Aaron Rothstein is a neurology resident at the NYU School of Medicine.
He blogs regularly about medicine for The New Atlantis
In Greek mythology, Asclepius, god of medicine, is the first physician in human history. He enters the world as his father, Apollo, pulls him from his mother's womb. Thanks to his training under Chiron, a centaur, Asclepius becomes a talented and skilled doctor. Such expertise is not without its temptations, though. He grows so powerful that, defying the will of the natural order, he cures those destined to die. Zeus, sovereign of all the gods, subsequently kills Asclepius for such insolence.
This popular myth warns of the perils of hubris and overreach. For the Greeks, any defiance of the natural order was heresy. There were boundaries to medical science or, rather, there ought to be boundaries. Medical science was not meant to encroach upon the will of the gods or the limits of our own humanity.
According to the Greeks, philosophy, literature, and history, also known as the humanities, played a role in clarifying those limits. And they forced citizens of Greece to ponder and discuss the question which would bring such clarification: what makes us human? The exploration of this question and others was integral to any life in the polity, but especially a life in medicine. As Plato wrote in Gorgias, "The soul and body being two, they have two arts corresponding to them: there is the art of politics attending on the soul; and another art attending on the body, of which I know no single name, but which may be described as having two divisions, one of them gymnastic and the other medicine." In other words, "the art of politics," or philosophy-and more broadly the exploration of a human being's place in the world-shares common ground with the discipline of medicine. Both, like the pairing of the soul and the body, are necessary to a life well-lived.
While the humanities which the Greeks so thoroughly reflected on and discussed are still widely studied, it seems they have lost their once-enshrined place in medicine. For instance, there is a chasm between the number of humanities majors and biology majors who enter medical school. In the 2016-2017 academic year, as documented by the American Association of Medical Colleges, only 1,915 students who majored in the humanities applied to US medical schools; 884 were admitted. This is dwarfed by the number of students who majored in the biological sciences: 28,582 students applied and 11,112 were admitted. Medicine is, even before training begins, overwhelmingly dominated by the biological sciences. And this makes sense. After all, a physician deals with human biology every day. But the humanities are necessary, too. In fact, as the Greeks surmised, they play a dramatic role in the medical field and are vital to the jobs of physicians.
In the early 20th century a eugenics movement percolated throughout the United States, a story which Adam Cohen, a co-editor of The National Book Review, thoroughly and frighteningly documents in his book, Imbeciles. Physicians sterilized thousands of people deemed unintelligent or burdensome to society's health. In 1905, for example, Dr. Martin Barr, the chief physician of the Pennsylvania Training School for Feeble-Minded Children, advocated for a sterilization bill in Pennsylvania. In the Pennsylvania bill, the state gave physicians the power to sterilize citizens if it was "inadvisable" that those citizens procreate. As Cohen indicates, this was done to improve the health of society: "In the eugenicists' view, Mendel's laws supported their belief that if the 'socially defective' were prevented from having children, and the highest-quality people had more, bad traits could be bred out, and good traits would proliferate."
Dr. Albert Priddy, superintendent of the Colony for Epileptics in Virginia, was another physician avidly in favor of forced sterilization. He and his colleague Dr. Joseph Dejarnette brought a case to the Virginia courts that they hoped the Supreme Court would eventually hear. The Supreme Court, they anticipated, would then rule in favor of forced sterilization and the physicians practicing sterilization would have no fear of legal trouble. Dejarnette and Priddy used Carrie Buck, an impoverished young woman judged to be "feebleminded," as their test case. Those appointed to defend her were in cahoots with Dejarnette and Priddy. Eventually, after multiple appeals, Carrie's case reached the Supreme Court. In an 8-1 ruling in favor of sterilization, Justice Oliver Wendell Holmes wrote, in reference to Carrie and her relatives: "Three generations of imbeciles are enough." Consequently, the Colony doctors sterilized Carrie. Though this chilling movement did eventually come to an end, much damage had been done.
