Frustrated in their attempts to access information, seek compensation, and prevent future deaths, the families convinced the flamboyant lawyer, Jan Schlichtmann, to take on what was thought to be a hopeless cause. Suddenly, the case seemed to promise a multi-million-dollar settlement. Large industrial concerns, as well as government officials, began to pay close attention. Obsessed with the enormity of the apparent crime, the creative Schlichtmann amassed a huge amount of damning evidence through careful and expensive scientific research. But the accused companies also invested large sums in experienced lawyers and scientists who used other data and legal technicalities to refute the charges. The families lost their case in 1986, and Schlichtmann was financially and emotionally ruined. By that time, 21 cases of leukemia had been identified – 4 times the anticipated rate for the population. A public health report found “no significant differences” in exposure between the leukemia cases and controls, yet concluded that “it is not possible to rule out exposure to this water as a factor” (Cutler et al 1986). 

Author Jonathan Harr began work on A Civil Action in 1986 before the opening of the trial, and he accompanied Schlichtmann to almost all meetings, relied on court transcripts, and conducted many painstaking interviews with the families and opposing lawyers. The result is an omniscient yet intimate perspective on these true events that reads like an action-packed thriller, complete with dialogue. It won many awards and was on the New York Times bestseller list for 65 weeks. It stands as an interesting commentary on the nature of environmental health and on the American justice system. 

Three years later, Steve Zaillian wrote and directed the award-winning film, A Civil Action (1998), based on Harr’s book and starring John Travolta and Robert Duvall. Shlichtmann received $250,000 for the portrayal rights, but is quoted as saying, “John Travolta made more money playing me than I ever did playing me” (Kix 2009). Forty years later, now at age 75, he continues to champion environmental causes, aiming for settlements rather than court cases and recounting his “lessons learned” on the speakers’ circuit. 

Woburn and A Civil Action had coincided with other prominent environmental disasters, caused by industrial failures: Three Mile Island (1979), Love Canal (1977-1979), Times Beach, Missouri (1983), Bhopal (1984), to name only a few. The book and the film contributed to rising awareness about the health risks of environmental damage, and they added to increasing skepticism over the intentions of private entrepreneurs and the courts. They also heralded a period that saw a growing body of legislation aimed to define responsibilities and regulate industrial pollution – measures coming, alas all too frequently, after new problems arose and covering jurisdictions defined only by political boundaries, which have nothing to do with the flow of water and air. In 2022, the United Nations declared that a healthy environment is a human right. Dozens of countries, including Canada (2023) and several American states, have enshrined that ideal in law, even if practicalities and protections lag far behind. 

Less known is that fact that Woburn triggered a public-health preoccupation with “clusters” and the nature of proof (Alexander et al., 1999; Kingsley et al., 2007) Do clusters indicate important dangers or are they unfortunate but random occurrences? A decade later, the Center for Environmental Health Sciences at Massachusetts Institute of Technology reported on its vain “search for causes” in the industrial toxins of the Woburn leukemia cluster (Durant et al., 1995). In 2002, a controlled study, based on Woburn, failed to establish a causal correlation between disease and contamination; it pointed out that incidence had returned to anticipated levels, while 8 consecutive years had seen no leukemia cases at all (Costas et al., 2002). Woburn has also been cited in efforts to provide better statistical evaluation of “clusters” (Waller, 2000). Woburn prompted recommendations to incorporate qualitative methods into public heath reporting (Brown, 2003) and to recognize the value of citizen science and epistemic differences in lay and professional “ways of knowing” (Brown, 1992; Petteway et al, 2019). Woburn is still being cited in public health assessments of environmental causes of malignancy, often with ambiguous outcomes (Binczewski et al., 2026). 

A Civil Action helped prepare the terrain for these many studies with their controls, statistics, and tracking of chemicals–mind you, only those chemicals that are already recognized and detectable. We no longer question the harm in smog and smoking, while improvements in respiratory diseases proclaim the benefits of keeping air clean. It is dismaying that the idea of water pollution as a harm to human health continues to be such a hard sell, while disasters like Flint, Michigan, or Grassy Narrows, Ontario, roil on. 

Water degradation is bad for flora, for fauna, and for the planet. Therefore, it is bad for us too. But for industry, the courts, and even some epidemiologists in their many ways of knowing, it remains an unproven hunch. 

