Literature as an Introduction to Psychiatric Ethics Edward Rudin, M.D. Rachel Edelson, M.S., M.A. Mark Servis, M.D. Responding to requests for an earlier introduction to psychiatric ethics, the authors added “An Introduction to Psychiatric Ethics Through Literature” seminar to their institution’s first-year curriculum. The authors’ primary objective was to increase the sensitivity of beginning psychiatric residents to ethical dilemmas. The 11-session seminar was co-led by a psychiatrist and a literary scholar. At each session, the group discussed a short story selected by the seminar leaders, with the discussion centering on ethical considerations raised by the story and their relevance to the practice of psychiatry. The residents gave the seminar high ratings for its increasing their ethical sensitivity and the stimulating content of the stories. (Academic Psychiatry 1998; 22:41–46)
T
he Project Panel on the General Professional Education of Physicians reported that “discussion of ethical issues arising from the practice of medicine ought to be an integral part of the education of every physician ” (1). Residents are asking for more education in ethics to help them deal with the confusing array of ethical issues that they meet within their clinical work, especially with the arrival of managed care (2). Literature is often used in the medical education of students and residents to stimulate and enhance learning (3–6). Generally the humanities are viewed as an adjunct or elective component in medical education and not as part of the core curriculum. We decided to use literature as an introduction to psychiatric ethics in our core curriculum for residents in psychiatry. RATIONALE FOR AN INTRODUCTION TO PSYCHIATRIC ETHICS For the past 7 years, our adult and child residency training programs have had an anACADEMIC PSYCHIATRY
nual seminar on psychiatric ethics for fourth- and fifth-year adult and child psychiatry residents. Evaluations have repeatedly suggested that the series be given earlier in the psychiatric training. The instructor believed, however, that the success of the seminar required participants with enough clinical experience to readily recognize the ethical dilemmas referred to in the medical-psychiatric literature. As William Carlos Williams told Robert Coles, “it takes time to be a doctor” and “if the reader were a doctor (as opposed to a student)— then so much the better !” (7) The instructor agreed and thought that it was too much to expect first- and second-year residents to Dr. Rudin is clinical professor of psychiatry. Ms. Edelson is clinical instructor in psychiatry. Dr. Servis is associate professor of clinical psychiatry and director of education. All are in the Department of Psychiatry, University of California, Davis, School of Medicine, Davis, California. Address reprint requests to Dr. Servis, Department of Psychiatry, University of California, Davis, Medical Center, 4430 V Street, Sacramento, CA 95817. Copyright 䉷 1998 Academic Psychiatry.
41
PSYCHIATRIC ETHICS
examine critically and discuss candidly ethical challenges so early in their subjective and professional experience. We decided to continue a more traditional senior-resident seminar in psychiatric ethics and develop a beginning-resident seminar with examples of ethical conflict coming not from their personal experiences but from a neutral, yet attention-getting, vehicle: literary fiction. The psychiatric ethics instructor, a psychiatrist, collaborated with a literature scholar who was a serious student of psychoanalytic theory to develop a list of short stories that met the criteria of being well written (1), concise and easily read, and representative of recurring ethical quandaries for a psychiatrist in clinical practice. The stories did not have to be about psychiatry or medicine as long as they dealt with ethical dilemmas commonly experienced in psychiatry. For our purposes, “well-written literature” was defined as 1) telling a story involving characters or conflicts that interest a variety of readers, often crossing age, gender, and cultural boundaries; 2) presenting complex and ambiguous situations and characters, even contradictory ones, but experienced as true and not merely good or bad; 3) creating a coherent form or pattern out of what had seemed incoherent; and 4) feeling “real,” even hauntingly so, even when the reader knows the story did not— or probably could not—happen.
