Abstract
By Sherwin B. Nuland. New York: Kaplan, 2009, 214 pp., $26.95.
The history of modern medical ethics can be traced back as early as the 18th century. Following in the rich tradition of Thomas Percival, award-winning author Sherwin Nuland publishes his third book, The Soul of Medicine-Tales from the Bedside. As he describes in his prologue, this book of nonfiction is an anthology of memorable doctor–patient encounters narrated in a style akin to Geoffrey Chaucer's The Canterbury Tales. Collected from his own 30-year clinical experience as a surgeon, and that of a handful of his esteemed colleagues of other disciplines, are varied stories, which he describes under the unifying theme of “the soul of medicine.” The book is well written and printed in the easy-to-read Adobe Garamond typeface. Each brief narrative with occasional commentary, disguised to protect confidentiality, challenges a core value in medical ethics, from autonomy to informed consent, beneficence to confidentiality, and communication to conflicts of interest. In this, we see the judgment exercised by doctors, and get a glimpse of the soul of medicine.
Sherwin Nuland begins with his own tale. The Surgeon's Tale is an account of a young man penned “Jimmy Tyson” who is suffering from a perforated loop of colon incarcerated in a diaphragmatic hernia. Not surprisingly, the equally young surgeon goes on to save Jimmy's life but is left to wonder if “Jimmy emerged from his ordeal a changed man.” At first glance, the reader might be appalled by the paternalism, elitism, and egocentricity of the author in relating this story. I certainly was. Nuland rescues this narrative with the commentary that follows. Nuland is introspective and reflective. He tells us of the writings of Ambrose Paré and the birth of medical literature, the passing of medical knowledge from mentor to student, and a lesson in humility he received from his own Chief of Surgery.
The seventh narrative entitled The Cardiologist's Tale is the story of Joe Dennet, the director of a rare book library. As he slowly dies of heart failure, Joe Dennet and his cardiologist are faced with the gut-wrenching decision of whether to turn off his defibrillator. In this touching narrative and insightful commentary, we are challenged to think about futility, euthanasia versus non-maleficence, and surrogate decision making when there are no advanced directives.
Nuland relates 21 tales in all. In some, like the cardiologist's tale above, it is easy to discern the ethical dilemmas faced by both the doctor and the patient. In others, like the dermatologist's tale, understanding why it is included in this anthology is more challenging. There is neither an obvious ethical dilemma nor a particularly obscure diagnosis revealed. In fact, Nuland teases us with “As promised, it's a (seemingly) simple story with a (seemingly) simple solution, and it doesn't even require a Commentary by the Narrator.” Perhaps he is instigating us to think about patient expectations, their hopes and fears in meeting a new physician. The reader will find that even from this bland narrative a rich lesson can be learned about how much a physician's ability to establish that trusting relationship with their patient impacts disease outcome.
This theme reverberates again in tales 10 and 11. The Neurosurgeon's Tale(s) begins as expected with the telling of a particularly tragic story of the death of a 2-year-old boy beaten by his mother's boyfriend. It is followed by another story, this time of a young woman born with hydrocephalus and her nurturing parents. In the author's narrative that follows, Sherwin Nuland poignantly shares his real-life experience as a parent of a child diagnosed with hydrocephalus. He reminds us that physicians are human too. Whether they are seemingly “hotshot” neurosurgeons, infallible chest surgeons, bronchoscopists, or pediatricians, they appear most infallible to their patients when they share their humanity. The reader cannot but feel empathy when the neurosurgeon drapes his arm around Nuland's shoulders and explains, “as softly and encouragingly as he could that he expected my [sic] baby to do well.”
The Soul of Medicine is a wonderful collection of medical stories, each a telling tale of the uniqueness of the physician–patient relationship. The tales are as varied as the specialists Nuland enlists to write them. We hear from a gastroenterologist, an obstetrician-gynecologist, an ophthalmologist, an anesthesiologist, a medical student, a nephrologist, and so on. Nuland has a remarkable gift of storytelling, and his characters and tales will appeal to a broad audience. He concludes in the epilogue that by the “soul of medicine” he means physician judgment, an all-encompassing term to describe “the ultimate mainstay of diagnosis.” I suggest that Nuland means much more than that when he talks of the “soul of medicine.” In this anthology, he describes professionalism, sympathy, empathy, humility, and morality as the foundation of medical ethics. It is a must-read for any student contemplating a career in medicine.