Literature and medicine: an evolving canon.

presented and developed in a literary way—that is, embedded in a complex human situation replete with highly charged emotions. The emotional and sometimes ambiguous context that makes these stories so pedagogically useful, however, makes some ethicists uneasy. They argue that the attention given to pain, suffering, and emotion in such literary cases can distract readers from the abstract reasoning skills necessary to analyse an ethics case. This inherent tension between logical and literary modes of reasoning has led over the years to the development of a richer variety of approaches towards not only these stories but also the practice of clinical ethics. Perhaps the best known of these literary cases is William Carlos Williams’ “The Use of Force”. Written in the 1930s, this story is one of many that came out of Williams’ experience as a general practitioner and paediatrician for a working-class population in Rutherford, New Jersey (figure 1). In “The Use of Force”, a physician is called to the home of a couple he has never seen before to examine their young daughter, who has been ill for several days. The young girl refuses to open her mouth for examination; The powerful affinity between literature and medicine goes back to ancient times, and there are hundreds of literary works that deal, in one way or another, with medical themes broadly construed, such as illness, suffering, and death. Among these are many masterpieces of western literature that have long been read and taught for their literary quality, psychological insight, and theological or philosophical vision. The biblical Book of Job, Sophocles’ Philoctetes, Eliot’s Middlemarch, Tolstoy’s The Death of Ivan Ilyich, Mann’s Death in Venice and The Magic Mountain, Kafka’s Metamorphosis, Camus’ The Plague, and García-Márquez’ Love in the Time of Cholera, to name only a few examples, are among the highly regarded works of art that raise ultimate questions about what it means to be ill, to suffer, and to die. These great works certainly belong in any canon of literature and medicine. They may be even more important for physicians than they are for “lay” readers—certainly they are no less so—because in the daily practice of their profession physicians must deal with the ultimate human questions examined in these works. Great literary works are, almost by definition, complex; they are often lengthy as well. Although their complexity makes them ideal texts for teaching students “to read, in the fullest sense”, and thereby helping train them medically—one of the first clearly articulated and defended purposes of incorporating the study of literature into medical education—their length works against their easy inclusion in the curricula of many medical schools and residency programmes. For this reason, and because the relevance of literature to the world of clinical practice was not as well understood in the 1970s as it has become two decades later, literature was first taught in many US medical schools in conjunction with medical ethics. Certain stories work so well as literary “cases”, illustrating traditional dilemmas of medical ethics, that they belong to an evolving canon of works frequently taught in medical humanities classes. Most of these works do not hold canonical status as literature in the way that such masterpieces as, for example, The Magic Mountain and The Plague do. Rather, it is a combination of their medical subject matter, their brevity, and their literary style that gives them special pedagogical value for medical education. Often written by physicians, these works may focus sharply on a doctor-patient encounter or an ethical dilemma in medical practice; in this, they are like the traditional ethics case. But the encounter or dilemma is