training and clinical practice. Our objectives included recognizing that the search for what is “right” is endless, that two or more actions each deemed “right” often conflict with one another, and that a “right” action can effect a “wrong” result. We wanted to introduce the residents to the process of “value balancing” and remove repression or denial around ethical conflict (9). Further objectives included the recognition that “psychiatric ethics” embrace personal and professional ethics and that all three reflect current cultural mores. We wanted the residents to learn the importance of transcultural ethical-value differences in medical and psychiatric practice. Finally, we wanted to impress beginning residents with the idea that a profession requires more than just “professing” knowledge and demonstrating skill; our specialty imposes on the professional a fiduciary responsibility for those seeking professional help. Society sanctions the intrusions of medical professionals into the lives of people with mental illness, in return for the professionals’ covenant always to act for the benefit of those entrusted to their care. This covenant requires that society monitor the practice of the professional and that the professional monitor his or her own competence and judgment. The combination creates a code of professional ethics (10). SEMINAR DESCRIPTION
GOALS AND OBJECTIVES Sir William Osler recommended that medical students read 10 classics, his “bedside library” to promote “the education, if not of a scholar, at least of a gentleman ” (8). As likely as it is that the psychiatrist who is “learned” as well as trained may be a better psychiatrist, we chose a less ambitious but more focused goal. We sought to sensitize first- and second-year psychiatric residents to ethical dilemmas and ambiguities they were likely to encounter in their psychiatric 42
We first introduced our seminar in 1995 at the University of California, Davis, School of Medicine. Eleven 50-minute sessions were held weekly. Following the first session, the residents were expected to discuss the following about each assigned reading: 1) the ethical or moral dilemmas posed by the story, 2) presentation and resolution of the dilemmas, and 3) personal and professional responses to dilemmas posed in the story. We also invited the residents to keep a VOLUME 22 • NUMBER 1 • SPRING 1998
RUDIN ET AL.
journal of pre- and postseminar impressions and reactions for later discussion and review by the seminar leaders. We hoped that such a written record might help the residents to identify their further responses to the readings and discussions, provide the residents with a written “progress report” of personal changes, and be a means of support for whatever anxiety-provoking selfdoubts might arise. In the first session, the co-leaders introduced themselves and identified their interest and experience in literature, psychiatry, and ethics, inviting the residents to identify their own interests and experience with literature. The seminar instructors defined “professional ethics,” “ethical dilemma,” and “well-written literature,” as well as emphasized the importance of attentive listening to each “patient story,” with the short story being a kind of “patient history.” The instructors also anticipated that the readings and discussion might result in more ambiguity than closure about professional ethics. The residents were told that the stories were selected not for their overt medical or psychiatric content, but because they presented a conflict between two or more principles reflected in the ethical guidelines of the American Medical Association, as annotated by the American Psychiatric Association. We suggested that each participant might also find other ambiguities in the stories and that all were worthy of discussion. The seminar instructors focused the discussion on the following questions: 1) What are the ethical dilemmas in the story, and how do they appear in psychiatric practice? 2) How are the dilemmas resolved in the story, and how else might they have been resolved? 3) What circumstances, past histories, and associated affects help determine the actions taken to resolve the dilemmas? 4) Whose story is being told, and how might other characters therein tell a different story? 5) How might the conflicts and the ACADEMIC PSYCHIATRY
determinants of behavior found in the story appear in psychiatric practice? The literary works studied are shown in Table 1 in order of presentation. The “game” for the readers was to identify the ethical dilemmas the instructors had found. Some were easy to decipher. William Carlos Williams’s Old Doc Rivers clearly illustrates the doctor of diminished capacity who could sometimes be extraordinarily beneficent and competent and at other times dangerously malevolent and incompetent. Williams’s Use of Force clearly demonstrates the ethical dilemma between respect for patient autonomy and the demands of paternalistic beneficence. Other stories were more obscure. Rosellen Brown’s How to Win illustrates the influence of personal values on treatment choice. Arthur Conan Doyle’s The Doctors of Hoyland demonstrates the struggles between competitiveness, sexual stereotyping, and the collegiality espoused by ethical codes since Hippocrates. One of the most complex stories in terms of ethical dilemmas, including those of physician treating physician and physician “treating“ family, was posed by Don Marquis’s The Other Room. SEMINAR EVALUATION The mean attendance for the 11 sessions of the seminar was 8.0 out of 12 resident enTABLE 1.