The aforementioned physicians used medical science and technology to further society's "health." This is not necessarily contrary to the principles of science if the doctors analyzed the experiments and results appropriately (this was not the case as we'll see below). After all, science is morally neutral; it merely provides us with descriptions about the ways in which our bodies and the world around us work. It doesn't guide us in how to use that knowledge. It tells us about the is not about the ought. As David Hume, the great eighteenth century Scottish philosopher argued, we cannot make moral claims about the way the world ought to work based on what is. Because of its detachment from the moral realm, science can be used even when ethical codes are violated in its service.
On the other hand, the humanities, if seriously studied, encourage physicians to contemplate the value of human life, the purpose of medicine and science, and the proper relationship between the doctor and the patient. For instance, history is the study of human nature, our past, and the death, success, and suffering that come with it. Human nature and questions about and examples of typical and atypical human behavior and the accompanying death, success and suffering are inextricably linked to medicine. Great literature lays bare the complexity of human relationships, a complexity which often characterizes the doctor-patient relationship. And philosophy attempts to confront existential questions about purpose, natural law, dignity, and what makes us human, issues that are so relevant when regularly facing life and death. In short, the study of the humanities pushes physicians to reflect on the proper use of medical knowledge, reflections which are vital when trying to avoid awful moral compromises that other physicians have made in the past.
To be sure, studying the humanities does not guarantee that any member of society, let alone physicians, will reject sinister, immoral ideologies. Indeed, the physicians above were not necessarily ignorant of all history and literature. Moreover, ignoring these subjects often does not lead to awful consequences. Nevertheless, the humanities can offer an intellectual checkpoint for science.
When we close medical science off from the rest of the world, the temptation, paradoxically, is to alter results in order to advance a scientific principle. In the case of Carrie Buck, the methods of assessing her intelligence were either purposefully fudged or simply inaccurate. Carrie underwent testing with the Binet-Simon test. Alfred Binet and Theodore Simon, two psychologists, invented the test in Paris in 1905 to identify children who would benefit from extra help in the classroom. It was not meant to assess basic levels of intelligence. As evidence of the shameful inaccuracy of the exam, one merely has to look at the results. When administered to immigrants at Ellis Island in 1913, 79% of Italians, 80% of Hungarians, 83% of Jews, and 87% of Russians were considered feebleminded. As for Carrie in particular, the physicians neglected to mention that up until 6th grade (Carrie was pulled out of 6th grade by her foster family) she did well in school.
The scientific idea behind sterilization was Darwinian theory, or survival of the fittest. But Darwin did not mean for his theory to pass moral judgment on the alleged "weaker" members of society or to relegate them to second-class citizenship and sterility. Darwin merely described how the world came to be the way it was. And in their single-mindedness eugenicists believed that this provided policy direction. Consequently, a larger scientific truth-survival of the fittest-justifies the means of supporting that truth or end even if the means lack scientific rigor. Without an outside force prompting an examination of the end of science as well as its means, we potentially corrupt the scientific method.
But science isn't always corrupted. Its results can demonstrate the benefit of many practices, even studying the humanities. Multiple studies, for instance, have shown that reading literature can make one more empathetic. In 2013 in PLOS, Dutch researchers examined whether fiction experiences change a reader's level of empathy. They separated students into fiction and non-fiction arms. After the students finished reading, the investigators administered Davis' broader empathy scale questionnaire to determine whether students experienced enhanced feelings of "sympathy and concern for others." They found that if readers become engaged in a fictional story, their empathy "increases over time." That same year another group at The New School for Social Research published a study in Science claiming something similar. They randomly assigned eighty-six participants to read one of six texts-three were fiction and three were nonfiction. The participants subsequently underwent a battery of tests to determine their Theory of Mind (ToM), a set of abilities that allows one to "identify and understand others' subjective states." Scores were higher in the fiction groups.
For physicians, empathy is an important quality. As Dr. Danielle Ofri, an associate professor of medicine at NYU, writes in her book What Doctors Feel, empathy is "so obviously a requirement in medicine" and it "requires being attuned to the patient's perspective and understanding how the illness is woven into this particular person's life." This, of course, enhances one's relationship with the patient, a consequence that affects patient health. In an August 2014 meta-analysis published in PLOS, researchers found that the patient-clinician relationship has a "small, but statistically significant effect on healthcare outcomes."
