Summary:

It was valuable to me that the friend who recommended this book also suggested that I avoid any hint of its content (including the Library of Congress's classifications on the title page), advice I would pass on to anybody scanning this before reading the novel.  Set in England, in the 1990s, this is the story of Kathy H.  She is currently a carer, providing support for donors at various stages in the donation process, before eventually becoming a donor herself.  As she travels across England to the different sites where her donors are recuperating, she thinks back to her schooldays and her friends, Ruth and Tommy.

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The young pathologist David Coleman (Ben Gazzara) arrives to join a hospital pathology lab. He encounters disorganization and a hostile, cigar-smoking chief, Joe Pearson (Frederic March), who declares his intention to keep working until he dies. Coleman tries to implement a few changes, but his suggestions are overruled.

The film revolves around two cases: possible erythroblastosis in the child of an intern and his wife whose first child died; possible bone cancer in Coleman's girlfriend, student nurse Kathy Hunt (Ina Balin). The infant's problem is misdiagnosed due to Pearson's refusal to order the new Coombs' test recommended by Coleman; the baby nearly dies, alienating the obstetrician (Eddie Albert), a long time friend who now presses for Pearson's dismissal.

Coleman disagrees with Pearson, who thinks that Kathy's bone tumor is malignant, but he opts for professional discretion, defers to the chief, and urges her to have her leg amputated anyway. He discovers that Pearson had been right: the surgery, which he thought unnecessary, has provided her with her only chance of survival. Just as Coleman realizes the enormity of his error, he learns that Pearson has resigned and that he will take over the lab.

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Twain paints a picture of an all female family of four: Margaret Lester, widow; her 16 year old daughter, Helen; and Margaret’s extremely proper twin maiden aunts, Hannah and Hester Gray, aged 67. It is a household in which "a lie had no place. In it a lie was unthinkable. In it speech was restricted to absolute truth, iron-bound truth, implacable and uncompromising truth, let the resulting consequences be what they might." With this background, Twain sets up a perfect scenario of hide-bound morality only to turn it on its head, an iconoclastic trick for which he is deservedly well known.

The doctor caring for the mother and daughter, suffering from typhoid, cuts the aunts’ pietistic morality about lying to shreds, demonstrates the shallow logic and inconsistency of it and predicts they will lie in a greater fashion than they can imagine. True to form, Twain has the aunts go to great lengths to falsify the condition of the critically ill daughter to the mother to prevent the truth from worsening her condition. The title derives from the final lines of the story when an angel of the Lord comes to their house and delivers the judgment for all their lies, a judgment the reader is asked to guess: Was it Heaven? Or Hell?

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Amelia Stern is an academic pediatrician in a large city hospital and mother of a bright, young son. She is deeply involved with her patients, including Darren, born with AIDS, and Sara, the malnourished child of anxious parents, both lawyers. As she struggles to answer to the demands of her work for "other women’s children," she neglects her own child and her marriage begins to fall apart. Her husband’s resentment and her own feelings of guilt come to a crisis when her son falls seriously ill while she is at the hospital.

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Aurelio Escovar is introduced as a poor dentist without a degree. He is busy polishing false teeth early one morning when the mayor arrives to see him. At first he refuses to see this would-be patient, until the mayor, who has been suffering severe toothache for five days and is desperate, threatens to shoot him. Eventually the dentist lets him in, examines him, and then removes the infected wisdom tooth, without anesthesia.

We realize that the dentist has deliberately made the mayor suffer all this time, and he gives the reason as he pulls out the tooth, saying "Now you’ll pay for our twenty dead men." When the mayor has recovered and wiped his tears, he leaves, telling the dentist to send the bill. When Escovar asks whether to send the bill "To you or the town?," the mayor replies, "It’s the same damn thing."

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A small-town doctor’s son is saved by a black man from a burning house. In gratitude, the doctor takes it upon himself to salvage the life of the badly burned and disfigured hero. Others warn him that he is doing no service to the patient, but the physician cannot let go of one whom he owes such a profound debt. The town begins to fear the newly created "monster." The burned man’s life becomes a nightmare of rejection; the physician and his family are progressively rejected by the community.

