Tag Archives: clinical care

Can Occasions Think?

Paul Krugman used to add a parenthesis to the title of some of his New York Times economics columns warning the reader to expect “geekish”. This blog posting may be my most abstract to date, but the implications of the issue are real, especially in my longterm quest to understand what happens in clinical encounters.

I begin for the third posting in a row (and it will stop after this) with the writing of Philip Davis, this time from his book Shakespeare Thinking. That title is literal: Davis’s project is to show how Shakespeare’s language creates spaces in which though is elicited; at the extreme, how Shakespeare creates, or generates, or even evolves the possibility of thinking, which sounds hyperbolic, until you see Davis showing how it happens. But let’s begin with something easier to hold onto. Here’s an observation that restates what others have suggested about Shakespeare:

“Shakespeare is closer to Renaissance tricks of double perspective. For the shape of a thing depends on the perspective–shift it ever so slightly and the ‘object’ changes. So, Edgar on Dover cliff [in King Lear] has different perspectives in the same painting. In that sense Shakespeare is more like a cubist in action: taking multiple points of view almost simultaneously until it is not two or three people separately inserted into one solidly external situational container so much as two or three reciprocally overlapping situations within one complex blended happening” (Davis, Shakespeare Thinking, p. 86).

Now imagine, please, a familiar hospital scene: a patient in bed, a physician standing over the bed, delivering news maybe about test results or whether a treatment is succeeding, a nurse standing slightly back, and a family member on the other side of the bed from the physician. Apply what Davis says about Shakespeare: “it is not two or three people separately inserted into one solidly external situational container so much as two or three reciprocally overlapping situations within one complex blended happening.” Most healthcare studies of what’s called “doctor-patient communication” assume the narrational privilege of one actor, the physician, and measure how well the patient understands and retains the information conveyed by that physician. More enlightened studies go further, recognizing that each person in this situation has her or his own interests and agenda; each not only comprehends (or not) the content of information, each assesses and interprets what is said, including messages that are enacted, not spoken (Goffman’s signs given off, beyond signs consciously given). Davis calls upon us to understand the situation as more complex still: “three reciprocally overlapping situations within one complex blended happening.”

The ethical question this raises–at least ethical is the best I can think to call it, although the word seems inadequate; should I just say human?–is whether the participants in this situation can each remain self-aware that the other participants do not share their perspective. Something beyond empathy (a word I seek to avoid) is involved here; it’s rather an awareness of the limits of fellow-feeling, the limits of what George Herbert Mead called taking the role of the other. To return to Davis’s metaphor, can we put ourselves inside a Cubist painting and live with the fracturing of the lines that, in normal perception, make the scene around us cohere?

Davis continues, and here is where I find his thinking going beyond anything I remember from all that sociologists have written about interaction and situational framing: “It is as though the occasion itself, like a living thing, knows nothing about the parts within itself being separate or, at least, thinking themselves to be so. It is we who habitually think in terms of subject and object…” (86, my emphases). Sociologists have talked for nearly a century about how people define situations. Goffman showed how situations frame interaction, but that only shifted the emphasis from human actors actively defining to definitions being culturally given as resources for humans. What Davis offers is the idea of the situation itself as one of the actors, like a living thing. But this thing is not fully self aware. It cannot understand that the people in it think themselves to be separate: subjects perceiving others as objects of their perception.

In what I think was one of the great observations of clinical medical practice, Anatole Broyard pointed out that his doctor did not realize that as he was examining Broyard, so also Broyard was examining him. Or Montaigne asking whether, as he played with his cat, the cat understood itself to be playing with him.

Neither Davis nor I is doing philosophy, so we don’t aim at a resolution. What I at least want is a change in perspective, or an opening to multiple perspectives. Decades ago Alfred Schutz wrote about multiple perspectives, drawing in part on William James. There’s nothing new here. It’s more a question of whether we can ever take seriously what’s been recognized all along. Whether it’s Edgar and his father on the Dover cliff in King Lear or an everyday hospital room consultation, there’s a dramatic tension that makes all the difference. Edgar actually can–he has the grace to be able to–see the cliff from above (the perspective he’s playing, for his father, Gloucester), from below (the perspective of Gloucester who believes he has fallen), and no cliff at all (which is reality to anyone observing them). Shakespeare’s art is to enable us, as we experience the play, for just a moment to see from all three perspectives at once.