To be fair, literature does not need scientific justification for its enlightening and beautiful qualities, and the studies referenced above are not without their faults. Nevertheless, these are interesting conclusions that help support literature's importance to physicians.
But reading literature, history, and philosophy takes time out of a physician's life, and time is perhaps the doctor's most important resource given the sheer volume of patients one must see. Wouldn't time spent on the humanities detract from time spent in the lab or at the patient's bedside? Would it not interrupt one's studies in the sciences which are so necessary for healing?
To be a great physician-scientist one needn't focus solely on science. Indeed, many of medicine's greatest minds were deeply interested in the humanities. Take, for example, Galen, the famous Greek physician in the 2nd century AD. One of the most influential figures in Western medicine, he dissected and vivisected animals to study their anatomy. Moreover, he was the only ancient source to describe a plague of smallpox passing through the Roman Empire. Thus, he laid the groundwork for future physicians. But he also considered himself a philosopher. As Galen wrote: "We came to cultivate the study of medicine, and throughout our whole life we applied ourselves to both disciplines [medicine and philosophy] in deeds more than in words." To Galen, becoming a great physician meant studying more than just science.
Sir Charles Scott Sherrington (1857-1952), one of the greatest neurologists in the history of the specialty, also immersed himself in medicine and the humanities. He was one of the first to use diphtheria antiserum on a human. He mapped the motor cortex of an ape as well as human dermatomes. He received honorary doctorates from twenty-two universities and shared the 1932 Nobel Prize with Edgar Adrian for characterizing the reflex as possessing reciprocal innervation in the muscles. But Sherrington was more than just a clinician-scientist. He published a collection of his poems, served as a trustee of the British Museum, and published a book, Man on His Nature, where he reflected on human consciousness in both a philosophical and scientific manner. He studied art, collected old books and manuscripts, and wrote history, poetry and philosophy.
Of course, one would be remiss if one didn't mention accomplished physicians in our own time who make the humanities a significant part of what they do: Dr. Siddartha Mukherjee, a hematologist-oncologist, wrote a history of the gene (The Gene) and a history of cancer (The Emperor of All Maladies). Dr. Atul Gawande, one of the most famous surgeons in the world, writes books and essays about checklists, mortality and the history of surgery. And Dr. Abraham Verghese wrote one of medicine's most celebrated novels, Cutting for Stone and received the National Humanities Medal from President Obama.
President Thomas Jefferson wrote a letter to Edward Jenner in 1806, praising Jenner for developing the smallpox vaccine. Jefferson concluded: "Medicine has never before produced any single improvement of such utility" and "future nations will know by history only that the loathsome small pox has existed and by you has been extirpated." Indeed, as the development of the vaccine demonstrates, physician-scientists have used science and technology to do a tremendous amount of good for humanity. They pulled millions of human beings from death's doors and the misery of illness, disease, and pain. Nevertheless, medical science cannot do everything. It cannot go beyond explaining the way human biology works or how we can alter disease pathology. It cannot point out the moral failings of its own experiments. It is morally neutral. For guidance on these questions, medical science, as the ancient Greeks understood, needs help from the humanities, from the study of history, literature, and philosophy, the three great pillars of the humanistic tradition.
And yet, we shouldn't make too large of a claim for the humanities either. Though we've examined literature's ability to enhance empathy, this is not universally true for everyone who reads it. And though we've covered examples of great physicians who had and have a deep interest in the humanities, there isn't necessarily causation there. Indeed, it would be hubris and an instance of overreach to say that studying the humanities will make one a great physician or will necessarily make one moral.
But the humanities do light the way for us. They prompt difficult questions about ethics, human relationships, life, and purpose. They give us pause when an aspect of a study is unethical; they illuminate the historical background of our profession and the decisions we make. They also put human beings in context-stories from literature and history provide us with an understanding of the wide variety of human experiences. In sum, the humanities offer guidance for practicing the art of medicine and a sense of the limits of medical science. They substitute the complexity of human beings for the simplicity of a data point. This is more than enough reason to encourage our aspiring doctors to study them.