Agnes recognizes William’s unique potential and supports his choice to leave his family and head off to London to make his name in the theater world. Shakespeare rarely returns home to Stratford, and we only learn of his growing success indirectly. Agnes is forced to raise her children as a single parent and has to deal with her overwhelming grief when Hamnet dies. As she mourns the loss of her son, she is overcome with doubt about the fidelity of her absent husband, and her faith in their marriage is threatened. Ultimately, Agnes is given a playbill featuring the production of a new play written by her husband and she sets off on a trip to London to confront him on his own turf. She arrives uninvited at the Globe Theater in time to witness a performance of the play in which her husband has been able to channel his own grief at the loss of his son into one of the enduring literary works in the Western canon.  

I first became aware of this book in a New York Times article that appeared in the early stages of the COVID 19 pandemic shutdown. It was recommended as a worthwhile book to read in quarantine. I had never heard of Maggie O’Farrell but the two-sentence summary captured the book and author perfectly. I do not think O’Farrell is a prophetess, but she was nothing if not attuned to our times and circumstances. Assuming she was writing this novel well before coronavirus escaped the food market in Wuhan, the way she frames Hamnet’s death in the setting of the bubonic plague in Stratford is inspired. Her story captures the explosive fear that envelops the town as the plague spreads — you can feel the wind in your face as the townspeople slam the door shut in the face of anyone suspected or proven to be infected. The story is written in the present tense which heightens the sense of immediacy of events as they unfold for William and his parents, Agnes and her family, and the people living in Stratford. O’Farrell’s prose feels Elizabethan – in the description of glove making, removing honey from a beehive, preparing shrouds for the dead child. As I read, I found myself looking up many more words than usual; the language itself has the power to transport you back in time.  

But, while the choice of bubonic plague as the cause of death may have been fortuitous for book clubs and book sales in the world we lived in during the pandemic, I do not think it is the driving force in this book. The dominant theme is how we deal with grief from any cause. O’Farrell is not the first author to use the death of a child as a vehicle to explore the myriad consequences triggered by the loss of a loved one, especially for parents who lose a young son or daughter. The steady movement of the plot to the climactic scene in London makes Shakespeare’s response seem the more substantive. His literary genius has enabled him to channel his sadness at the loss of the son he adored into the creation of an authentic character into whom he could project all the hopes and dreams that he had for Hamnet.  

Interestingly, O’Farrell never names Shakespeare throughout the novel, referring to Shakespeare always as “he” or “him” I can only speculate what O’Farrell means to convey with this literary device. I think she is acknowledging that it is the truly rare individual who can accomplish what Shakespeare was able to do in redirecting his grief from personal sadness into a timeless literary masterpiece. We are thus like Agnes who must go through our day-to-day routine, try to find meaning in tragedy and the courage and strength to stay on our feet and continue to move forward. That is Agnes’ accomplishment — that she can summon the will to travel to London to confront William, and by her action have the goodness of heart to realize that her husband shares her loss. She is able to appreciate the gift he has been given to transform his personal grief into a meaningful expression that the world can share. With this newfound knowledge, her marriage will be reinvigorated, and their mutual love will be reinforced. Agnes is thus the named character who occupies center stage as the story unfolds.  

O’Farrell has written a truly beautiful book that brings to life the pain of loss and the capacity of men and women to endure. As we coped with the COVID-19 pandemic as individuals and communities, many were forced to deal with unexpected pain, suffering and death. Hamnet is a book for our time. Physicians and all other health professionals do their best to support families and communities as they deal with untimely loss of loved ones. I only hope that it will not set the bar too high on expectations of how to transform grief into meaning. We are not all going to be Shakespeares but we can hope to be Agneses, who can still find joy and meaning in our lived lives in the aftermath of devastating loss.   

