  This essay is taken from a paper presented in 2020 by the author at the Joske Colloquium, a gathering of physicians, philosophers, historians, lawyers, social scientists, and creative writers that met biannually at the University of Tasmania from 2002 to 2020 to discuss broad topics of human experience and flourishing.  We feel that it nicely supports and illustrates some of the philosophical underpinnings, multidisciplinary nature, and real-life applications of the field of medical humanities.  

Photos from Wikimedia. CC BY-SA 3.0.

We feature James Dickey’s poem, Diabetes, with our guest, the renowned physician-poet Dr. Jack Coulehan. We discuss insights the poem offers about the trajectory of type 2 diabetes from the time of symptom onset until the time a balance is achieved between maximum compliance with disease management requirements and the compromises an acceptable lifestyle can necessitate for many individuals. In addition to providing his perspectives on how the poem expands on the biomedical components of diabetes in recognizing effects such as fear, anxiety, frustration, and oppression, Dr. Coulehan recounts how he has used this poem and others in teaching medical students and residents. He also tells stories of particular instances in which he used poetry as part of the care he provided certain patients, and as a way to connect with them. 

Links:
Dr. Jack Coulehan’s bio and posts on Medhum.org

The poem, Diabetes, and the comparative biomedical text discussed can be seen here in Russell Teagarden’s blog, According to the Arts. 

Dr. Coulehan’s poem, I’m Gonna Slap Those Doctors, which was central to one of the stories he told, can be accessed here. And, his poem, The Man with Stars Inside Him, which was central to another story he told, can be accessed here.

In this episode, we make a distinction between illness as the subjective perceptions of a health problem and disease as the pathological basis of a health problem. This distinction is explained in much greater depth here in According to the Arts. 

The Clinic & The Person is a podcast developed by our editor Russell Teagarden to summon or quicken the attention of health care professionals, their educators, researchers and others to the interests and plights of people with specific health problems aided through knowledge and perspectives the humanities provide.

Feature image by Álvaro Serrano