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Elie Wiesel, 82-years-old, has pain that he thinks is in his stomach or esophagus, perhaps caused by his chronic acid reflux. After tests, however, doctors diagnose cardiac illness and insist on immediate surgery. Reluctant to go to the hospital, Wiesel dawdles in his office. When he does go, doctors believe a stent will do the job. Instead, the intervention becomes a quintuple bypass.
This brief memoir—a scant 8,000 words—presents the “open heart” of a gifted writer as he contemplates his open-heart surgery, his past life, and the future. He asks himself basic, even primal questions about life, death, and the nature of God.
Although a man with an extraordinary career—prizes, fame, honorary doctorates, friends in high places, professorships—Wiesel experiences and describes ordinary feelings of anxiety, pain, and doubts about his cardiac emergency and possible death. His stylistic gifts describe frankly and vividly a patient’s fears. As many have observed, patients with a serious disease have two difficulties, the disease itself and their emotional responses to that disease. As Wiesel is wheeled into the OR, he looks back on his wife and son; he wonders whether he will ever see them again.
He writes that his “thoughts jump wildly; I am disoriented.” He recalls a friend undergoing similar surgery; she died on the table. He says he can’t follow the jargon of physicians. The texture of the prose is rhapsodic, jumping from the present to memories, many of them about war, his past surgeries, or important family events. This short book has 26 “chapters,” some just half a page; they are like journal entries.
As he slowly recovers, he feels pain and has visions of hell, including the concept of ultimate judgment. “Evidently, I have prayed poorly…; otherwise why would the Lord, by definition just and merciful, punish me in this way?” (p. 38). Because he has a “condemned body,” he feels he must search his soul. In the longest chapter of the book, he reviews several of his writings.
Wiesel asks some of the questions from his famous novel Night (La nuit, 1958). If there is a God, why is there evil? Auschwitz, he says, is both a human tragedy and “a theological scandal” (p. 67). Nonetheless, he affirms, “Since God is, He is to be found in the questions as well as in the answers” (p. 69).At the end, he still has some pain but feels much gratitude for his continuing active life and for his grandchildren.
Summary:This book describes San Francisco’s Laguna Honda Hospital, where Victoria Sweet worked as a doctor for 20 years. In the tradition of the Hôtel-Dieu in Paris (literally “God’s Hotel”), Laguna Honda cares for the sickest and poorest patients, many staying there indefinitely because there is no alternative for them. Sweet learns from her long experience at Laguna Honda that “Slow Medicine” has benefits, that a holistic or unified view of patients works best, and that the reductionism and specialization of modern medicine has limitations and costs. During these years Sweet becomes fascinated by the medieval abbess Hildegard of Bingen and earns a Ph.D. focusing on medieval medicine. At the same time (and increasingly) various forces—economic, legal, political, bureaucratic—cause many changes at Laguna Honda, mostly contrary to Sweet’s vision of medicine.
Part history, part memoir, part social criticism, the book is informative, entertaining, and important for its discussion of the care of our least-well-off citizens and for its perspectives on modern, Western medicine.
There are three intertwining strands to this engaging book: Sweet’s medical evolution as a physician, the changes in Laguna Honda, and her investigations of Hildegard of Bingen and other spiritual matters.
Sweet joins up with Laguna Honda initially for only two months, but she finds the hospital and her work there so fascinating that she stays for 20 years. As an almshouse, Laguna Honda takes care of indigent patients, most with complicated medical conditions, including mental illness and dependencies on alcohol and/or drugs. Many of these cases come from the County Hospital with continuing (but not carefully reviewed) drug treatments. Every 15 or 20 pages, Sweet describes the dilemmas of a particular patient, and her medical (and personal) attention to that patient. The cases are vivid and instructive.
Clearly Laguna Honda is a major figure on the book; we can even consider it (or “her”) a beloved character and a teacher to the young Dr. Sweet, who learns three principles from her work there: hospitality, community, and charity.
Because Laguna Honda is old-fashioned in many ways, Sweet reads her own X-rays, goes the to lab to see results, and spends large amounts of time with each patient. Laguna Honda has an aviary, a farm with barnyard, and a solarium; such features help to heal the whole person. While respectful of modern medicine, Sweet slowly learns that a careful review of a patient through Slow Medicine is more accurate and more cost-efficient than standard, reductionist, high-tech medicine. She comes to respect approaches from “premodern” medicine, including that of Hippocrates and Hildegard.
The second strand is the evolution of Laguna Honda itself. Sweet describes a variety of pressures: the recommendations of consulting firms, rulings from the Department of Justice, a lawsuit, financial difficulties (including fiscal mismanagement), administrators focused on a narrow concept of efficiency, a utilization review board, forms and more forms, and a pervasive sense that modern (including Evidence Based Medicine) is always good. All these and more create a “relentless pressure squeezing the hospital’s Old Medicine into the New Health Care” (p. 322). Sweet demonstrates that her Slow Medicine can actually save money in the long run. Confident that her way is better, she proposes an “ecomedicine unit” that she would match against the modern, “efficient” units in a two-year experiment. (For more information on her concept of ecomedicine proposal, see http://www.victoriasweet.com/.)
