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Thomas Alured Faunce, "Pilgrims In Medicine: Conscience, Legalism And Human Rights"

Pilgrims In Medicine: Conscience, Legalism And Human Rights: An Allegory of Medical Humanities, Foundational Virtues, Ethical Principles, Law and Human Rights in Medical Personal and Professional Development by Thomas Alured Faunce (Martinus Nijhoff: Brill Academic Publishers) Unabashedly literary, allusive and dialogic, Faunce has created a synthetic account of the humane issues involved in the doctor-patient relationship. The work challenges clinicians to approach whole to whole in the dance or as Fanunce fancies it, pilgrimage, that practice of medicine can become even in our highly technocratic institutions of medicine. Part spiritual direction, legal treatise, bioethics premier, and, with always an eye for the formation of personhood of the physician, this work deserves a wide professional readership.

This arrestingly novel work develops a normative synthesis of medical humanities, virtue ethics, medical ethics, health law and human rights. It presents an ambitious, complex and coherent argument for the reconceptualisation of the doctor-patient relationship and its regulation utilising approaches often thought of as being separate, if not opposed (virtue-based ethics and universal human rights). The case is argued gracefully, with moderation, but also with respect for opposing positions.

The book's analysis of the foundational professional virtue of therapeutic loyalty is an original departure from the traditional discourse of patient autonomy, and the ethical and legal duties of the medical practitioner. The central argument is not merely presented, as bookends, in the introduction and conclusion. It is cogently represented in each chapter and section and measured against the material considered.

A remarkable feature is the use of aptly selected "canonical" literature to inform the argument. These references run from Hesse's The Glass Bead Game in the abstract, to Joyce's Ulysses in the conclusion. They include excerpts from and discussion about Bergman, Borges, Boswell, Tolstoy, de Beauvoir, Chekhov, Dostoevsky, Samuel Johnson, Aristotle, Orwell, Osler, Chaucer, Schweitzer, Shakespeare, Thorwalds, Kafka and William Carlos Williams. Such references are used not merely as an artistic and decorative leitmotif, but become a critical, narrative element and another complex and rich layer to this work. The breadth and quality of the references are testimony to the author's clear understanding of the modern law and literature movement.

This work provides the basis of a medical school course. As many medical educators as possible should also be encouraged to read this work for the insights it will give them into using their own personal life narratives and those of their patients to inform their decision-making process. It will also be of value to the judiciary, whose members are often called upon to make normatively difficult judgments about medical care and medical rules.

The human rights material leads to a hopeful view of an international movement toward a universal synthesis between medical ethics and human rights in all doctor-patient relationships.

Abstract: Soon, the 21st century's vast aggregate of clinical medical encoun¬ters and the comparatively smaller volume of professional and aca¬demic commentary upon them, will, like those remnants from the Hippocratic age, distort into the ambiguous strata of history. Scholars may then seek to sift those narratives for relics testifying to important themes.

This work suggests some such thematic candidates. To emphasise their humanity and inherent dignity, they have been made here into literary characters. They will be shown progressing through the vary¬ing quadrants of their fated careers, from medical students into pro¬fessional practice, retirement and death.

This interdisciplinary technique draws upon an established liter¬ary genre involving personification of the virtues and vices.' It seems a vehicle well serviced to attempt a conceptual tour that integrates those hitherto dispersed academic hamlets known as moral philoso¬phy, virtue ethics, medical humanities, bioethics, jurisprudence, health law and human rights. Like Prudentius' Psychomachia or "soul bat¬tle," their tales may often resemble dynamic "inward" struggles between opposing moral values. Indeed, it has been argued that the contesting imagined persons from the Psychomachia (for example, Fides, Spes, Sobrietas and Ira) actually represented dieties and dae¬monic powers in the heart of man.'

As Chaucer gave us a brief sketch of those pilgrims setting out from the Tabard to Canterbury, so will I now the personified med¬ical students whose journeys in conscience are narrated in these pages.

"Genome", as we first meet him, is an ambitious young man who, with little difficulty, has graduated from science to study medicine.

Married with two children, he carries more weight than he should and wears glasses. Genome is proud of his cultural background. His father, a Greek fisherman who worked on trawlers and his Egyptian mother, have much love for him but little comprehension of the amount of study required to be successful in such a course. Genome's dream is to buy an established home in the wealthiest suburb of town. He has not accepted a rural-bonded scholarship from the Uqbari Government.

