Summary:

This remarkable book takes the reader into a Dutch nursing home where many of the 300 patients are terminally ill. The main protagonist is Anton, a competent, tough, and compassionate physician who tries to discover some meaning in the suffering of his patients, while at the same time disavowing any such meaning. Anton’s colleagues include Jaarsma, a somewhat detached and bureaucratic older physician, and Van Gooyer, a young physician who still believes that science has all the answers.

The first-person narrative consists of short, punchy segments (almost like an endless series of discrete physician-patient interactions) detailing the stories of Anton’s patients and his reactions to them. Many of these persons request assisted suicide or euthanasia. Anton reveals what he feels about these requests, how he goes about judging their validity, and the manner in which he actually carries out assisted deaths. A strong spiritual theme permeates the book; while Anton denies the relevance of God and religion, he seems constantly to be searching for a spirituality that "makes sense" of contemporary life.

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Max, who has lost his wife after a long life and career together as circus acrobats, reluctantly retires to an assisted living home. There he finds unexpected friendship first in his neighbor, Lettie, a widow who has a gift for uncomplicated kindness, and Alison, a thirteen-year-old he meets when he gives juggling and stunt lessons at the local junior high. The unhealed ache of his wife's slow death from cancer makes Max skittish about opening his heart to either of them, though Lettie offers him patient companionship and Alison, full of adolescent restlessness, unfocused intelligence, and need, desperately wants something of the grandfatherly good humor and wit she finds in Max.

Alison's mother is pregnant with a long-delayed second child and the distance she feels from her parents drive her to lengthy novel-writing and to rather pushy efforts to make Max her special friend. For him, she learns to juggle. She cuts class to visit him, and to go out for sodas with Lettie. Alienated from peers she finds silly, the old people touch a place in her that needs love. After a heart attack, Max comes home with newly raised defenses, and retreats from the budding friendship with both women.

But when Alison runs away to a circus he refused to attend with her, and then to Penn Station, Max goes with her parents and finds her on a hunch. Found, she clings to him like a small child, and he finds himself full of a long-resisted love. On the way home, however, he succumbs to a heart attack. In the final chapter, Lettie helps Alison begin the long, difficult process of accepting mortality, grief, and the possibility of eventual healing from a loss of a kind she finds herself still unable fully to articulate to anyone she believes will understand.

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In 28 autobiographical stories, the narrator writes of his patient encounters (and self encounters) as a medical student, resident, and finally Emergency Room attending physician. "The Unknown Assailant" opens the collection, a tale of a criminal and his victim who are both brought into the doctor-narrator's emergency room. The young doctor chooses "the young one" (p. 1), not knowing he is the assailant, and works frantically to save his life. This criminal allegedly killed two men a year before, but his current victim lives and the doctor learns the story of the attack from this victim's point of view. The assailant, who slowly recovers, has "an aura about him" (p. 5) and the doctor is strangely drawn to him, thankful that this man means him no harm. Perhaps aware of the irony of healing a man who, in another environment, might kill him, the doctor helps the assailant get better.

This underlying theme--that nothing is black and white in medicine or life--shapes every story. "Prelude," is the revealing, three-page tale of a medical student's life outside the hospital juxtaposed with his first encounter with death in the anatomy lab.

Every story deals with significant issues: the physician's inner emptiness when a patient dies ("Through the Dark, Softly"), how a greater power might suddenly intervene ("Faith"), how narrow the margin is between a successful and a missed diagnosis ("Sugar"), how both patients and residents survive because of, or in spite of, their medical attendings ("A Difference of Opinion"), and how things that seem final or sinister--like death and leeches--become instruments of hope and cure ("The Dead Lake"). [Sugar and The Dead Lake have been annotated in this database.)

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A woman with breast cancer describes dealing with doctors and medical procedures, from facing "embarrassing questions" to the finality of the mastectomy itself. She copes passively with the procedures by escaping into a fantasy world; but when it is time for the doctors to remove her breast, she assumes an active role and "[gives] it to them."

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A 30 year-old woman describes with chilling power her three suicide attempts. She compares herself to a cat with nine lives and to a concentration camp victim; yet "dying / is an art . . . / I do it exceptionally well." The doctors/men that save her are the enemy, and she warns them to "beware."

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Written with controlled elegance, this is an absorbing autobiographical account of psychiatric hospitalization. Twenty-five years after the fact, the author describes the two years during her late adolescence in which she "slip[ped] into a parallel universe." The surreal nature of the experience is reflected in darkly comedic recollections of her inner life, the other patients, their families, the staff, and of forays into the outside world.

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The author came to Houston in 1962 as a visiting professor. While there, he and his wife decided to become volunteers at "J.D." (Jefferson Davis), the county hospital. They found that the hospital was overcrowded, understaffed, over-bureaucratized, and very poorly supported by the county. In particular, they found that the volunteer corps (Women-in-Yellow) was primarily involved in clerical work, rather than providing service to patients.