As the hospital is “modernized,” many important features of the old place are gone and many “new and improved” aspects don’t work. Somehow there are no rooms for physicians in the new building while there is plenty of space for administrators and managers. A sophisticated computer system doesn’t work. Sweet doesn’t say “I told you so” directly, but we get the picture.
The third strand is Sweet’s investigations of spirituality and pilgrimage. She is fascinated by Hildegard’s notions of the healing power of nature, the ability of the body to heal itself, and wholeness as an aim for a person and for a community. Sweet attends a Swiss conference on Hildegard. She hikes the pilgrimage route from France to Santiago de Compostela in four installments and considers notions of pilgrimage. She feels called to pursue her ecomedicine project and to write this book.
By the end of the book, both Sweet and Laguna Honda have changed and are now headed in different directions.
Hillel D. Braude, a physician and a philosopher, has written an important, albeit dense and narrowly circumscribed, study. While “Intuition in Medicine” is the main title, the subtitle, “A Philosophical Defense of Clinical Reasoning” is a more accurate description of the book, which originated as a doctoral dissertation. While some of the prose will appeal only to specialists, there are important and thoughtful analyses of such topics as Evidence-Based Medicine, modern dehumanized medicine, the relation of beneficence and automony, and principalist ethics in general.
Throughout, intuition is narrowly conceived and in the service of clinical reasoning, as it applies to standard, Western physicians and not to other healers (or nurses), and the emphasis is on interventive medicine to cure illness and relieve suffering more than on health promotion.
Braude writes in the introduction that intuition has long been understood to be “a direct perception of things,” but he resists a more precise definition: “Rather than defining and using a single concept of intuition—philosophical, practical, or neuroscientific—this study examines intuition as it occurs at different levels and in different contexts of clinical reasoning” (xviii).
Eight chapters explore these different levels in such topics as moral intuitionism, Aristotle’s phronesis (or practical reason), the rise of statistics (a basis for Evidence-Based Medicine), and C. S. Peirce’s notion of abduction. Braude’s careful analysis traces historical and theoretical developments in analytic philosophy and how these may be applied to clinical reasoning. He uses an impressive range of thinkers: Achenwall, Albert, Allan, Andre, Ashcroft, Aristotle, Bacon, Barrow, Barton, Beauchamp, Bergson, Bernard, Bichat, Black, Bottero, Bourdieu, Brody, Browne—just to take names headed by A or B.
Throughout, Braude puts in dialectic two poles on a spectrum arguing that they both have contributions to make. He believes that between them is an “ethical space,” where discoveries and applications can be made, but he clearly favors all the concepts from the lefthand list for medicine. In tabular form, we can list aspects of the two poles:
Aristotelian practical reasoning Kantian abstraction
Naturalist approaches Nonnaturalist approaches
Primacy of beneficence Primacy of autonomy
Fact and value joined Fact and value separated
Case-based Evidence-Based Medecine
Individual patients Large groups of patients
Narrative experience Statistical correlations
Anthropocentric focus Mechanist, positivist foci
Tacit, organic knowledge (Polanyi) Dualism (Descartes)
Braude believes intuition is a cognitive process but has other dimension, the corporeal and the social. While these provide a grounding, intuition for him is generally rational. He also argues for medical care at the personal, face-to-face level, not through applications of algorithms.
A brief conclusion, “Medical Ethics beyond Ontology” clarifies some of the arguments and sketches some valuable notions from Husserl and Levinas. He writes “intuition . . . does appear to be fundamental for human judgment” because “an intuition faculty” can “extract universals from the particular” (p. 170). Drawing on Husserl, he defines phenomenological intuition as “the primary means through which objects are presented to consciousness.” This affirmation includes the basic human, which is also the focus for medicine. For Levinas (and my summary is much too brief), “interhuman solidarity” is a source for medical care, a form of responsibility that is different from Foucaultian power relationships, ethical rules and priniciples, or “an uncritical acceptance of medical authority” (p. 177).
Simon Bear is a hard-charging physician; his wife Emily is a successful public relations executive, now a senior partner in her firm. Although they have a lavish house, a teen-aged daughter, and much wealth, their marriage is troubled, in large part because they have never fully mourned the death of their baby Caleb.
The title “Remedies” fits well with the long struggle for how to heal their grief. The remedies that clearly have not worked are obsessions with career, professionalism, rationalism, and the trappings of American materialism.
Simon has two obsessions about his practice. The first is that he is a rescuer, the perfect doctor who listens to his patients and gives them what they want. As a self-appointed expert on pain, he is free and easy about prescribing opiates. When his father-in-law feels no pain after a car accident, Simon is sure that a drug that the man is taking is, in fact, the Holy Grail of pain medications. Simon becomes obsessed with this “discovery,” promoting it to his patients, without a scientific study or consideration of ethical implications. When he flies to a national medical meeting to trumpet the news of this remedy, no one will listen to him.