References 

• Alexander, Freda E. 1999. Clusters and clustering of childhood cancer: A review 
• European Journal of Epidemiology 15: 847-852.
• Binczewski, N.R., Morimoto, L.M., Wiemels, J.L., Richardson, D.B., Bartell. S.M., Metayer, C., Vieira, V.M. 2026. Spatial analysis of residential location at birth, PFAS in public water, and childhood cancers in Southern California (2000-2019). Journal of Exposure Science & Environmental Epidemiology 2026 Mar 5:10.1038/s41370-026-00850-1. doi: 10.1038/s41370-026-00850-1. Epub ahead of print. PMID: 41781477; PMCID: PMC13032745. 
• Brown, Phil. 1992. Popular epidemiology and toxic waste contamination: lay and professional ways of knowing. Journal of Health & Social Behavior 33(3):267-81. 
• Brown, Phil. 2003. Qualitative methods in environmental health research. Environmental Health Perspectives 111(14):1789-98.  
• Costas, K., Knorr, R.S., Condon, S.K. 2002. A case-control study of childhood leukemia in Woburn, Massachusetts: the relationship between leukemia incidence and exposure to public drinking water. Science of the Total Environment 300(1-3):23-35. 
• Cutler, J.J., Parker, G.S., Rosen, S., Prenney, B., Healey, R., Caldwell, G.G. 1986. Childhood leukemia in Woburn, Massachusetts. Public Health Reports 101(2):201-5. 
• Durant, J.L., Chen, J., Hemond, H.F., Thilly, W.G. 1995. Elevated incidence of childhood leukemia in Woburn, Massachusetts: NIEHS Superfund Basic Research Program searches for causes. Environmental Health Perspectives 103 Suppl 6:93-8. 
• Kingsley, B.S., Schmeichel, K.L., Rubin, C.H. 2007. An update on cancer cluster activities at the Centers for Disease Control and Prevention. Environmental Health Perspectives 115(1):165-71.  
• Kix, Paul. 2009. In the shadow of Woburn, Boston Magazine, City Life, 22 September:  https://www.bostonmagazine.com/news/2009/09/22/in-the-shadow-of-woburn
• Lagakos, S. W., Wessen, B. J., Zelen, M. 1986. An analysis of contaminated well water and health effects in Woburn, Massachusetts. Journal of the American Statistical Association 81(395):583–596.  
• Petteway, R, Mujahid, M., Allen, A., Morello-Frosch, R. 2019. Towards a people’s social epidemiology: Envisioning a more inclusive and equitable future for social epi research and practice in the 21st century. International Journal of Environmental Research and Public Health 16(20):3983. 
• Waller, L.A. 2000. A civil action and statistical assessments of the spatial pattern of disease: do we have a cluster? Regulatory Toxicology & Pharmacology 32(2):174-83. 
• Jonathan Harr discusses A Civil Action on C-Span 

Web image by Medhum.org

Henry’s severe illness and his difficulties accessing treatment prompted Green to contemplate the horrifying statistics of tuberculosis and the paradox of our extensive knowledge about it. More than one million people still die every year from this ancient disease; yet the bacterial cause was elucidated a century and a half ago, and effective treatments have been around since the 1950s. Barring eradication, the germs mutate and become resistant. Given dire living conditions, it spreads. Effective therapy can be prohibitively expensive. “The cure is where the disease is not, and the disease is where the cure is not” (p. 5). People die where cures cannot be obtained. 

History is woven though Henry’s story, but so are politics, culture, and economics: the discoveries, the 19^th-century romanticization of ‘wasting away,’ the hard realities of pharmaceutical development and delivery. Henry has survived, become healthy and an inveterate TikToker and youtuber. He even has an episode on the power of storytelling. But other people that we encounter through this tale have died. 

We still have tuberculosis because statistics de-personify it, and geography allows ignoring it. Green uses Henry’s story to invite us to ‘[t]hink about how rare and precious humans are, and how many of them you get to worry for and care about. Then if you can, find a way to multiply that 1,250,000 times’ (p. 189).  

The book flows easily in language that is clear and accessible, a tribute to Green’s experience in writing young-adult fiction. In the end, without denying the benefits of medical interventions, he calls for a focus on the real cause of tuberculosis: injustice—tolerated and unchallenged. ‘Ultimately,’ he writes, ‘we are the cause’ (p. 184).  