Marjorie de Hartog wished to form a group that would feed and nurture infants in the nursery, but the hospital authorities thought that was out of the question. This book is an account of how the de Hartogs, their Quaker community, and other Houston citizens developed a significant volunteer presence at "J.D." and, in the process, became aware of the frightful state of patient care. They became activists supporting the opening (and better funding) of a new public hospital.

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This documentary, narrated alternately by the daughter-filmmaker and mother whose stories it tells, focuses on how two women move apart and together while experiencing, respectively, adolescence and mid-life. The mother has cancer, a mastectomy, and then rheumatoid arthritis, and these experiences intertwine thematically and structurally with the narrative of the mother-daughter relationship.

Another provocative juxtaposition cross-cuts scenes from the daughter's modeling career (and the social and erotic body that context constructs for her) with scenes of the mother's illness, stigmatization, and erotic daydreams. Both women come to a new awareness of the social meaning of mastectomy within heterosexual and same-sex contexts by the documentary's end; they also come to a place of recognition of the mother's personal and social value and the nature of their relationship.

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In the early 1950's, Milan, Georgia is a racially divided town where secrets are plentiful and the meaning of justice is muddled. J. T. Malone, a 40-year-old pharmacist who failed his second year of medical school, is diagnosed with leukemia and told he has only 12-15 months to live. In some ways, Malone's last year of life parallels the declining fortunes of the town's leading citizen, Judge Fox Clane, an overweight and elderly former Congressman who suffers from diabetes and a previous stroke. Judge Clane's wife died of breast cancer, his only son committed suicide, and his daughter-in-law died during childbirth. He raises his grandson, John Jester Clane, and aspires to restore the grandeur of the South in conjunction with redeeming his personal hoard of Confederate currency.

Judge Clane hires Sherman Pew, a "colored boy" and orphan, as his personal assistant, but Sherman eventually resigns from the position when he can no longer tolerate the Judge or his prejudice. Sherman moves into a house located in a white neighborhood. A group of townspeople including the Judge plots to get rid of him. A local man bombs the building and Sherman dies. Shortly after his death, the United States Supreme Court announces its decision supporting school integration.

The Judge is infuriated and goes on the radio station to express his opinion, but he has not prepared a speech. Instead, he begins babbling Lincoln's Gettysburg Address. The radio station cuts him off. Malone has been listening to the Judge on the radio, but his wife turns it off. Integration no longer matters to Malone. Near the end of his life, Malone finds solace in the renewed love for his wife, Martha. He finally appreciates the order and simplicity of life. The pharmacist dies peacefully in his own bed.

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This is an ambitious and far-ranging book, the result of years of thinking, teaching, and working with patients. An internist at the College of Physicians and Surgeons at Columbia University, Charon sees a wide range of patients in an urban setting. Also a Ph.D. in English literature, Charon has devised a "Parallel Chart" and other means for caregivers to write personally about the dynamics between healer and patient, to read texts--narratives in particular--and, as a result, to listen better to patients, thus improving the delivery of medical care.

Charon defines narrative medicine as "medicine practiced with these skills of recognizing, absorbing, interpreting, and being moved by the stories of illness" (4). She calls this a "new frame" for medicine, believing that it can improve many of the defects of our current means of providing (or not) medical care. Caregivers who possess "narrative competence" are able to bridge the "divides" of their relation to mortality, the contexts of illness, beliefs about disease causality, and emotions of shame, blame, and fear.

Charon finds that medical care and literature share five narrative features; she argues that careful reading of narratives builds skills that improve medical care, including intersubjectivity between caregiver and patient, and ethicality. Beyond the theory, there are powerful and persuasive examples of interactions between caregiver and patient, many from Charon's own practice. A mother of a sick daughter experiences stress that makes her ill; when she sees a narrative connection, she begins to heal.

Charon sees wider applications. As caregivers understand better concepts of attention, representation, and affiliation, they become more ethical, more community minded, and better healers to their patients. Patient interviews will be different: instead of following a grid of questions, physicians will converse with patients in an open-ended way. What is most important will emerge and emerge in ways that are most beneficial to the patient. Yes, this method will take more time but it will be more efficient in the long run. Bioethics, Charon argues, has been limited by legal approaches and philosophical principles. For her, narrative bioethics offers more human values in how people feel, experience reality, and relate to each other. Finally, there are implications for social justice: why are the poor underserved in this country and in many others?

One of the most exciting and radical formulations comes late in the book: ". . . practitioners, be they health care professionals to begin with or not, must be prepared to offer the self as a therapeutic instrument" (p. 215). This notion links up fruitfully with concepts of energy medicine (v1377v), therapeutic touch (Tiffany Field), and intentionality (Wayne W. Dyer).

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