While Simon is the point of view for Parts One, Three, and Five, Emily—structurally separated—is the voice and focus of Parts Two and Four. She is troubled by her distance from Simon and, increasingly, her 13-year-old daughter, who is sullen and rebellious. When she meets Will, a former lover, she seeks another kind of remedy in an affair with him, even prospects of marriage. Contrasting with her strategic, rational approach to life, Will is an open, easy-going man, conveniently separated from his wife.
A series of crises rock Emily, then Simon. Emily begins to understand her anger; she has a breakthrough with her daughter. Simon has several setbacks, including humiliations, but he is not crushed. Although ordinarily a secular Jew, Simon attends the Kol Nidre service the evening service before Yom Kippur, the Day of Atonement. In a powerful and moving passage, he finds healing, relief, and a new direction for his life—a true remedy.
This is a huge and wonderful book about cancer, the collection of diseases that sickens people all over the globe and kills many of them. An epigraph to the book states, “A quarter of all American deaths, and about 15 percent of all deaths worldwide, will be attributed to cancer,” but the book also describes medical advances that now heal, prevent, or palliate most forms of cancer.
Mukherjee, a cancer physician and researcher, has several strong themes. He sees cancer as an affliction with a long history, a story worthy of a biography; indeed recent discoveries show it to be rooted in our genes (although external factors such as viruses, asbestos, and tobacco smoke can cause genetic disruption). The story of cancer implies a surrounding triangle, the stories of sick people, treating physicians, and biological researchers, all of which Mukherjee artfully weaves across 472 pages. Cancer has Rohrschach blot qualities: depending on time, place, and role in life, humans have perceived different attributes of cancer. As the book ends, however, there is a coalescence of scientific understanding that is satisfying—although there is certainly more to be learned and we are all still vulnerable to genetic errors and, of course, we are intractably mortal.
Another strand is the nature of stories themselves, their twists and turns, presumed early solutions, and personal and social values embedded in them. Mukherjee threads throughout the book the case of a contemporary kindergarten teacher, Carla Reed, who has a leukemia. He bookends his text with ancient Persian Queen Atossa with (presumably) breast cancer. Reed, healed by the end of the book, was Mukherjee’s patient; Atossa was described by Herodotus: both suffered emotional turmoil because of their disease. Mukherjee understands the affective dimensions of disease for patients and caregivers alike; literature represents these in various ways, and he quotes in his chapter epigraphs and in his prose many writers who describe human experience deeply: Aleksandr Solzhenitsyn, Susan Sontag, Charles Dickens, Thomas Mann, William Carlos Williams, Carlo Levi, and Italo Calvino, to name a few.
The primary story, however, is the interplay of cancer and a large cast of observers, investigators, doctors, scientists, activists, and government officials. Sidney Farber and Mary Lasker dominate the first 100 pages with their two-decade war against cancer. While surgery—historically dramatic and disfiguring—had been a mainstay for treatment of cancer, Farber pursued a biochemical route, which elaborated into chemotherapy, the second major approach of the late 20th century.
Mukherjee also explains ancient views, Hippocrates’, Galen’s humors, Vasealius’ anatomy, Hunter’s stages, Lister’s antisepsis, and Röntgen’s X-rays, which became the third major approach. By 1980, however, the American “War on Cancer” had not been won.
Further advances in cellular biology and genetics would be needed to make targeted molecular therapy possible. Mukherjee tells this complicated story clearly and engagingly, showing the human investigators to be personable and dogged in their pursuits.
Another important approach is prevention. The biostatistical work of Doll and Hill, for example, showed the links between tobacco and lung cancer. Screening, such as Pap smears and mammograms, also saved lives, but the basic cellular understanding still eluded investigators.
The final 150 pages explain the search for and discovery of genetic factors, specifically oncogenes. Harold Varmus and J. Michael Bishop were the leaders, winning a Nobel Prize in 1989. Bert Vogelstein, Judah Folkman, Robert Weinberg and Douglas Hanahan took the work further, opening the doors for such drugs as Herceptin, Gleevec, and Avastin.
Summary:This short, gripping book describes Taylor's massive stroke, a burst blood vessel in the left side of her brain. Ironically, she was at 37, a neuroanatomist at Harvard, well versed in the anatomy and function of the brain. Her knowledge allowed her to understand from the inside her rapid loss of mental function and, with treatment, her very long (some eight years) recovery to health and, once again, professional activity.
Summary:This is a collection of four stories and a novella with pervasive themes of death, loss, grieving, mourning, and anger; the characters live in rural parts of the upper midwest, and there is much unhappiness in their lives.
Summary:This is an anthology of 32 pieces, many directly relating to war and its aftermath, or, in general, kinds of violence humans inflict upon each other and the ensuing suffering: hence the title, "echoes of war." The pieces include short fiction, essay, a dozen poems, and a photo collection. Since none are lengthy, this is a good reader to supplement other longer texts or to serve as an anthology for a reading group. A short essay, "Suggested Longer Readers," mentions some three dozen pivotal topics, including "homecoming" and "sense of identity."
Summary:Suzanne Poirier has studied over 40 book-length memoirs describing medical training in the United States. These texts vary in format from published books to internet blogs, in time (ranging from 1965 to 2005), and in immediacy, some reporting during medical school or residency while others were written later--sometimes many years later.