Short stories read and discussed
Short Story
Author
The Big Nurse The Other Room Use of Force
Ken Kesey Don Marquis William Carlos Williams Rosellen Brown George Garrett William Carlos Williams William Carlos Williams Arthur Conan Doyle Walter White
How to Win Wounded Soldier Jean Beike Old Doc Rivers The Doctors of Hoyland A Negro Doctor in the South The Consultation The Enemy
Richard Selzer Pearl Buck
43
PSYCHIATRIC ETHICS
rollees. At the conclusion of the seminar, 10 participants completed anonymous evaluations. The mean overall rating for the seminar was 4.0 on a scale of 1 (does not meet expectations) to 4 (consistently exceeds expectations). The highest ratings were given in the subcategories of “ability to stimulate the interest of trainees” and “quality of the assigned reading.” The lowest rating was in the subcategory of “instructor’s knowledge of the subject,” though even this subcategory had a relatively high mean rating of 3.7. These ratings are well above the mean overall ratings of 3.3 for other seminars in the curriculum, with statistical significance as measured by t-test (t⳱2.85, df⳱9, P⬍0.05). More impressive than the evaluations were the participants’ unelicited comments to the residency training director and seminar instructors. Several residents identified this seminar as their “favorite” in the curriculum because of its stimulating and provocative content. Many, especially several foreign-educated residents, expressed appreciation for the increased sensitivity to ethical issues in the psychiatric workplace. One international medical graduate described the powerful acculturation and education in American norms and values obtained from reading and discussing Western literature. An example of the enthusiasm of many participants was their request for a monthly meeting to continue the seminar’s work, exploring ethical issues through film and literature. DISCUSSION There are many links between medicine and literature. Doctors have become writers, bringing their insights into their writing. At the same time, nonmedical writers’ insights about physicians and other caregivers can shake the professional image of self-assured altruism and beneficence. Whether medical or nonmedical, writers who deal with the 44
“whole person” illuminate the biopsychosocial approach to patient care. However, are conclusions derived from literature that is written to entertain and to evoke feelings applicable to clinical practice? Are they sufficiently relevant to help prepare psychiatric residents for the ethical dilemmas they will encounter during their clinical experience and before their formal instruction on ethics? Can literature facilitate and improve ethical decision making in psychiatric training and practice? Terry and Williams express grave reservations about using literature to teach ethics (11). They cite the differences between the goals and methods of teaching literature vs. those of teaching bioethics. We acknowledge these differences, but we do not share their objections to using a safe, entertaining, and absorbing medium for examining “the emotional and experiential” before locking in on “the objective and reasonable.” We have no compunctions about offending “the integrity of a work of literature” if, by “changing characters or plots,” we can suggest variant outcomes or moral points and promote our teaching objectives. We are not teaching literature; we are using it to “promote sensitivity and empathy,” to increase awareness of the “wealth of connotation and the indeterminacy of expression,” and to examine a range of meanings instead of settling on a single definitive meaning. We prefer to strengthen the beginning resident’s tolerance for ambiguity, to permit a well-analyzed, “value-balanced” clinical decision instead of a rapid resolution of an ethical dilemma through a rule, law, or code. Terry and Williams feared that “the use of literature in discussions of bioethics offers an escape from too often dry analytic discourse” that might “subordinate, misdirect, or obscure ethical analysis and discussion.” We encouraged the residents to search for the story’s ethical applications to psychiatry. When they strayed, often to issues of diagnosis or transference and counVOLUME 22 • NUMBER 1 • SPRING 1998
RUDIN ET AL.
