LITERARY BIOETHICS AND THE CHANGING DOCTOR-PATIENT RELATIONSHIP

“…the two of them skilled physicians.” The phrase from the Iliad explicitly expresses the link between the sons of Asclepius (and I don’t say this to embellish the text, since, in the case of Greek mythology, we are “really and truly” speaking of the offspring of the god of medicine) and the Achaean warriors. Although Podaleirios and Machaon were demigods, Homer omits to mention their divine lineage in favor of their activities as professional healers (and possibly colleagues, if the suspicions of certain historians concerning the poet are correct) in a context where medical skill is at a premium: the battlefield.

In their first appearance on the stage of Western literature, doctors play an honored role, with deserved praises heaped upon them. For the great majority of the casualties wounds caused by spears, arrows, or rocks to the head, chest, abdomen, hips, or extremities, including even snakebites―, recorded in hexameter verse with the detail and precision of a surgeon (the aforementioned suspicions are by no means idle), the timely intervention and trauma management of the two “leeches” (to use an archaic term) led to the survival of the patient and, as a result, a low mortality rate: 5%, compared to 77.5% for those unfortunates in the epic poem who did not receive medical attention. The only exception? Wounds to the head, which were invariably mortal. Demigods they may have been, but they couldn’t perform miracles.

Homer was as detailed in his descriptions of battle wounds and the results of medical intervention as he was sparing of insights into the relations between physicians and their patients, among both Trojans and Greeks (or rather Achaeans). But we know at least that the healers were not described as insensitive to the pain of those they cared for: when Machaon learns that Menelaos has been wounded by an arrow, “the heart in breast was roused.” And as mentioned above, there is no lack of appreciation for the profession in Homer: “… for a doctor is worthy of many other men, whether for cutting out arrows or for applying soothing drugs.” An unfavorable opinion of Machaon and his colleagues is foreign to the Homeric poems.

1. See C. Koutserimpas, K. Alpantaki, and G Samonis, “Trauma Management in Homer’s Iliad,” International Wound Journal, 14(4) (2017), pp. 682-684.

If there is any profession of which depictions abound in world literature, it is that of the medical doctor, and if we turn from classical epic to the Middle Ages, in Dante’s Divine Comedy there is a place for practitioners of medicine in Purgatory (Hippocrates, Galen, and Avicenna), in the Inferno (to which Dante, channeling God, condemns the alchemist Michael Scot, notwithstanding his merits as a mathematician and translator of Averroes), and in Paradise (Taddeo Alderotti, the most famous physician of Dante’s time and possibly the poet’s teacher at the University of Bologna). Dante’s career and recurrent use of medical language bear witness to his interest in medicine, not surprising in someone who was a member of the Florentine guild of physicians and apothecaries. Unfortunately, neither Hell, nor much less Heaven, are places suited to displaying doctor-patients relationships, likely to be torturous in the underworld and perhaps sickly in purgatory.

Many and varied are the paths whereby to discuss, from the perspective of fiction, the changing views held by society of its healers. Nineteenth-century Russian writers are particularly useful to a discussion of medical ethics: Tolstoy and The Death of Ivan Ilyich, with its reflections by the main character on the value of life; Chekhov (a doctor himself, let us not forget) and “A Medical Case,” with the compassionate Dr. Korolev, who, when he says “we’ve come to take care of you,” is referring not only to the patient’s physical ailments; and Mikhail Bulgakov (a colleague of Chekhov’s in both the literary and medical professions) and his A Country Doctor’s Notebook, where the author of the much more famous novel Heart of a Dog (equally relevant from a bioethical perspective) examines an issue familiar and common to both Russians and Mexicans: paternalism and its (in) advisability, or the physician who decides for his or her patient what is best for him or her (or, at the opposite extreme, not necessarily or morally better, the physician whose leaves decisions entirely to the patient).

But what particularly interests us here is to examine our subject rather from a humanistic viewpoint than a scientific one (without excluding the latter more systematic approach, or even, insofar as bioethics permit, an experimental one). And we can attest that, in recreating the idea of the complex interaction between doctor and patient, of what it should and should not be, there is nothing like opera. In around fifty of the five hundred or so opera libretti produced over a period of almost two hundred years, a doctor and patient are members of the cast.

Although they sing, doctors do not always play the leading role, but range from itinerant quacks, more concerned with their own profits than with healing the patient (even if the ailment be love), like Dr. Dulcamara in Donizetti’s L’elisir d’amore (The Elixir of Love), to respected and empathetic professionals who accompany the dying in their final moments, like Dr. Grenvil in Verdi’s La Traviata. Thus far, all well, until, in the twentieth century, we come across the figure of the doctor as amoral scientist, for whom the patient is merely an object of study with whom to experiment (an omnipresent fear since the revolution made possible by modern science), like Wozzeck in Alban Berg’s opera of the same name. If we began this literary and musical tour with money and fame in mind, we do not expect to end it by simply replacing the wellbeing of the patient with the social status conferred by academic merit.

2. A discussion of literature’s boundless capacity to present nuanced answers to concrete bioethical problems, and to explore issues of medical ethics in particular, exemplified in the most representative Russian authors of the nineteenth century, can be found in N. Nikolaevna-Sedova and M. Vladimirovna- Reymer, “From Literary Bioethics to Bioethical Literature,” Life Science Journal, 11(10s) (2014), pp. 538-543.

What is the future of relations between doctors and patients? To what extent will they be influenced by new technologies? Will the internet, virtual reality, different applications, and artificial intelligence facilitate them, making them more relevant than ever, or will they diminish them and render them dispensable? If there is anywhere we can reflect on these and other real questions, and imagine possible responses, that place is the realm of literary fiction.

3. Véase, por ejemplo: Soriano, J.B., 2018, On doctors and their operas: A critical (and lyrical) analysis of Medicine in Opera, CHEST, 154(2), 409-415.

Luis Javier Plata Rosas

Born in Mexico City. He emigrated to Ensenada, Baja California, to study a degree in Oceanology (UABC), a master’s degree in Physical Oceanography (CICESE) and a doctorate in Coastal Oceanography (UABC, again). He emigrated to Puerto Vallarta, where since then he has been wearing the Black Lions shirt of the University of Guadalajara, since he works at the University Center of the Coast of this worthy institution. He lives with his wife (also an oceanologist, also a doctor, also Leona UDG), two sons and five cats and runs a marathon per year.