Hamnet
Maggie O’Farrell 
Alfred Knopf, 2020: 384 pages 

A previous version of this review was published in the NYU Literature, Arts, and Medicine Database 
Web image by Medhum.org

“At once it struck me what quality went to form a Man of Achievement, especially in Literature, and which Shakespeare possessed so enormously — I mean Negative Capability, that is, when a man is capable of being in uncertainties, mysteries, doubts, without any irritable searching after fact and reason.”¹ 

The young physician then went on to cite Samuel Taylor Coleridge as a poet whom he considered deficient in negative capability because he was “incapable of remaining content with half-knowledge.”¹ What exactly did Keats mean? That Coleridge was too curious or too intellectual to be a great poet? We’ll never know because Keats, who died of tuberculosis less than four years later, never referred to negative capability again, either in his letters or other writings.  

A single mention in a private letter is not much of a pedigree. Nonetheless, Keats’ casual turn of phrase has generated plenty of writings by others in the centuries that followed. Literary critics generally interpret negative capability to mean being open to the world without having preconceived theories, a willingness to suspend judgment, and/or the ability to function imaginatively in the face of incomplete knowledge (e.g. uncertainties, mysteries). In recent decades notable psychoanalysts and philosophers have championed the importance of negative capability in their own fields. In fact, with the enthusiasm of a dilettante who knows little about literary criticism, I’ve gone so far as to argue that negative capability is an important quality for clinicians to develop.²  

Wait a second! There’s something wrong with this picture. Physicians not “searching after fact and reason”? Doctors “remaining content with half-knowledge”? How can negative capability be a positive quality in scientific medicine? It sounds negative for sure, but not very capable.  

What did John Keats have in mind when he invented the term? In 1816 he had successfully passed his examination for a medical license and joined the Worshipful Society of Apothecaries, yet had also become increasingly ambivalent about a career in medicine. By late 1817 he and his brothers had rented a house in Hampstead, where John devoted himself to writing poetry, as well as taking care of Tom, who was dying of tuberculosis. Keats had given up the idea of practicing medicine. Yet could medical training have had any influence on his concept of negative capability?  

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, medical knowledge, or even logical deduction—with all due respect to Sir Arthur Conan Doyle and his teacher, Dr. Joseph Bell, who served as the model for Sherlock Holmes. When I was a medical student, my teachers referred to this quality as clinical intuition or clinical judgment. Yet the word “intuition” was always suspect because it smacked of mysticism, and “judgment” was co-opted in the 1970s by clinical epidemiologists, like Alvan Feinstein, who characterized it in mathematical terms of probability and utility, which sounded good but didn’t capture the experiential quality of medical thinking.³  

In an episode of “Star Trek,” when Spock questions Captain Kirk about an apparently foolhardy decision that has endangered the entire crew of the USS Enterprise, Kirk replies, “It’s not logical. It doesn’t make sense. It’s my gut feeling!” Kirk, as usual, had chosen the right course of action and by the end of the episode saves the day. However, even if clinical judgment can’t be reduced to an algorithm, surely it must have more going for it than gut feelings. I recently found an interesting, and I think plausible, definition in the nursing literature: “a judgment in which visual and verbal cues are so rapidly and subliminally observed that their contributions to the final decision are virtually forgotten.”⁴ 

Yet visual and verbal cues can’t stand alone. They require something to integrate them, a process, a creative spin. Some years ago Edward de Bono coined the term “lateral thinking” for an indirect approach to problem solving, involving ideas that might not be obtainable by using traditional step-by-step logic. (Parenthetically, I imagine that for de Bono the more traditional approach to problem solving must logically be entitled “medial thinking, i.e. closer to the center, whatever that means.) De Bono’s lateral thinking seems roughly equivalent to today’s favorite metaphor for creativity, “thinking outside the box.” Alternatively, those of us who slavishly adhere to reason are doomed to remain trapped inside the box, like Schrödinger’s cat, neither dead nor alive.  

Whatever you call it, I find something attractive about attributing a special openness and curiosity to the art of medicine, an openness that permits a greater variety of information to enter the box, rather than kicking the logical brain out of it. In his famous turn of phrase, Keats obviously chose to give “negative” a beneficial meaning. Negative in this context implies passivity, receptivity, and humility , yet it seems these qualities are precisely what made the difference between a competent poet like Coleridge and a truly creative one. Does this sense of negativity have a place in the art of medicine? Does it tell us anything about the difference between merely competent and master clinicians?  