Everything is Tuberculosis: The History and Persistence of Our Deadliest Infection
John Green
New York: Penguin/Crash Course Books
2025
ISBN 9780525556572 

Web image created by Medhum.org

The modern world is full of inexplicable conflicts. As one who has spent my life developing vaccines against infectious diseases it is puzzling to see the growing opposition to vaccination, which in the United States and other developed countries have eliminated or limited diseases that once decimated populations. I am old enough to remember as a child the deaths of other children, and indeed as a child I suffered three serious infectious diseases, one of which caused temporary paralysis of my face. 

Later in life, I graduated medical school and became an intern at a large metropolitan hospital in Cleveland. One of the common infections I saw in children was due to a bacterium called Hemophilus influenzae type B, which causes meningitis and epiglottitis (swelling of the structure at the top of the trachea that leads to the lungs). I treated those infections with antibiotics, but that succeeded best if the illnesses were in early stages. I remember one night on duty when a 3-year-old gasping for air was brought in to the Emergency Room by his father. The child had been put to bed that evening appearing to be healthy, but became ill hours later. I rushed into the room ready to help but in seconds, before I could do anything, the child died before my eyes. I will not forget the anguish of his father, or the anguish of other parents I saw whose children were ill with infections. Owing to the later development and employment of a vaccine against H. influenzae type B, the disease has disappeared from the United States. 

In part, the current opposition to vaccines can be attributed to the absence of these diseases they cause, which makes people feel invincible, and in part to a society in which communication of lies and fabrications is easy and rife. Modern communication allows dissemination of arguments based on fabrications to masquerade as facts, and to allow some to profit from those fabrications. Another example of a foolish approach to the issue of vaccination is the attempt by the current administration to break up the measles-mumps-rubella vaccine into three separate injections, despite years and years of safe use of the MMR vaccine that has dramatically controlled those diseases. The effects on public health will be awful. 

Although there is no easy way to deal with this situation, I have long thought that including education in statistics for all school children would be one useful step, so that they understand the relations between risk and benefit when they become adults. The fact of the matter is there is no choice in life that is without risk. The question is what is the ratio of risk to benefits in making that choice? All statistical analyses show that vaccination has little risk and great benefit, so why should we let lies about vaccination prevail? 

All licensed vaccines go through a process involving 5 Phases: Phase 1 involves testing a vaccine in a small number of people. Phase 2 involves increasing the number to several hundred. Phase 3 involves thousands of vaccinees, compared to a group of placebo recipients, checking for safety and efficacy of the vaccine. Phase 4 is after licensure, when observations are accumulated in millions of vaccinees. Phase 5 involves collection and analysis by CDC and potentially other organizations of reports by physicians about safety and efficacy of the vaccine. 

Obviously, if a reaction to a vaccine is frequent, that will be detected in the first three phases. If a reaction is uncommon but significant, it will be detected in phase 4. (Actually, a vaccine against rotavirus, an important cause of infantile diarrhea, dehydration, and death, was taken off the market because of phase 4 findings, to be replaced by a safer vaccine developed in my lab.) The problem is that when millions are being vaccinated, bad things are certain to happen by chance. The question then is are they caused by the vaccine? The answer to that question can only be ascertained by careful study, not by jumping to conclusions. 

Web image from Wikicommons.

The Knick portrays all that goes on in and around a hospital struggling to provide care for the poorer classes in lower Manhattan during the early 1900s. It shows that many of what were then considered important advances in medicine, technology, society, and culture were later considered dangerous, unethical, barbaric, inhumane, and racist. The series asks whether health care of any era, along with associated social and cultural factors at work, are destined to be seen sometime in the future in similar ways. 

Storylines of the Poor and the Famous 

The Knick was inspired by the Knickerbocker Hospital, founded in Harlem in 1862 to serve the poor. In this twenty-part television series spread over two seasons, the fictional Knick is located somewhere in the lower half of Manhattan around 1900. The time covered during the series is not marked in any distinct way. The characters do not age much, and although fashion and customs remain static during the series, the scope and significance of advancements that come into play were actually adopted over a longer time than the episodes cover.  