"Human Rights" is a young, female graduate of law, enlivened by righteous anger in her pursuit of injustice. She is involved in many politically active groups on campus and lives with a group of like-minded friends. Human Rights is a vegetarian and wears clothes she makes herself. Her family were Cambodian farmers who nar¬rowly escaped the atrocities of Pol Pot's "Year Zero". Human Rights has a left arm that is a little shorter than her left, with a scar across the prominent knuckle.

The third character, a self-assured honours law graduate, depicts a regulatory attitude referred to in this book as "Legalism." Legalism and Human Rights were living together, but have recently separated. Legalism's parents have bought him a house in a leafy suburb near the University in which to stay for the duration of the medical course. Legalism keeps fit through involvement in many sporting activities in which he displays gifts of natural prowess that provoke much envy. His mother is a Muslim who fled Iraq and has separated from her community. His father is a third generation Uqbarian sheep and wheat farmer. Legalism intends to practise medicine in a rural location in Uqbar, but has not accepted a rural-bonded scholarship, as he wants to keep open the option of gaining clinical experience in a major urban teaching centre. Legalism has never failed an exam and has an aura of almost invincible optimism.

Our fourth character, boasting an eccentric graduate education in the humanities, is "Virtue Ethics." Virtue ethics has been twice divorced and is currently enjoying the relative ease of a bachelor's life. He has written a well-received treatise on the virtues and vices in English literature and regularly pens acerbic and sarcastic book reviews for the Times Literary Supplement, Quadrant and the London Review of Books. He lives on campus in post-graduate accommodation acquired by a bureaucratic ruse. He periodically makes it a rule that all vis¬itors must enter his room wearing one of the amusing hats racked by his door. He is frequently found at the bar, amiably intoxicated, smoking a variety of licit and illicit substances and philosophising. His family once had a country home in Sussex, England. His mother was the daughter of a Jewish refugee and his father the last of a long line of British soldiers. He has vowed that he will never again fall in love with either man or woman He has decided to write a novel about his experiences in medical school.

The fifth character is "Professional Conscience (PC)." PC lives in a group house with students from a variety of Faculties. She owns an impertinent cat called "Hodge." Her father is an irascible Scottish engineer and her mother a genteel Italian Professor of Fine Art. PC is involved in a Christian organisation that organises food for the homeless. She has recently comforted her mother through a long battle against ovarian cancer. PC lacks self-confidence and agonises each night about her social mistakes during the day. Other medical students you may encounter include the strange and irascible Charm, Collegiality, Stress, Professionalism, Spiritual Competence and Cultural Competence.

The journey into doctor-patient regulation we are about to com¬mence bears interesting comparison to the unique game that forms a central interactive sculpture in the echoing hall of Hermann Hesse's novel Das Glasperlenspiel [The Glass Bead Game].

Das Glasperlenspiel is an eclectic "game" played by the monastic spiritual guardians of future nation states. Players of the Glass Bead Game use the symbols and formulas of a common language created from music, philosophy, art, architecture, literature, mathematics, ethics and law. They begin by stating, then elaborating, varying and developing themes in the manner, simultaneously, of, for example, a Bach fugue, a Shakespearean tragedy, a Gothic cathedral, a philo¬sophical work by Immanuel Kant, a painting by Leonardo da Vinci, the Mahabharata, Illiad, Basho's Narrow Road to the Deep North even, one presumes, the Universal Declaration of Human Rights.

"For a long time" writes Hesse "one school of players favoured the technique of stating side by side, developing in counterpoint, and finally harmoniously combining two hostile themes or ideas, such as law and freedom, individual and community." The aims of the Glass Bead Game are obscure, but appear to involve providing a source of spiritual aspiration for society and the acquisition of virtue by its participants.

The "Student Life" section strives to resemble the tempo and tone of that great conversation of humanity beginning with the Kyrie of Bach's Mass in B Minor. Here we gradually perceive the key ele¬ments and interactions of conscience, virtue ethics and medical human¬ities. By the "Professional Practise" section, echoing the Gloria and Credo of the B Minor Mass, we begin to integrate these with med¬ical ethics, health law and human rights. The notion is gradually introduced that we may view this integrated scheme of doctor-patient relations either as a positivistic enforcement pyramid, or as a more probabilistic community of principle clouding round conscience and personal and professional narrative coherence. All these concepts are drawn together and critiqued in the final section, "Retirement," which tries to echo elements of the Santus and Agnus Dei components of the great Mass.

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