The reflective essayist (book excerpt: The Uncertain Art)

In this first excerpt, Dr. Nuland, a clinical professor of surgery at Yale University, delves into the characteristics of medical writing,and the tension between privacy and truthful descriptions.

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The first and most obvious rule is never to use any person's actual name unless given permission to do so. If other circumstances can be disguised without prejudicing the verisimilitude of the narrative, this, too, must be done. But it is necessary to be extremely wary in such things. A medical case history by its very nature is a story in which the altering of a few apparently small details may have a significant effect on the judgments to be made or the lessons to be drawn. The finest distinctions of fact, or the most intimate characteristics of a patient and the course of his disease, may carry clues to the entire point of the story. Some of this material can be sufficiently unlovely that there might be hesitancy in disclosing it. But in clinical descriptions, there is no substitute for absolute truth, and often no substitute for the depiction of grim or grimy images.

And there's the rub. The absolute truth in all of its stark clinical reality may be perceived by the patient as a violation of confidentiality, even when names and places are changed. What is to be done about this, short of so modifying the story that it loses its meaning?

Another way to put this question is the form in which it was asked of me not long ago by a young physician-writer, a man deeply concerned with the ethical consequences of such narratives. Even when the patient has been rendered completely unrecognizable, is there a violation of trust if no permission is sought, or if the man or woman has died? Is there a violation of trust when permission has actually been granted but the patient has no idea of the detailed scrutiny to which he and his disease will be subjected by the physician? Does the physician's need to tell a story that may have wide -- even life-changing -- implications for his readers justify such a breach of confidentiality? Is it, in fact, a breach of confidentiality at all? Further, since clinical descriptions routinely appear in standard medical journals, usually without permission, is there really a difference between such writings and those of a more literary nature? As my correspondent so trenchantly summarized the conundrum: "To whom does the story belong?"

Many will disagree with my response, but I submit it for reflection by all who would undertake such writings. What I propose here would seem to follow naturally from the methods by which I have suggested that truth may be found in all forms of literary work.

The act of writing is a process that enables us to recall things as they were experienced while they were happening -- especially if they are long-ago events -- in the light of later years. It permits us to articulate both how those events appear to our minds at the moment of recording and what lessons they may teach. Writing makes it possible to find out what we think, often for the first time. It is a process that will be totally honest if we are willing to feel those emotions that are coming forth from preserved memory and to put them down on paper uncensored. While this process is taking place, there can be no consideration of ethics, confidentiality, or even loyalty to participants. There is only the reality of what the writer feels to be the truth of what he is describing. In short, what I do is change the names and never consider the consequences that may result from my efforts to achieve the essential truth.

Others have written that all writers ultimately betray those who are their subjects. But they would betray themselves were it otherwise -- and their readers too. Writing is not an exercise in discretion; it is an exercise in seeking the clues to our lives. In this sense, the story belongs to the storyteller, because the storyteller is the truth seeker. At the risk of appearing lofty, I believe that the storyteller is also the person communicating the truth to the world, perhaps to posterity. A distinguished medical historian, now long dead, once told me that doctors are the only real philosophers, because only doctors know how people actually behave. Perhaps that is an overstatement, but the practice of medicine has been my key to understanding the way we live, and I use it to search for the reality of the human condition.

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This second excerpt examines the physician's role in ensuring public welfare and treating society's ills.

Of all the resounding nouns in the First Aphorism -- "Life," "Art," "occasion," "experience," "judgment," "physician," "patient," "attendants," "externals" -- the one whose applicability to the doctor is most controversial must surely be externals. In Hippocratic times, externals referred to the patient's surroundings: the general ambience most likely to encourage cure. A salubrious climate, good water, healthful and restorative food, an atmosphere of serenity -- these were essential ingredients of the way of life that the Greeks called regimen. There was no disagreement about the physician's role in prescribing them. But in the late 19th century, medical reformers began to point out that disease is frequently the result of social conditions. This meant that doctors should not only become involved in matters of public health -- such as water purification, safe housing, sewage disposal, immunizations, and the advocacy of personal cleanliness -- but also work to advance social equality and relieve the conditions of the poor. Thus began a vigorous debate about the boundaries of medical responsibility, one that rages to the present day and will no doubt always rage. That society values the intervention of the profession in some of these matters is beyond doubt -- one need only recall that the 1985 Nobel Peace Prize was awarded to an organization called International Physicians for the Prevention of Nuclear War.

But not all doctors, and certainly not all members of the general public, agree that white-coated influence is appropriate in such matters, and some argue strenuously against it. True, the followers of Hippocrates were committed to "make the externals cooperate," but of what should the externals consist today? What are their limits? How far should medicine -- and, under its urging, society -- go in imposing strictures on self-determination in the name of "taking charge of our own health"? It is one thing to legislate the listing of nutritional factors on food packages, another to impose a fiat banning junk-food machines from schools; it is one thing to demand that fast-food chains publish the caloric contents of their offerings, another to legislate the fat content of their hamburgers; it is one thing to print the surgeon general's warning on a pack of cigarettes, another to deprive someone of his right to light up in a public place; it is one thing to discourage smoking by taxing cigarettes out of proportion to their value, another to make the taxes so onerously high that many individuals are deprived of their free choice to indulge. In other words, it is one thing to oversee public and personal health in a free society, another to deprive people of the freedom to make their own decisions. As a physician committed to all the seemingly harsh dictates I have just listed, I nevertheless worry about the coercion that comes with such well-intended regulatory actions. It is a worry that has existed since the founding of our republic: how to balance the public welfare against the rights of the individual.

It is clear that the second sentence of the famed First Aphorism is far more problematic than the first. Whether the problem is the conundrum of autonomy or the question of how best to interpret the meaning of the word "cooperate," we physicians seem to waver in our conception of both authority and its limits. Here, as in so many other aspects of our calling, we practice the uncertain art.

Perhaps it is appropriate in this context to stop for a moment and consider the derivation of the word "physician," coming as it does from the Greek physis, meaning "nature": the essence of health was considered to be harmony with nature. But nature has another connotation. In preventing and treating illness, our constant companions and often our antagonists are human nature and the nature of personal liberty. As physicians, we ignore them to our peril, the peril of those we would help, and the peril of a free society.

Excerpted from The Uncertain Art: Thoughts on a Life in Medicine by Sherwin B. Nuland. Copyright © 2008 by Sherwin B. Nuland. Reprinted by arrangement with the Random House Publishing Group. $25.

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