The series builds on some known history. The central character, the chief surgeon Dr. John Thackery, is modeled on a famous surgeon of the time, Dr. William Halsted, in both his surgical adventurism and in his drug addictions. The character, Dr. Algernon Edwards, who is an African-American, Harvard-educated, and European-trained surgeon, is based in part on Dr. Louis T. Wright, who became the first African-American surgeon at Harlem Hospital during the first half of the twentieth century.   

Storylines of human drama and folly run through the series. Among them are medical cases both ordinary and bizarre, heroic successes and catastrophic failures, loves won and lost, gilded lives and wretched existences, honor and corruption, racism and more racism. Within these storylines are the scientific, medical, and industrial advances of the period, as well as the social frameworks that form fin de siècle hospital care and medical research in New York City.   

Some of the industrial advances adopted by the hospital include electrification, telephone service, and electric-powered ambulances. We see that transitions to these new technologies are not without risks and catastrophes: patients and hospital staff are electrocuted, and when the ambulance batteries died — a frequent occurrence– many of the patients they carried died, too. 

Medical advances integrated into various episodes include x-rays, electric-powered suction devices, and an inflatable balloon for intrauterine compression to stop hemorrhages. Thackery is a driven researcher taking on some of the big problems of the day, such as making blood transfusions safe, curing syphilis, and discovering the physiologic mechanisms of drug addiction. We see how he learns at the cost of his patients, or rather his subjects. We also get a glimpse of movements directed at population health. For example, epidemiological methods are applied to find the source of a typhoid outbreak, which drew from the actual case of Mary Mallon (aka, Typhoid Mary). Shown juxtaposed to the advances in epidemiology is the concurrent interest that was rising in eugenics and its broad application to control for unwanted individual traits and particular groups of people. Research ethics and regulations were a long way off.  

Time Tells 

Each era possesses its own hubris based on the technological advances and social progress made over those of previous eras, and on the certainty that the mistakes made before have not been repeated. Time reveals whether those attitudes and positions were justified. For Soderbergh, the director of the series, this idea was top of mind, and he stated as much in an interview published in the August 1, 2014 New York Times:  

There are so many treatments on the show that make you gasp because they’re so wrong…It just makes you wonder what treatments we’re all taking at face value that 10 or 15 years from now we’re going to be told, ‘Well, that didn’t work, and in fact that makes it worse.’  

Early twenty-first-century medical care has benefited from advances in molecular biology, medical devices, surgical procedures, data analytics, and epidemiological methods among others. People only participate in experimental protocols with their informed consent, and health care workforces are highly diverse. Impressive indeed, but none that in any way dwarf some of the advances shown during the series, and many that make twenty-first-century medical care possible. And, while The Knick shows how patients were often victims of bad science, bad technique, unproven technology, and malfeasance, the current era of health care is rife with risks for its own harms. Based on a complex analysis from several sources, the U.S. Institute of Medicine estimated in 1999 that between 44,000 and 98,000 people die from preventable medical errors each year in the US (To Err is Human). In 2016, researchers from The Johns Hopkins University reported in the May 3, 2016 issue of The BMJ (The British Medical Journal), that at the time The Knick was running in 2014–2015, medical errors were the third leading cause of death in the U.S. While the the accuracy of these estimates could be challenged, we can take from them with some amount of certainty that medical error exists today to a significant degree.  

The Knick pushes us to consider and to beware of what we may see resulting from modern-day biomedical and technological advances as time passes. To the medical drama and personal drama of most television medical serious, The Knick adds the drama of time. 

—————————- 

The Knick
Steven Soderberg, director 
Cinemax 
Twenty episodes, 2014-2015 
Running time: 42–57 minute episodes 

Awards
Peabody Award 
Six Primetime Emmys 
Three Critics Choice Television awards 

The Knick began streaming on HBO Max on February 20, 2021 

Undergirding Victorian-era political economy was the influential work of the British cleric-economist, Thomas Malthus, and the rise of statistics. Malthus’s well-entrenched theories maintained that starvation, or large-scale famine, was a natural (and therefore inevitable) response to overpopulation. “In Malthus’s thinking,” Mangham clarifies, “hunger is the greatest tragedy in human economics: in the worst of times it rises up as a horrible check on those nations whose resources have been overrun by improvident birth rates” (1). These theories further solidified within religious contexts, which produced the peculiar notion of “salutary starvation” (26) or “the providential law of starvation” (30)—an understanding of famine and other disasters as just consequences for exceeding the material capacities of God’s “natural system” (26). Malthus’s theories, imbued with religious interpretations, were pernicious and far-reaching, seeping into how the British government and affluent classes viewed and (mis)understood poverty.  