tertransference, we helped differentiate those issues from issues of clinical ethics. The discrepant perspectives of fictional characters enabled us to steer the residents away from premature diagnosis and toward examination of the actions and conflicts of the characters themselves, the unfolding story rather than “the bottom line.” Once the residents recognized the breadth of complicating factors in the story, the psychiatrist turned to analyzing the ethical issues and their relationship to the codes that guide ethical psychiatric practice. We were seeking a breadth of viewpoint, an avoidance of premature closure, and an enhanced ability to listen to each patient’s story before reducing it to a clinical diagnosis. Further experience, later casecentered ethical deliberations, and the senior-resident seminar in ethics would address ethical decision-making choices and closure. Radwany and Adelson warn that short stories may not develop plot and characters as well as a play or novel (3), but we found that a highly crafted, condensed short story can provide extraordinary impact, emotional resonance, and ethical ambiguity. A searching analysis of a short story can provide an in-depth experience that replicates the challenges and frustrations of shortterm treatment, especially as encountered in the managed-care environment. We had not anticipated the residents’ interest in stylistic and structural elements of the short stories. The best stories offer a cohesiveness that attunes the ear and eye of any reader and adds to the observational skills and “narrative competence” of the clinician (12). Indeed, the stories offered our international medical graduates a rapid acculturation to American cultural mores and norms. Another unexpected outcome of the course was that residents discovered hitherto unknown interests and talents of their colleagues. In many psychiatric residencies, ACADEMIC PSYCHIATRY
the clinical rotations take place at a number of affiliated sites, thereby separating the residents from each other. Although the residents connect for self-defense, and fortuitously discover shared experiences and interests, they often develop a high degree of fragmentation and interpersonal distance, hence a low degree of interpersonal loyalty and camaraderie. Our “Introduction to Psychiatric Ethics Through Literature” seminar gave the residents a legitimate occasion to leave the work setting and enter a part of their lives associated with play: reading fiction. They rediscovered the joy of literature and found that their colleagues also shared that same joy. They learned the perspectives and viewpoints of their colleagues, which fostered group cohesion, even intimacy. Apparently, the seminar met an important social as well as educational need. CONCLUSION Short stories provided a safe, pleasant, and condensed way to emphasize the emotional and experiential and to learn about inherent ambiguities and connotations in life’s crises. As beginning residents discovered differences in ways that both fellow participants and stories’ characters resolved their dilemmas, they learned greater respect for ethical ambiguities and diverse perspectives. They learned how to delay decision making while staying within the constraints of a short story—or a clinical session. The psychiatrist leader of the seminars saw to it that the ethical problems were analyzed and were not “subordinated, misdirected, or obscured”; the literary leader helped attune the eye and ear to collect additional information relevant to making ethical decisions. In the hectic—and often fragmented and fragmenting—early residency experience, the more relaxed social context of talking about fiction and sharing personal views provided a unifying learning environment. The residents from other than 45
PSYCHIATRIC ETHICS
mainstream U.S. cultures found universally shared human experiences in the stories. They recognized familiar dilemmas and discovered a broad scope for desirable resolutions of those dilemmas, all in a context in which their viewpoints were respected. Long- and short-term effects await evaluation. In an already jammed curriculum,
will the expenditure of time and resources be warranted? Would more advanced residents benefit from such a seminar? Would fiction other than short stories or would other leadership combinations help residents retain or recapture the traditional professional ethos that compelled many to choose medicine and psychiatry? We need to know.
References