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Doctor Yashvin sits with his colleagues and admits, "I have killed a man." The story of his resistance activity during the Bolshevik revolution ensues. The young doctor was called to serve as the personal physician of an enemy colonel. In this command the doctor witnesses horrible atrocities against common people as well as resistance fighters, the last straw being the brutal beating of a woman who comes demanding to know why her husband has been shot. Called upon to attend to a knife wound sustained by the colonel and finding the latter in a vulnerable position, Yashvin takes advantage of the moment, shoots the colonel dead, and escapes.

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This little novel is the retrospective tale of a childhood event told by the protagonist 40 years later. Family relationships and bonds in conflict with professional and community obligations vie with the shadow of racism and sexual abuse in the doctor/patient relationship for the core tensions in the book. The setting is a small rural community where the pioneer family about which the tale evolves controls the law and the medicine. The boy narrator relates his view of the breakdown of family as its secret--a physician uncle who is suspected of sexually abusing his native-American women patients--becomes a force that demands action from the doctor’s brother who serves as the sheriff.

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In March, 1981, in Vermont, Charlotte Bedford goes into labor. She has decided to give birth at home with the help of a midwife, Sybil Danforth, but complications develop. Charlotte has a seizure, her heart stops, and she does not respond to CPR. The fetus is still alive, so Sybil delivers him successfully by Cesarean section, with a kitchen knife. But the bleeding when Sybil makes the incision convinces her assistant that the patient’s heart was still beating. She reports this to the police and Sybil is put on trial for involuntary manslaughter.

The story of the trial is told by Sybil’s daughter, Connie, fourteen years old at the time and now an obstetrician-gynecologist. The acquittal comes at a price: the midwife finds herself no longer capable of delivering babies, and both she and her daughter are given a new insight into the uncertainty which underlies so many of medical decisions. At the end of the novel we are left uncertain whether or not Charlotte was still alive when her baby was delivered.

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The New Medicine and the Old Ethics, in Albert Jonsen’s own words, is a "secular aggadah." Jonsen explains that one Talmud reviewer defined aggadah as "a magical rabbinic mode of thought in which myth, theology, poetry and superstition robustly mingle" (4). The book begins with a personal essay entitled "Watching the Doctor." Jonsen establishes his premise that the moral history of Western medicine is best understood as a paradox between altruism and self-interest, a paradox alive and well entering the 21st Century.

He then takes the reader on his "secular aggadah," blending history, myths, and stories that trace important moral developments in the practice of Western medicine. In "Askelepios as Intensivist," we learn of the early Greek values of competence in shaping medical practice. Through the influence of the Church in the medieval period, Western medicine incorporates the value of compassion through the Biblical Good Samaritan, struggles with problems of justice in the care of the poor, and further elaborates the meaning of benefit.

In "The Nobility of Medicine," Jonsen describes the contribution of Sir William Osler and other knighted medical men of the 19th Century who established the ethics of noblesse oblige in the medical profession. He traces this noble tradition to the medieval Knights Hopitallers of Saint John of Jerusalem, a group of religious who provided hostels for pilgrims to the Holy Land and cared for the sick. With essays on John Locke and Jeremy Bentham, Jonsen brings us to the 20th Century and the play of individual rights and utilitarian values in the moral life of Western medicine.

In the final essays, Jonsen describes the mingling of these traditions as a means to establish a moral frame for Western medicine in our current times where technology and science have achieved and threatened so much. Ethics, he argues, "is disciplined reflection on ambiguity" (130). In the last essay, "Humanities Are the Hormones," Jonsen brings his "secular aggadah" full circle.

He argues that the paradox of altruism and self-interest that runs through the moral history of Western medicine must continually be vitalized and examined through the Humanities. The Humanities are "the chemical messengers that course through the complicated institution of medicine and enable it to respond to the constantly changing scientific, technological, social, and economic environment" (147).

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