Mangham also maintains that Malthus’s theories were augmented by the emergence of statistics during the first several decades of the century, which enabled the government to measure and evaluate epidemiological patterns, demographic data, and other information about human populations (53). He notes that while statistics were used to collect data about starvation, the data were frequently presented in ways that skewed the prevalence of malnutrition, food scarcity, and diseases and mortality rates related to starvation (56). Using a range of literary and primary sources, Mangham underscores that support for statistics was far from monolithic, that for all the scientific certitude that government officials invested in the discipline, there were critics who vociferated about how statistics were often reductive representations of human experience. In other words, masses of tabulated numbers created a cold, mathematical distance between government authorities and those human lives suffering starvation (56–57). Overall, Mangham outlines a bleak picture of Victorian political economy and its views of material privation. 
 
For Mangham, then, one of the most injurious consequences of political economy was its failure to observe starvation (and its manifold health complications) as a material, indeed physiological, experience. As noted, political economists viewed starvation as anything but a form of bodily suffering, using theories instead to explain the naturalness and necessity of hunger and thus blaming the poor, not government and industry, for their problems (31).  

While political theorists were preoccupied with these explanations, Mangham traces the era’s concurrent developments in medicine that examined the physiology of hunger and digestion. The gastrointestinal research of the Italian Lazzaro Spallanzani influenced Victorian physicians, namely John Hunter, Charles Thackrah, George Henry Lewes, Thomas Southwood Smith, and others, who sought to describe the anatomical workings of the stomach and explain the bodily sensations of hunger (36). Against this backdrop, Mangham argues that Charles Kingsley, Elizabeth Gaskell, and Charles Dickens—united in their “antipathy towards Malthusianism” (17)—recognized the power in articulating starvation using physiological terms, and turned to science to limn “. . . the material sufferings of the starving and, more importantly, on detailed analysis of what it means to go hungry and to observe and to write about it in a way that seeks to be truthful” (16). In chapters that individually examine each author’s literary works (among them Kingsley’s Yeast, Alton Locke, and Two Years Ago; Gaskell’s Mary Barton, North and South, and Sylvia’s Lovers; and Dickens’s Bleak House and others), Mangham demonstrates how “. . . physiological ideas offered both an alternative way of thinking about hunger and an exploration of the ways in which it might be interpreted” (47). This volume’s close readings of these authors’ various novels, journalism, and speeches reveal that medical science offered a language that could undermine theories that misunderstood human starvation and the sociopolitical conditions that perpetuate it.  

Mangham’s study traces compelling connections among nineteenth-century political economy, medicine, and literature, demonstrating that writers looked to science for inspiration to critique feckless government policy and represent the concrete physicality of hunger. If writers could emphasize that impoverished people experiencing starvation were undergoing an “unnecessary, unjust, and unnatural” process, their stories could begin to demystify for readers the opposite claims of political economy (18). Kingsley, Gaskell, and Dickens used new science to depict not only physiologically accurate but also humanized renderings of the poor and Mangham provides close readings of novels to emphasize how these authors used physiology’s vocabulary to describe the material dimensions of poverty, which enabled them to push back against the theories of political economy. It is not that Victorian writers resorted to stale clinical language, but instead worked in confidence, knowing that what they represented in their narratives was grounded in scientific fact. Mangham’s analysis shows how literature and medicine intersected in ways that produced trenchant critiques of government policy. 

The Science of Starving in Victorian Literature, Medicine, and Political Economy
Author Andrew Mangham 
Publisher Oxford University Press 
Place Published United Kingdom 
Edition 2020 
Page Count 240 

An earlier version of this review was published in the NYU Literature, Arts, and Medicine Database (Litmed).
Web photo from The Cleveland Museum of Art 

Interview with Andre Mangham

Sebastian Galbo Jun 2, 2025

Andrew Mangham explores how Victorian literature, medicine, and political economy intersected to shape powerful narratives about hunger and poverty.

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

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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.