1. Report of the Working Group in Personal Qualities, Values, and Attitudes: Physicians for the 21st Century: Report of the Project Panel on the General Education of Physicians and College Preparation of Medicine. Journal of Medical Education 1984; 2:177–189 2. Blackwell B, Schmidt GL: The educational implications of managed mental health care. Hospital and Community Psychiatry 1992; 43:962–964 3. Radwany SM, Adelson BH: The use of literary classics in teaching medical ethics to physicians. JAMA 1987; 257:1629–1631 4. Ness DE: Short stories about doctors and patients: a course. Acad Med 1989; 64:390–391 5. Rodenhauser P, Leetz KL: Complementing the education of psychiatry residents: a study of novels, plays, and films. Journal of Psychiatric Education 1987; 11:243–248 6. Sondheimer A: The literature and medicine sem-
46
inar for medical students: a potential recruitment tool. Academic Psychiatry 1994; 18:38–44 7. Coles R: The humanities in postgraduate training (editorial). JAMA 1987; 257:1644 8. Osler W: Bedside Library for Medical Students. Equanimatas With Other Addresses. Philadelphia, PA, Blackstone, 1947 9. Hundert EM: A model for ethical problem solving in medicine, with practical applications. Am J Psychiatry 1987; 144:839–846 10. Pellegrino ED: Altruism, self-interest, and medical ethics. JAMA 1987; 258:1839–1840 11. Terry JS, Williams PC: Literature and bioethics: the tension in goals and styles. Lit Med 1988; 7:2– 21 12. Edelson M: Telling and enacting stories in psychoanalysis and psychotherapy, in The Psychoanalytic Study of the Child, Vol 48, edited by Solnit AJ, Neubauer PB, Dowling AS. New Haven, CT, Yale University Press, 1993, pp. 41–45
VOLUME 22 • NUMBER 1 • SPRING 1998
T
he Project Panel on the General Professional Education of Physicians reported that “discussion of ethical issues arising from the practice of medicine ought to be an integral part of the education of every physician ” (1). Residents are asking for more education in ethics to help them deal with the confusing array of ethical issues that they meet within their clinical work, especially with the arrival of managed care (2). Literature is often used in the medical education of students and residents to stimulate and enhance learning (3–6). Generally the humanities are viewed as an adjunct or elective component in medical education and not as part of the core curriculum. We decided to use literature as an introduction to psychiatric ethics in our core curriculum for residents in psychiatry. RATIONALE FOR AN INTRODUCTION TO PSYCHIATRIC ETHICS For the past 7 years, our adult and child residency training programs have had an anACADEMIC PSYCHIATRY
nual seminar on psychiatric ethics for fourth- and fifth-year adult and child psychiatry residents. Evaluations have repeatedly suggested that the series be given earlier in the psychiatric training. The instructor believed, however, that the success of the seminar required participants with enough clinical experience to readily recognize the ethical dilemmas referred to in the medical-psychiatric literature. As William Carlos Williams told Robert Coles, “it takes time to be a doctor” and “if the reader were a doctor (as opposed to a student)— then so much the better !” (7) The instructor agreed and thought that it was too much to expect first- and second-year residents to Dr. Rudin is clinical professor of psychiatry. Ms. Edelson is clinical instructor in psychiatry. Dr. Servis is associate professor of clinical psychiatry and director of education. All are in the Department of Psychiatry, University of California, Davis, School of Medicine, Davis, California. Address reprint requests to Dr. Servis, Department of Psychiatry, University of California, Davis, Medical Center, 4430 V Street, Sacramento, CA 95817. Copyright 䉷 1998 Academic Psychiatry.
41
PSYCHIATRIC ETHICS
examine critically and discuss candidly ethical challenges so early in their subjective and professional experience. We decided to continue a more traditional senior-resident seminar in psychiatric ethics and develop a beginning-resident seminar with examples of ethical conflict coming not from their personal experiences but from a neutral, yet attention-getting, vehicle: literary fiction. The psychiatric ethics instructor, a psychiatrist, collaborated with a literature scholar who was a serious student of psychoanalytic theory to develop a list of short stories that met the criteria of being well written (1), concise and easily read, and representative of recurring ethical quandaries for a psychiatrist in clinical practice. The stories did not have to be about psychiatry or medicine as long as they dealt with ethical dilemmas commonly experienced in psychiatry. For our purposes, “well-written literature” was defined as 1) telling a story involving characters or conflicts that interest a variety of readers, often crossing age, gender, and cultural boundaries; 2) presenting complex and ambiguous situations and characters, even contradictory ones, but experienced as true and not merely good or bad; 3) creating a coherent form or pattern out of what had seemed incoherent; and 4) feeling “real,” even hauntingly so, even when the reader knows the story did not— or probably could not—happen.