So here’s the ethical question, so far as Davis concludes it, or maybe as far as anyone can conclude it, and here also is another take on what Davis means by thinking: “…it is thought that has to come out there, in the world, rightly taking its anomalous place amid the whole intervolved reality to which it so uncomfortably belongs and refers” (87). It’s not the communication, or the definition of the situation, or the frame–although each of these attends to something–rather it’s thought, taking its anomalous place, so uncomfortably. Having seen this enacted on Shakespeare’s stage, can we experience our lives as thought arising?

Shakespeare’s Lessons About Care

My travelling companion during the last couple of weeks was Marianne Novy’s 1984 book Love’s Argument: Gender Relations in Shakespeare. Novy has many insights into how Shakespeare positioned men and women in the comedies and the tragedies. She is especially sensitive to moments when one character acts as the audience to another’s performance. In the comedies, “characters of both sexes can be alternatively actors and audience, cooperating in a relationship of mutuality” (83). Mutuality is Novy’s ideal for gender relations; she reads the plays as forming a continuum from mutuality achieved to failed mutuality. The failures tend to occur in the tragedies; that failure is both a cause and an effect of things turning tragic.

In the comedies, the male heroes enjoy women being actors in the dual sense of both active agents and role players. In the tragedies, “The heroes’ suspicion of female pretense darkens their view of the women, whether the women actually pretend or not. The men’s own acting–whether deed or pretense–discourages female participation….Thus, the tragic women are often confined to being audience to the hero, mediating the offstage audience’s sympathy with their own, as Ophelia does for Hamlet, Desdemona for Othello, and even Lady Macbeth for Macbeth” (82).

All this is interesting enough, but it becomes especially relevant to vulnerable reading in Novey’s later comments. She quotes Stanley Cavell’s essay on Lear, in which he writes that in both tragedy in a theatre and tragedy in actuality, “people in pain are in our presence”. What, he asks, is the difference? Cavell then makes what I consider a crucial comment on the ethics of responding to suffering: “In actuality acknowledgement is incomplete … unless we put ourselves in their presence, reveal ourselves to them” (90). That’s where I start thinking of clinical professionals responding to their patients’ pain and also family members responding. Novy’s commentary on Cavell seems to speak directly to the dilemma of response for clinicians, maybe especially hospital workers: “For the theatre audience … no self-revelation to those they see suffering is expected or possible” (90). That last phrase resonates heavily in my experience of hospital care.

Clinical professionals care, often deeply. But here’s the problem: “Many of the examples of sympathy expressed by the women discussed previously have been more like that of a theatre audience–incomplete by the standards of actuality–because they have been expressed in the hero’s absence”, Novy writes (90). Again her examples are Ophelia and Lady Macbeth. Cordelia is a significant exception, because she does express herself directly to Lear in their reconciliation scene.

Care, that most over burdened word, involves both doing and expressing. Those who are cared for often experience the expressing to be as important as the doing, and health humanities is about pulling up the expressive side of clinical practice. I remember a moment in a hospital rounds that I was invited to attend. The discussion was about a patient who was making demands that were upsetting because, in my view, everyone knew they were fully legitimate was embarrassed by not being able to admit that. At one point, someone in audience said, in a tone I heard as indignant, “Doesn’t he know how much time has been spent talking about him?” That line sticks with me because it expresses so much of what patients experience as lacking in care, and how professionals don’t get the problem. That audience member self-positioned like one of the women in a Shakespearean tragedy or the theatre audience member who can only express sympathy in the hero’s absence. The “Nothing about us, without us” thing hadn’t registered. Or in this instance, maybe it should be: nothing for us, except to us.

Ophelia and Lady Macbeth end up mad, then dead. Cordelia ends up dead, but we believe that in her last moments, she felt the redemption of being where she had chosen to be, having said what she needed to say. Getting killed is not, in itself, a tragedy.

Clinical care, especially in hospitals, is all about the duality Novy identifies between acting-as-doing and acting-as-role-playing, and I understand what she calls pretense as a neutral description of an actor’s proper work. It’s not about dropping the pretense; that’s not the goal that Novy imagines for Shakespeare’s women or I imagine for clinicians. What it’s about is achieving the mutuality in clinical care that Novy seeks in gender relations. The comedies are lessons in achieving mutuality; Novy even manages to rescue Taming of the Shrew from the oblivion of irredeemable sexism. The tragedies are cautionary tales of what happens when mutuality fails.