One aspect of the comparison fails immediately. Unlike Keats, whose primary goal was beauty, physicians are heavily invested in truth. So “searching after fact and reason” is the name of the game in medicine, not the road to mediocrity. But other aspects of negative capability seem more promising. What if you view negative capability as intellectual and emotional openness, a willingness to be reflective and mindful about one’s practice? While “reaching after fact and reason” may be a defining feature of scientific medicine, clinicians confront a human reality that remains opaque, even after machines and lab tests have yielded their results. If we as clinicians predicate our care entirely on “irritable reaching,” or abandon patients because of “uncertainties, mysteries, doubts,” we lose much of our effectiveness as healers.  

Of course, poetry is only one of many tools that can assist us in developing the habit of reflectiveness, but for me it offers a glimpse into the paradox of the art of medicine: the ability to function at the interface between detachment and engagement, steadiness and tenderness, resilience and vulnerability, science and art. In pursuing the steadiness and detachment required to master clinical practice, it is tempting to neglect the more difficult project of nourishing engagement and tenderness in our relationships with patients—and with ourselves. In an address to medical students at McGill University, William Osler claimed,  

“Nothing will sustain you more potently in your humdrum routine… than the power to recognize the true poetry of life—the poetry of the commonplace, of the ordinary man, of the plain, toil-worn woman, with their loves and their joys, their sorrows and their griefs.”⁵  

That “power to recognize the true poetry of life” is a function of negative capability. Notice that Osler speaks of sustaining the physician through the “humdrum routine” of professional life, not specifically of patient benefit. Could it be that physicians who develop negative capability are happier, more productive, less likely to burn-out? 

I’ll end with an example close to home. In my narrative medicine elective at Stony Brook, I used to ask students to keep a clinical journal. In one of her final entries, one fourth year student, reflecting on her experience in medical school, wrote, “The practice of medicine is simply poetry in motion. The art of medicine is the validation of everything that makes the human experience. I learned more about myself than I ever imagined….”  

Simply poetry in motion.  

I wonder what John Keats, who rejected medicine for poetry, would have to say about that?  

References

1. Keats J. The Complete Poetical Works and Letters of John Keats, Cambridge Edition. Houghton, Mifflin and Company, 1899, p. 277. 
2. Coulehan J, Clary P. Healing the healer: Poetry in Palliative Care, J Palliative Medicine, 2005; 8: 382-389. 
3. Feinstein A. Clinical Judgment. Baltimore, Williams & Wilkins, 1967. 
4. Cioffi J. Heuristics, servants to intuition, in clinical decision-making. J Adv Nurs 1997; 26: 203-8. 
5. Osler W. The student life. In Osler’s ‘A Way of Life’ & Other Addresses With Commentary & Annotations, eds. S Hinohara and H Niki, Durham, Duke University Press, 2001, pp. 305-330.  
   

Web image from Keats Letter Project.

Human behaviors in many segments of society during the Covid-19 pandemic could have been predicted based on literary texts from the past and right up to the moment the pandemic began. In this episode, we compare excerpts from selected literary texts imagining or depicting human reactions to plagues ranging from as far back as 700 years to just one month after the pandemic began with statements made or actions taken during the pandemic. The similarities are uncanny. Russell is inclined to think this means we’re doomed; Dan is not so inclined.

Links:
Links to Russell Teagarden’s blog pieces in According to the Arts on the sources discussed in episode:
— The Decameron, Giovanni Boccaccio, New York, Penguin Classics, 1972 (written in 1351-1353) 
— The Pandemic’s Impact on NYC Migration Patterns, New York City Comptroller Scott M. Stringer, Bureau of Budget, November 2021.
— Arrowsmith, Sinclair Lewis, In: Sinclair Lewis: Arrowsmith, Elmer Gantry, Dodsworth, Library Classics of the United States, New York, 2002 (first published in 1925)
— The Betrothed, Alessandro Manzoni, Penguin Books, New York, 1972 (first published in 1827)
—The End of October, Lawrence Wright, Alfred A. Knopf, New York, 2020

Links to sound clips:
Contagion (2011) – Steven Soderbergh, director; Scot Z. Burns, writer

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 CDC