training and clinical practice. Our objectives included recognizing that the search for what is “right” is endless, that two or more actions each deemed “right” often conflict with one another, and that a “right” action can effect a “wrong” result. We wanted to introduce the residents to the process of “value balancing” and remove repression or denial around ethical conflict (9). Further objectives included the recognition that “psychiatric ethics” embrace personal and professional ethics and that all three reflect current cultural mores. We wanted the residents to learn the importance of transcultural ethical-value differences in medical and psychiatric practice. Finally, we wanted to impress beginning residents with the idea that a profession requires more than just “professing” knowledge and demonstrating skill; our specialty imposes on the professional a fiduciary responsibility for those seeking professional help. Society sanctions the intrusions of medical professionals into the lives of people with mental illness, in return for the professionals’ covenant always to act for the benefit of those entrusted to their care. This covenant requires that society monitor the practice of the professional and that the professional monitor his or her own competence and judgment. The combination creates a code of professional ethics (10). SEMINAR DESCRIPTION
GOALS AND OBJECTIVES Sir William Osler recommended that medical students read 10 classics, his “bedside library” to promote “the education, if not of a scholar, at least of a gentleman ” (8). As likely as it is that the psychiatrist who is “learned” as well as trained may be a better psychiatrist, we chose a less ambitious but more focused goal. We sought to sensitize first- and second-year psychiatric residents to ethical dilemmas and ambiguities they were likely to encounter in their psychiatric 42
We first introduced our seminar in 1995 at the University of California, Davis, School of Medicine. Eleven 50-minute sessions were held weekly. Following the first session, the residents were expected to discuss the following about each assigned reading: 1) the ethical or moral dilemmas posed by the story, 2) presentation and resolution of the dilemmas, and 3) personal and professional responses to dilemmas posed in the story. We also invited the residents to keep a VOLUME 22 • NUMBER 1 • SPRING 1998
RUDIN ET AL.
journal of pre- and postseminar impressions and reactions for later discussion and review by the seminar leaders. We hoped that such a written record might help the residents to identify their further responses to the readings and discussions, provide the residents with a written “progress report” of personal changes, and be a means of support for whatever anxiety-provoking selfdoubts might arise. In the first session, the co-leaders introduced themselves and identified their interest and experience in literature, psychiatry, and ethics, inviting the residents to identify their own interests and experience with literature. The seminar instructors defined “professional ethics,” “ethical dilemma,” and “well-written literature,” as well as emphasized the importance of attentive listening to each “patient story,” with the short story being a kind of “patient history.” The instructors also anticipated that the readings and discussion might result in more ambiguity than closure about professional ethics. The residents were told that the stories were selected not for their overt medical or psychiatric content, but because they presented a conflict between two or more principles reflected in the ethical guidelines of the American Medical Association, as annotated by the American Psychiatric Association. We suggested that each participant might also find other ambiguities in the stories and that all were worthy of discussion. The seminar instructors focused the discussion on the following questions: 1) What are the ethical dilemmas in the story, and how do they appear in psychiatric practice? 2) How are the dilemmas resolved in the story, and how else might they have been resolved? 3) What circumstances, past histories, and associated affects help determine the actions taken to resolve the dilemmas? 4) Whose story is being told, and how might other characters therein tell a different story? 5) How might the conflicts and the ACADEMIC PSYCHIATRY
determinants of behavior found in the story appear in psychiatric practice? The literary works studied are shown in Table 1 in order of presentation. The “game” for the readers was to identify the ethical dilemmas the instructors had found. Some were easy to decipher. William Carlos Williams’s Old Doc Rivers clearly illustrates the doctor of diminished capacity who could sometimes be extraordinarily beneficent and competent and at other times dangerously malevolent and incompetent. Williams’s Use of Force clearly demonstrates the ethical dilemma between respect for patient autonomy and the demands of paternalistic beneficence. Other stories were more obscure. Rosellen Brown’s How to Win illustrates the influence of personal values on treatment choice. Arthur Conan Doyle’s The Doctors of Hoyland demonstrates the struggles between competitiveness, sexual stereotyping, and the collegiality espoused by ethical codes since Hippocrates. One of the most complex stories in terms of ethical dilemmas, including those of physician treating physician and physician “treating“ family, was posed by Don Marquis’s The Other Room. SEMINAR EVALUATION The mean attendance for the 11 sessions of the seminar was 8.0 out of 12 resident enTABLE 1.
Short stories read and discussed
Short Story
Author
The Big Nurse The Other Room Use of Force
Ken Kesey Don Marquis William Carlos Williams Rosellen Brown George Garrett William Carlos Williams William Carlos Williams Arthur Conan Doyle Walter White
How to Win Wounded Soldier Jean Beike Old Doc Rivers The Doctors of Hoyland A Negro Doctor in the South The Consultation The Enemy
Richard Selzer Pearl Buck
43
PSYCHIATRIC ETHICS
rollees. At the conclusion of the seminar, 10 participants completed anonymous evaluations. The mean overall rating for the seminar was 4.0 on a scale of 1 (does not meet expectations) to 4 (consistently exceeds expectations). The highest ratings were given in the subcategories of “ability to stimulate the interest of trainees” and “quality of the assigned reading.” The lowest rating was in the subcategory of “instructor’s knowledge of the subject,” though even this subcategory had a relatively high mean rating of 3.7. These ratings are well above the mean overall ratings of 3.3 for other seminars in the curriculum, with statistical significance as measured by t-test (t⳱2.85, df⳱9, P⬍0.05). More impressive than the evaluations were the participants’ unelicited comments to the residency training director and seminar instructors. Several residents identified this seminar as their “favorite” in the curriculum because of its stimulating and provocative content. Many, especially several foreign-educated residents, expressed appreciation for the increased sensitivity to ethical issues in the psychiatric workplace. One international medical graduate described the powerful acculturation and education in American norms and values obtained from reading and discussing Western literature. An example of the enthusiasm of many participants was their request for a monthly meeting to continue the seminar’s work, exploring ethical issues through film and literature. DISCUSSION There are many links between medicine and literature. Doctors have become writers, bringing their insights into their writing. At the same time, nonmedical writers’ insights about physicians and other caregivers can shake the professional image of self-assured altruism and beneficence. Whether medical or nonmedical, writers who deal with the 44
“whole person” illuminate the biopsychosocial approach to patient care. However, are conclusions derived from literature that is written to entertain and to evoke feelings applicable to clinical practice? Are they sufficiently relevant to help prepare psychiatric residents for the ethical dilemmas they will encounter during their clinical experience and before their formal instruction on ethics? Can literature facilitate and improve ethical decision making in psychiatric training and practice? Terry and Williams express grave reservations about using literature to teach ethics (11). They cite the differences between the goals and methods of teaching literature vs. those of teaching bioethics. We acknowledge these differences, but we do not share their objections to using a safe, entertaining, and absorbing medium for examining “the emotional and experiential” before locking in on “the objective and reasonable.” We have no compunctions about offending “the integrity of a work of literature” if, by “changing characters or plots,” we can suggest variant outcomes or moral points and promote our teaching objectives. We are not teaching literature; we are using it to “promote sensitivity and empathy,” to increase awareness of the “wealth of connotation and the indeterminacy of expression,” and to examine a range of meanings instead of settling on a single definitive meaning. We prefer to strengthen the beginning resident’s tolerance for ambiguity, to permit a well-analyzed, “value-balanced” clinical decision instead of a rapid resolution of an ethical dilemma through a rule, law, or code. Terry and Williams feared that “the use of literature in discussions of bioethics offers an escape from too often dry analytic discourse” that might “subordinate, misdirect, or obscure ethical analysis and discussion.” We encouraged the residents to search for the story’s ethical applications to psychiatry. When they strayed, often to issues of diagnosis or transference and counVOLUME 22 • NUMBER 1 • SPRING 1998
RUDIN ET AL.
tertransference, we helped differentiate those issues from issues of clinical ethics. The discrepant perspectives of fictional characters enabled us to steer the residents away from premature diagnosis and toward examination of the actions and conflicts of the characters themselves, the unfolding story rather than “the bottom line.” Once the residents recognized the breadth of complicating factors in the story, the psychiatrist turned to analyzing the ethical issues and their relationship to the codes that guide ethical psychiatric practice. We were seeking a breadth of viewpoint, an avoidance of premature closure, and an enhanced ability to listen to each patient’s story before reducing it to a clinical diagnosis. Further experience, later casecentered ethical deliberations, and the senior-resident seminar in ethics would address ethical decision-making choices and closure. Radwany and Adelson warn that short stories may not develop plot and characters as well as a play or novel (3), but we found that a highly crafted, condensed short story can provide extraordinary impact, emotional resonance, and ethical ambiguity. A searching analysis of a short story can provide an in-depth experience that replicates the challenges and frustrations of shortterm treatment, especially as encountered in the managed-care environment. We had not anticipated the residents’ interest in stylistic and structural elements of the short stories. The best stories offer a cohesiveness that attunes the ear and eye of any reader and adds to the observational skills and “narrative competence” of the clinician (12). Indeed, the stories offered our international medical graduates a rapid acculturation to American cultural mores and norms. Another unexpected outcome of the course was that residents discovered hitherto unknown interests and talents of their colleagues. In many psychiatric residencies, ACADEMIC PSYCHIATRY
the clinical rotations take place at a number of affiliated sites, thereby separating the residents from each other. Although the residents connect for self-defense, and fortuitously discover shared experiences and interests, they often develop a high degree of fragmentation and interpersonal distance, hence a low degree of interpersonal loyalty and camaraderie. Our “Introduction to Psychiatric Ethics Through Literature” seminar gave the residents a legitimate occasion to leave the work setting and enter a part of their lives associated with play: reading fiction. They rediscovered the joy of literature and found that their colleagues also shared that same joy. They learned the perspectives and viewpoints of their colleagues, which fostered group cohesion, even intimacy. Apparently, the seminar met an important social as well as educational need. CONCLUSION Short stories provided a safe, pleasant, and condensed way to emphasize the emotional and experiential and to learn about inherent ambiguities and connotations in life’s crises. As beginning residents discovered differences in ways that both fellow participants and stories’ characters resolved their dilemmas, they learned greater respect for ethical ambiguities and diverse perspectives. They learned how to delay decision making while staying within the constraints of a short story—or a clinical session. The psychiatrist leader of the seminars saw to it that the ethical problems were analyzed and were not “subordinated, misdirected, or obscured”; the literary leader helped attune the eye and ear to collect additional information relevant to making ethical decisions. In the hectic—and often fragmented and fragmenting—early residency experience, the more relaxed social context of talking about fiction and sharing personal views provided a unifying learning environment. The residents from other than 45
PSYCHIATRIC ETHICS
mainstream U.S. cultures found universally shared human experiences in the stories. They recognized familiar dilemmas and discovered a broad scope for desirable resolutions of those dilemmas, all in a context in which their viewpoints were respected. Long- and short-term effects await evaluation. In an already jammed curriculum,
will the expenditure of time and resources be warranted? Would more advanced residents benefit from such a seminar? Would fiction other than short stories or would other leadership combinations help residents retain or recapture the traditional professional ethos that compelled many to choose medicine and psychiatry? We need to know.
References
1. Report of the Working Group in Personal Qualities, Values, and Attitudes: Physicians for the 21st Century: Report of the Project Panel on the General Education of Physicians and College Preparation of Medicine. Journal of Medical Education 1984; 2:177–189 2. Blackwell B, Schmidt GL: The educational implications of managed mental health care. Hospital and Community Psychiatry 1992; 43:962–964 3. Radwany SM, Adelson BH: The use of literary classics in teaching medical ethics to physicians. JAMA 1987; 257:1629–1631 4. Ness DE: Short stories about doctors and patients: a course. Acad Med 1989; 64:390–391 5. Rodenhauser P, Leetz KL: Complementing the education of psychiatry residents: a study of novels, plays, and films. Journal of Psychiatric Education 1987; 11:243–248 6. Sondheimer A: The literature and medicine sem-
46
inar for medical students: a potential recruitment tool. Academic Psychiatry 1994; 18:38–44 7. Coles R: The humanities in postgraduate training (editorial). JAMA 1987; 257:1644 8. Osler W: Bedside Library for Medical Students. Equanimatas With Other Addresses. Philadelphia, PA, Blackstone, 1947 9. Hundert EM: A model for ethical problem solving in medicine, with practical applications. Am J Psychiatry 1987; 144:839–846 10. Pellegrino ED: Altruism, self-interest, and medical ethics. JAMA 1987; 258:1839–1840 11. Terry JS, Williams PC: Literature and bioethics: the tension in goals and styles. Lit Med 1988; 7:2– 21 12. Edelson M: Telling and enacting stories in psychoanalysis and psychotherapy, in The Psychoanalytic Study of the Child, Vol 48, edited by Solnit AJ, Neubauer PB, Dowling AS. New Haven, CT, Yale University Press, 1993, pp. 41–45
VOLUME 22 • NUMBER 1 • SPRING 1998
